Yves here. As well intentioned as this post and its underlying effort, are, I’m not sure what to make of it. In the stone ages of my youth, a pretty high proportion of people who went into medicine did so because they wanted to have a relatively low risk, solidly middle to upper middle class income, while also helping people. The ones who wanted less hand holding went into specialities like radiology and ophthalmology.
It now seems that some in the medical field realize that patient care has been becoming divorced from the patient, to the detriment of care. But that is due to a whole host of factors. A biggie is corporatized medicine, where even doctors who do care and are good listeners face time and other institutional constraints in treating patients the way they’d like. Another is the burgeoning cost of being educated, which to a degree winds up leading at least some doctors being more mercenary (witness the dearth of less-well-paid GP and I would assume thin ranks of less lucrative specialities, such as pediatrics). And we have societally-supported bad habit, such as overuse of devices eroding interpersonal skills to the acceptability of looking down at the poor and less educated.
So I find it hard to think that courses like the one below will lead to more compassionate attitudes. I suspect, as they found with ethics classes at Harvard Business School, that one’s moral compass is set long before. However, it may be that courses like the one described below could be helpful if they took a more instrumentalist approach, as in teaching doctors to be better fact-finders via increasing their skills of observation and questioning of patients, and encouraging them to explain their reasoning and answer questions….if not out of respect, so as to increase compliance.
By Jonathan Weinkle, Clinical Assistant Professor of Medicine and Part-Time Instructor of Religious Studies, University of Pittsburgh. Originally published at The Conversation
Patients frequently describe the U.S. health care system as impersonal, corporate and fragmented. One study even called the care delivered to many vulnerable patients “inhumane.” Seismic changes caused by the COVID-19 pandemic – particularly the shift to telehealth – only exacerbated that feeling.
In response, many health systems now emphasize “relational medicine”: care that purports to center on the patient as a human being. Physician Ronald Epstein and health communication researcher Richard Street describe “patient-centered care” as advocating “deep respect for patients as unique living beings, and the obligation to care for them on their terms.”
In 15 years as a primary care physician, I have seen the effects of dehumanizing medical care – and the difference it makes when a patient feels they are being respected, not just “treated.”
Though “relational medicine” may be a relatively new phrase, the basic idea is not. Seeing each person before you as someone of infinite value is fundamental to many faiths’ beliefs about medical ethics. In my own tradition, Judaism, “person-centered care” has roots in the biblical Book of Genesis, where the creation story teaches that “God created the Human in God’s own image.” As a medical educator, I teach students how to turn these abstract ideas into concrete clinical skills.
Divine Dignity
Traditional Jewish law sets rules that shape my understanding of these skills. As the influential French sage Rashi wrote in an 11th century commentary on the Bible, it is forbidden to publicly embarrass a person “so that their face turns white,” even while rebuking them. For doctors today, this might mean taking care not to inflict shame on a person with a stigmatized illness like substance use or obesity.
The Bible forbids wronging or abusing strangers not once, not twice, but 36 times – a reminder not to “other” people or obscure their basic humanity. A similar value appears in the 18th century Physician’s Prayer, written by the German-Jewish physician Marcus Hertz, who states, “In the sufferer, let me see only the human being.”
American Rabbi Harold Schulweis used the concept of “covenant” – a holy, mutual agreement – as a model for the bond between physician and patient, working toward a common goal. This idea inspired my own book, “Healing People, Not Patients.”
Similar connections between medicine, respect and religion are found in other traditions, as well. A 1981 Islamic code of medical ethics, for instance, considers the patient the leader of the medical team. The doctor exists “for the sake of the patient … not the other way round,” it reminds practitioners. “The ‘patient’ is master, and the ‘Doctor’ is at his service.”
Seeing and Hearing the Whole Patient
In undergraduate classes that I teach for future health professionals at the University of Pittsburgh, we focus on communication skills to foster dignified care, such as setting a shared agenda with a patient to align their goals and the provider’s. Students also read “Compassionomics,” by medical researchers Stephen Trzeciak and Anthony Mazzarelli, which aggregates the data showing caring’s impact on the well-being of patients and providers alike.
However, even health professionals steeped in these practices can encounter people whose humanity they struggle to see. Students wrestle with a classic article about “the hateful patient” and practice an exercise called the “second sentence.” This asks providers to look beyond their first impressions of a patient they might have trouble treating with compassion, imagining a “second sentence” that humanizes the person in front of them.
The course evaluation is based on a project in which students interview a friend, relative or neighbor about their experience of illness and care. Ultimately, they identify one element of the person’s care that could have been improved by attending more to the person’s individual needs and listening to their story.
One student recounted her brother’s experience after he suffered a serious sports injury. The trauma team followed protocol precisely, but this meant that they did not register him screaming in pain, telling them that what they were doing was making him feel worse. Only in the hospital did doctors discover that those screams were a clue to a specific injury that should have received radically different care in the field, which could have been caught earlier had the team attended more closely to his words. His sister explored the medical literature on when EMS needs to break its own rulesto care for a complex patient, and she suggested her own mnemonic – stop-ask-listen-evaluate (SALE) – for how to make “breaking protocol” one of the options in the protocol itself.
Another student related his father’s experience living with chronic illness. His condition frequently deteriorated because of delays in refilling medicine through his regular physician’s office. This student pointed to medical literature detailing how pharmacists can be given greater authority to refill medications for chronic diseases, preventing gaps in treatment, which would have saved his father significant hardship.
Listening with Both Ears
Down the road at Chatham University, I work with physician assistant students who are about to enter clinic for the first time. These students complete a workshop including many of the same communication exercises, including “listening with both ears”: listening not only to the patient, but also to what they themselves say to the patient, considering how it will be received. Students are encouraged to go home and practice until the words feel natural in their mouths, not scripted or mechanical – just like they drill anatomy facts and suturing skills.
After their clinical year, the students return to reflect. Many of them report using patient-centered skills in challenging situations, such as validating patients’ concerns that had previously been dismissed.
Yet they also report a work culture where effective communication is often seen as taking too much time or as a low priority. Sixty years ago, Rabbi Abraham Joshua Heschel and psychiatrist William C. Menninger presented on The Patient as a Person to the American Medical Association. Heschel declared that the profession was suffering from a “spiritual malaria,” his term for precisely the “high-tech, low-touch” attitude that my students encounter. The emphasis on technology and a rapid pace of treatment leaves scant room for caring, whether in Heschel’s day or ours.
In both programs where I teach, I aim to provide new practitioners with tangible skills that their future patients will experience as real “whole-person care” and not just a slogan on a commercial. Those patients will know that the people caring for them value all of them – their livelihoods, their life stories and the worlds they inhabit.
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I think this comes down to one thing: Humility. If the doctor is not humble, the aping of humility will only come out as uncaring or gaslighting. And I worry that humility is difficult to teach. I think it must mostly be learnt the hard way: By being wrong. But perhaps the education the author mentions at least gives doctors permission to be wrong, and permission to learn humility. Perhaps that is a start.
I am deeply grateful to the medical professionals I have seen who were humble enough to admit when they did not know something.
Humility, empathy, values. If not taught in childhood, they can rarely be improved later.
That said, the “profits are the highest value” medical system (and country) makes it easy for workers to leave their true values at the door in order to preserve themselves from trauma and an examined life.
I checked a few of the linked studies (love links), but they differ from how presented.
Relational medicine (which to me seems like a marketing buzzword to assuage the damage done by investor-owned health care), is about not putting the patient at the center, but creating a team with the patient, doctor and family.
from the citation:
“This approach focuses on human connection and relationships between patients, their families, and the care team”
“foster dignified care, such as setting a shared agenda with a patient to align their goals and the provider’s.” Re align goals is actually about the doctor not cutting off the patient and listening to their health problems – aka, doing a proper patient history, and has nothing to do with dignified care.
At this point I became uninterested in wasting time checking others.
I applaud teaching students to care about patient care, but once they enter the profit mill that is the US health care system….. its like teaching ethics to the IOF (or the Azov Battalion) – a waste of breath in a corrupt system and an example of using the bible to argue for the most inhumane.
I agree with Yves on the fixed moral compass. The author takes a prescriptive approach that’s unlikely to move that needle.
It might be possible to improve student formulations of moral dilemmas. In some cases, better problem definitions can lead to better solutions. But that compass needle unlikely to move after that.
When teaching sessions on AI ethics, I introduce my business students to a set of principles they might use to better frame these problems broadly. As with most liberal arts approaches, I reward students for the quality of the arguments presented, not their solutions.
Students in programs designed for licensure (e.g. health care) tend to take a more prescriptive approach to ethics. The licensing authorities have codes of ethics that instructors can use to determine right from wrong when faced with ethical issues. Ideally, those codes would be developed through democratic processes with input from all affected.
If Yves is right about the moral compass, a good way to improve ethical behavior in health care would be to select for the desired characteristics in the admissions processes. Right now, medical programs seem to be selecting a higher proportion of psychopaths than exist in society. These folks may be less likely to burn out but their morals aren’t benefiting patients.
Yves says:
After almost 30 years being a patient in various specialties/countries, and having worked with/taught medics, most notably in the (at the time pretty revolutionary) Community Oriented Medical Practice (COMP) course in the Medical Faculty at University of Bristol, UK (c2000), I (unfortunately) agree entirely with Yves’s pessimistic take. Some British readers with knowledge of the “red brick” universities might know of the *ahem* reputation Bristol has but suffice to say I did not enjoy teaching there (and I beat the world leaders in my field on an exec education course we ran in terms of attendee evaluations, so I don’t *think* I’m the person at fault here, hehe).
I really do applaud the attempts by various medical courses to improve empathy and respect for the patient amongst the med students. Alas, the vast majority of my experiences as a patient with physicians who I know had such training have been middling to awful. The comment about physicians loving the high-tech stuff really rang true when I needed cardio-catheter cryoablation in 2005 to correct my SVTs (which were particularly severe, especially given a fast pulse anyway and had me in the ER for 2 hours in SVT at the worst point getting a – gentle it must be said – lecture from the head of Dept asking how on earth a PhD Med Stats guy can get to his mid 30s before getting this seen to).
The ablation was done by a Specialist Registrar (one grade down from Consultant). Exactly the type of physician who loved the new tech coming into use around the turn of the millennium. I had the worst ever encounter with a physician in my whole life. Fans of the Big Bang Theory who remember when Sheldon told Leonard to “not” when Leonard was having a panic attack will relate – when they’re waiting for my heart to get down back below 80bpm to do the ablation (having zapped me up to some insane voltage to induce the SVT and find the short-circuit) and I’m told to “just calm down” by the rudest sob ever was horrid. I didn’t complain (since I didn’t want them to do the almost certainly failed ablation again)….I saved my whistle blowing for later in my career (though learnt the hard way that even when you win, you lose – don’t ever be a whistle blower).
One final point came from a pro bono study I did for my local General Practice a few years ago. Essentially patients get “the GP they want but likely with 15+ minute waiting time and difficulty booking convenient times” OR “any GP but no wait and convenient time slot”. Surprise surprise I found that there were 2 groups, one favouring each type of appt. Older people and mums with young kids wanted the former whilst “middle class professionals, especially if youngish” wanted the latter. Moral of the story was “don’t assume everyone wants patient-centred care – some treat the consultation as a transaction”. (Personally I think that view as a transaction is silly but I’m old fashioned…….)
Is the Hippocratic Oath not enough? I have heard that most medical students memorize it until they can recite it by heart.
Sorry to tell you but it is not remotely useful in huge numbers of instances and thus is largely irrelevant, being dropped in favour of local guidelines/mandates/laws.
Ethics classes … Harvard Business School … thanks for making my day with that one. Laughter is the best medicine.
As for the main thrust of the piece, I don’t see how it is possible to reconcile patient-centric medicine with the modern practice of treating patients as a profit center.
Faced with a decision to treat ethically or make profits, profits win in our current clown world.
They don’t need your history, they have “best practices.” They don’t need to examine you, they have “imaging” They don’t seek your understanding, they have “scripting”
I’m starting to think 99% of US medical care is diagnostic tests
The distressingly ironic thing is that the US is not completely wrong (I’m a Brit/Aussie). The USA typically tests MASSIVELY. The UK NHS, unless there is a very obvious, well-acknowledged set of guidelines, WILL NOT. Both have prima facie cases for what they do. The USA wants to know if an infection is a bacterium and if so, what. This enables FAST administration of the correct antibiotic. The UK NHS adopts the mindset “it might need an antibiotic, but on balance of probabilities won’t, and we can still probably address it if we tell the patient to bugger off and come back if it is no better in 10 days”.
MOST of the time the NHS approach works. However, breakdown of societal norms are letting more things develop. Plus, more and more people (perhaps quite rightly) are annoyed that “you can test this…..you can KNOW what it is…or at least rule out *real nasties*….so why won’t you do that?”
I myself was terrified that my local teaching hospital, having established that an animal bite had led to a growing infection in my arm (possible sepsis), just plugged IV bog-standard antibiotics in, rather than culturing it and knowing EXACTLY what I had (and whether I needed a top-of-the-line antibiotic) and so I was admitted to a COVID plague pit of a hospital. THAT IS NOT COST-EFFECTIVE CARE, never mind appropriate clinical care.
If my dodgy heart gives me a heart attack I’ll discharge myself ASAP. Because my chances of living will be better by getting some blood thinners etc and going home. The systemic clinical pathways are wrong. And just to be clear – this is NOT to say the USA is better. It’s “wrong in the other direction”. The best is somewhere in between. But that doesn’t work in the current timeline.
Corporate Medicine has discounted “expertise” for “providers” with uneven training and experience. The less competent the provider the more ancillary testing to the bottom line.
In the end a mentality of profit maximization with each patient encounter. Helping the patient is now very much an after thought.