The doctor-patient relationship in the twenty-first century

“Therefore, send not to know for whom the bell tolls. It tolls for thee.”

John Donne

I would like to thank the class of 2008 for the opportunity and honor of speaking with you today and also to thank the Arnold P. Gold Foundation for sponsoring this important event. This is what most, if not all, of you have been waiting for. The chance to finally leave the classroom and apply the knowledge you have been accumulating to the care of patients. It is an important milestone in your careers. The responsibilities we bear are enormous but the privilege with which we are entrusted is even greater.

When I first received this invitation, the very first thing that came to my mind is a well-known saying, “La médecine c’est guérir parfois, soulager souvent, consoler toujours” which translated means “to cure sometimes, to relieve often, to comfort always”. This aphorism has been attributed to the famous French surgeon Ambroise Pare but recent scholarship suggests that it had been roaming through medicine for centuries. It emphasizes that while curing is important, albeit inconstant, caring and comforting are always the healer’s objectives. I hope that this sentiment will always guide your interactions with your patients as you continue in your careers.

What is “humanism”? The Oxford English Dictionary has five major definitions of the word humanism. The one which is germane to our field is, “The character or quality of being human; devotion to human interests”. As I thought about humanism in medicine, I was struck by the fact that it was even necessary to discuss humanism and its role or place in the healing arts. Is it not implicit that the practice of medicine is, above all, a human endeavor which brings the physician and patient into a deep and, at times, almost mystical relationship?  A relationship in which, at times, the patient shares some of her deepest concerns and hopes with her physician, trusting that that physician will accept her unconditionally and do his utmost to help heal her be it physically or emotionally. This relationship, of course, flows in both directions. We physicians also get much from this relationship . The essayist Anatole Broyard reflecting on his own experience as a patient, wrote, “Not every patient can be saved, but his illness may be eased by the way the doctor responds to him – and in responding to him the doctor may himself be saved.”

Now to be perfectly honest, there are times in which some patients can be frustrating and exasperating and one may wonder why one has ever agreed to take them on as patients. However, I assure you that, at times, your patients will be frustrated and exasperated by you and will wonder why they ever came to you in the first place. That is the nature of human relationships and, in my opinion, does not detract from them. One must always keep in mind that the role of patient can be very difficult. With more severe illnesses, patients often feel helpless and afraid not to mention the sense of not being in control. It is the responsibility of the physician to help the patient regain some sense of control and to give hope, when appropriate. At the very least, the patient must be made to understand that, regardless of the prognosis, the physician will always be there to alleviate suffering and to offer an understanding ear. In my case, I have cared for many older patients for more than two decades and I can assure you that getting older is not for sissies.

There are many reasons why we physicians might lose our humanistic bearing . Medicine is an arduous profession, one which can be physically and emotionally draining. A century ago, Sir William Osler recognized the effects of clinical practice on its practitioners when he wrote, “In some of us, the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started. Against this benumbing influence, we physicians and nurses, the immediate agents of the Trust, have but one enduring corrective – the practice towards patients of the Golden Rule of Humanity as announced by Confucius : “What you do not like done to yourself, do not do to others.” In modern day practice there seem to be even more numerous external pressures – productivity quotas, time constraints, mountains of paperwork and streams of bureaucratic red tape, to name a few. Nevertheless, when dealing with patients, one must always remember, “but by the Grace of God, there go I”.

So, does being a humanistic physician entail listening attentively and showing genuine concern? Yes, that is part of it but by no means all of it. Does one place the occasional gentle touch or give an understanding look? That too is important. It is also important to realize that as healers, there is nothing that is beneath you when it comes to caring for your patients. If a patient cannot cut his food, do it for him. If she needs to get on a bed pan, help her to do so. If a patient is nauseated and vomiting, hold his forehead while he vomits into an emesis basin. That patient will more likely remember that act of kindness that the fact that you diagnosed his pheochromocytoma. Sir William Osler, one of the two physicians I admire the most (my father is the other) epitomized the humanistic physician. He had been on his way to a ceremony all decked out his academic regalia when he stopped off at the home of a young boy who was dying of diphtheria and who was not eating. Osler, entered the sick room and sat on the bed by the boy. He spoke to the boy while he peeled an orange and told the boy that it would be the most wonderful thing he had eaten. Piece by piece the fed the lad until the boy had eaten the entire orange. Osler, who was one of the most venerated physicians of his time, returned that evening and did the same thing. He then returned every day, bringing with him his academic regalia, which he slipped on outside of the boy’s room, and then fed the boy an orange. Sir Osler did this twice a day for several weeks and the boy eventually recovered.

What stories will each of us be remember for?

Several generations ago, the proper professional demeanor was of unemotional detachment. Thankfully, we have outgrown that stage. More recently, it has become acceptable, and even desirable, to show sympathy, empathy and emotional concern. And that is good. However, I would like to suggest something even more radical. The mystic poet John Donne wrote in his thirteenth meditation – “No man is an island, entire of itself; every man is a piece of the continent, a part of the main. Ifa clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee”.

What I would put to you, therefore, is that we should love our patients. We are, after all, part of the larger human family. What has dawned on me in the last few years is that our patients are, in a very real sense, our aunts and our uncles, our brothers and our sisters. Treat your patients as you would your family. There has been much written and discussed recently about diversity and the importance of acknowledging and celebrating it. I am all for that. However, there is much more that binds us as human beings than makes us different. I have never met anyone who did not wish to feel needed and loved; who did not wish to feel special and part of a greater whole. I would suggest to you that you should respect our diversity but embrace our commonality.