In a recent article extracted from a meeting titled “Physicians Leading/Leading Physicians,” three speakers proposed that the doctor-patient relationship was the key and should be where physicians start to disrupt the healthcare system in a positive way.
“There is something special, even sacred, about taking care of a person who is sick, and I think that as long as we are able to express ourselves in a relatively selfless manner, it makes it difficult to have our arguments assailed.
If we clearly decide to own that patient relationship, and not just in the current day, but for their entire lives, and build it on trust and make that the central theme of what we are all about, then all the noise with Washington ultimately will play out and we’ll be OK.”
It is a privilege that patients allow us at the most intimate, personal times in their lives. And we can harness that energy and we can be sure that the answers are the right ones long term.”
The authors were making a case for optimism about the role of physicians in healthcare reform, but it seems to me the lessons are more important for helping practicing physicians deal with the stresses in the current environment that are leading to burnout and psychic distress. While it is commonplace to assert that the doctor-patient relationship is the key to what matters in medicine, I think a deeper look might show why we seem to have trouble believing it.
My key to thinking deeper about this is an article published by David Brooks in the New York Times titled “When Life Asks for Everything.” Mr. Brooks points to two different conceptions of human development. One he labels “Four Kinds of Happiness.”
“The lowest kind of happiness is material pleasure, having nice food and clothing and a nice house. Then there is achievement, the pleasure we get from earned and recognized success. Third, there is generativity, the pleasure we get from giving back to others. Finally, the highest kind of happiness is moral joy, the glowing satisfaction we get when we have surrendered ourselves to some noble cause or unconditional love.”
The second model is Maslow’s hierarchy, in which the pinnacle of development is “self-actualization, which is experiencing autonomy and living in a way that expresses our authentic self.” Mr. Brooks observes that the first model reflects the view of most religions and moral systems, which view selfishness as the great human problem. Maslow’s system, though, views the chief problem of life as liberating and enlarging the self. While he makes several observations about each of these systems, his critique of Maslow’s theory is summed up by noting:
“…Maslow’s hierarchy of needs has always pointed toward a chilly, unsatisfying vision of self-fulfillment. Most people experience their deepest sense of meaning not when they have placidly met their other needs, but when they come together in a crisis.”
As I have thought about these ideas in the context of medical practice, it seems to be another way of phrasing the same concept is to see medical practice as transactional or relational. Now this dichotomy is artificial as all medical encounters have aspects of both. And by transactional, I do not mean strictly mercantile. As I said in a previous article, no physician is ever likely to be asked how much advice/care can be purchased for $100. What I am trying to get at, though, is to recognize how much of medical practice has been conceived of as a simple transaction—the patient comes and sees the doctor, who does the professional work required, and that is the end of it. A patient needing a cholecystectomy is generally looking only for a transactional relationship with the surgeon—after all it is not something that is ever going to need to be repeated.
Transactional relationships need not apply only to surgeons and others who do procedures, though. I remember a conversation, now more than two decades ago, with a friend who had figured out how to efficiently process his office visits in a way designed to maximize his economic productivity. He was bragging about his efficiency, but I challenged him by pointing out that at some point his practice would become mind-numbing, and he was depriving himself of the opportunity to get to know some of his patients as people. A few years ago, he reminded me of our discussion and noted that now he was older, his kids were grown, and he now valued his long-term patients and spent time with them, even when it was not billable. In other words, he had learned the value of relationships. Primary care physicians have always stressed the primacy and the value of the relational aspects of their work. Knowing the patient, and understanding where the patient is in their course of life can be valuable both for diagnosis and for setting goals of care as the burden of disease mounts. But this sort of service continues to be financially undervalued, and primary care is in short supply in my area.
So, where are we? I believe physicians, as opposed to “providers,” need to recognize and embrace the relational aspects of practice. And I think this is true no matter what specialty is considered. Yes, we are all going to provide “billable services” and we are all going to make a living doing it, but that needs to be only part of the equation. Some years ago, I was talking to a hospital executive about these issues. I noted there have always been doctors who took care of patients and that was how they made a living. And there have always been doctors who made a living and taking care of patients was how they did it. These two groups differed mostly in emphasis, as those who emphasized making a good living had to recognize this also meant taking good care of patients. But now we seemed to have a third group who wanted to make a living, but not take of the patients. Our current fragmented system makes that an actual career path, but one taken only by providers, not physicians.
The paradox, then, is that easing our psychic distress does not mean withdrawing, becoming the proverbial woodcarver in Vermont, but in diving deeper—getting more involved with our patients. Yet that is so counter-intuitive as to be scary, particularly to the young who don’t see many role models out there. The challenge for me, and for others of like mind, is to emphasize that at the end of our careers, it is the relationships and the stories we treasure, not the financial treasures we acquired along the way.
10 December 2017
 Harrison M, Paulus KH, Kaplan GS. Where Physicians and Disruption Should Meet. https://catalyst.nejm.org/videos/physicians-disruption-politics-patient-relationship/ Accessed 11 October 2017.
 Brooks D. When Life Asks For Everything. 29 September 2017. https://www.nytimes.com/2017/09/19/when-life-asks-for-everything.html.
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