Monday, February 28, 2011

Family Medicine: Hippocrates, Hope and Heart

The Hippocratic Oath
(Original Version)
"I SWEAR by Apollo the physician, AEsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this Oath and this stipulation.
TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look up his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according the law of medicine, but to none others. ...."

 The Hippocratic Oath
(Modern Version)
"I SWEAR in the presence of the Almighty and before my family, my teachers and my peers that according to my ability and judgment I will keep this Oath and Stipulation.

TO RECKON all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient....."

The second paragraph of the oath I took as a graduating medical student in 1976 (the modern version of The Hippocratic Oath) includes a teaching mandate for physicians to teach others.  This may include learners of many levels, including medical students.  Teaching (and learning from) medical students has always been rewarding for me.  They know a lot and they are a member of my "guild".  Patients almost always enjoy their youth, energy, knowledge and promise for the future of medicine.  They also feel a sense of pride, as I do,  in helping the student to become a physician.  

Young, smart enthusiastic learners, like all humans, are flawed.  One of the outstanding flaws of almost all medical students is their desire to reassure patients, even if they don't know enough to be able to reassure them.  I have taught medical students since 1977, often using audio and video technology to assist.  Early in the experience almost all medical students falsely reassure a patient or two. "You will be better after the surgery (or chemotherapy)".  "Don't worry about the side effects, you probably won't get any."  "I think this infection won't bother your diabetes."  "You're going to be OK." Etc.

Why are they so compelled to make comments to ill people with disease processes they may not understand? (Some of the students had just completed their first year of med school).  I don't know.  I do tend to tell the students that, if they need to reassure patients, reassure them that the student will review the situation with Dr. S. and we'll be in soon to further examine and clarify the patients situation.

My current best theory about the intense need of the student to reassure is that it fulfills their dream of helping people, at least by giving them hope.  The dream might be so intense that they forgot the part about knowing more medicine before they prematurely reassure.  The students are living part of what I call the "paradox of the medical healer".  Their heart is so committed to be a helper that it's blind to the brain, which is inadequately prepared to be a helper.  The other end of the paradox is that a trained physician may have so much medical brain that the helper in their heart is overwhelmed into silence.

Teaching medical students is one of the ways to balance the "paradox of the medical healer".  Being around the passion in the healing hearts of the students may warm the hearts of their mentors, teachers and patients with hope.  The other part of the paradox is that many patients feel the caring heart of the student and sometimes appreciate the hope it generates more than the medical brain of their personal physician, which they know is going to follow the student part of the ambulatory clinical encounter.

How might the dyad of student-teacher balance out their respective shortcomings?  Somewhere between Malcolm Gladwell (and between Blink and Outliers) and Donald Berwick, MD's speech to Yale U graduating medical students on June 11, 2010 is the potential to imagine the development of physicians from the neophyte who puts on the white coat at The White Coat Ceremony to the master,coat-less, busy family physician.  The white coat is a symbol of separation- from patient to doctor, from all heart to mostly brain, from free spirit to burdened potential healer, from broke-ness to huge debt and potential brokenness, unless heart and brain get to balance, from helpee to helper.  (A full discussion of the white coat is beyond the scope of this post.)

So how can physicians learn about heart from students and students learn about brain from their mentors and teachers, while learning together how to balance the two?
One aspect comes from the Berwick speech:
“…But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an “aching” world, as your Chaplain put it this morning, that has never needed healing more.”

The (experienced-"Outlier") teaching Family Physician is someone who can help with overcoming the potential for the "paradox of the medical healer".  The experienced, teaching Family Physician knows how to role model for the student by taking off the white coat and leaving it off.  Their humanity is easily shared with the patients humanity.  Even while empathizing with the patients plight, they are helping the patient and the system of care to get better connected.  They are relating the natural history of the disease process to the patients life and family processes while reflecting on the patients illness and suffering.  They know that the patient has an illness that may or may not include a "medical" disease process.  Their human to human connection skills already span the gap between big heart and big brain medical learners.  Teaching medical students is one way to hold onto the "heart" part of health care while sharing the much needed clinical brain that the students desire.

As discussed in The Foundations of Primary Care (by Joachim P Sturmberg, MBBS DRACOG MFamMed FRACGP PhD Radcliffe Publishing 2007), illness is "a loss or disturbance of the unconscious taking for granted of one's body...defined by the disruption of embodiment, rather than necessarily a structural change.  ....illness is intimately related to the patients personality and his life experience and understanding the doctor's role as helping patients to come to terms with, i.e., to find personal meaning in, their illness has a profound impact on the way we organize and deliver health care.  Illness is a whole person problem, not a problem of one part."  This perspective is at the heart of the patient-physician relationship in family medicine.  We're already there, and the students can keep us there.

The intensity of this era unfortunately is driving the family physician from practice and the medical students from selecting it as their specialty.  Both the "hearts" and the "brains" are being crushed by the cash registers of the Medical Industrial Complex.  The "paradox of the medical healer" faces a difficult challenge as we head toward the PCMH and the ACO.  Let's make sure the students go with us.  They can reassure us that everything will be OK.

No comments:

Post a Comment