“A really good liver” I remember when I was a medical student the excitement of going round the wards with a keen doctor who would take us to feel a “really good spleen” or listen to an “interesting cardiac murmur”. Like my fellow students in our new, pristine white coats, I was very excited. However, something in me rebelled and a little voice said, “This isn’t quite right”. It was not that we did not greet the patient, ask permission to examine and do all that medical etiquette and politeness required. I felt uneasy and could not articulate why.
One day my group was invited by the professor to examine a “really good liver”. We all trotted behind him, got to the patient’s bedside and I recognised her distinctive face immediately. I thought, “This isn’t a liver, she’s a person – my old teacher”. She had taught me in primary school. It is a lesson that remained with me throughout the rest of medical school and my practice of medicine. Patients have to be seen in their entirety and not as fragmented parts. The poem “Technology and Medicine” written by Rafael Campo encapsulates his clinical experience:
The transformation is complete. My eyes
Are microscopes and cathode X-ray tubes
In one, so I can see bacteria,
(…) and even through to bones.
My hands are hypodermic needles, touch
Turned into blood: I need to know your salts
And chemistries, a kind of intimacy
That won’t bear pondering (…) my mouth, for instance,
So small and sharp, a dry computer chip
That never gets to (…) taste or tell
A brief truth like «You’re beautiful», or worse,
«You’re crying just like me; you are alive».
2. General practice: a definition
I trained to do general practice. General practice is not a specialty in the usual sense but General Practitioners (GPs) are often described as the last of the true generalists in medicine. However GPs do specialise in one thing: their patients. They have knowledge of patients, knowledge of disease and the ability to diagnose health. To do their role properly, GPs have to practice medicine in a holistic way and look not just at the physical aspects of health and sickness but also the psychological, social, cultural and – I would add – spiritual dimensions. GPs – like all doctors – have to know how to communicate with their patients.
3. A vignette from practice
Recently I was working in a practice that was new to me.
A woman entered with her husband. They were African and the wife could speak only a little English. I noticed that she had failed to attend hospital four times for an operation. My first reaction was to be annoyed with the patient and her waste of valuable resources. I then realised that I had to listen to this woman and try to understand why she had not gone for her operation. Her husband explained to me that she had not gone because she had not understood the procedure that the gynaecologist wanted to do. No one had given her any explanation – at least an explanation that she could understand. She knew she was getting a hysteroscopy but she had not really understood what the doctors were going to do to her. I then drew out a piece of paper and started to draw a uterus explaining what the procedure entailed. The patient’s face brightened up and she seemed more at ease. I then asked myself if I had done absolutely everything for her – given her the understanding that I would have liked to have in her place. I remembered a website that had leaflets for patients on a variety of medical conditions and procedures. I therefore took the time to go to the website to download and print information on hysteroscopies and on her medical condition. In taking the time to understand the patient, some intuition made me realise that she probably had thought that the gynaecologist wanted to do a hysterectomy. When I voiced this, the patient and her husband nodded in vociferous agreement. I tried to imagine what having a hysterectomy might be for a woman and perhaps especially for this African woman: a perceived loss of identity and womanhood. She and her husband were so relieved that a hysteroscopy was not the same as a hysterectomy. They both left thanking me profusely, deciding to go ahead with the procedure.
4. The “Holistic” consultation
In April 2006, the British Journal of General Practice 1 published the report of a study involving 26 GPs. The study looked at a holistic quality marker called the Consultation Quality Index (CQ1-2). The index is based on patient enablement, continuity of care and consultation length and these were measured in 3,044 consultations. GPs with lower CQI-2 scores valued empathy and longer consultations less than the GPs with higher scores. The GPs whose scores were in the bottom 25% also felt less valued by patients and colleagues while patients showed less confidence in and gained less satisfaction from these doctors.
5. “Entering” the other
Empathy is an important part of communication. Dean Koontz said, «the functions of intellect are insufficient without courage, love, friendship, compassion and empathy». An unknown source says, «Communication by empathy is a talent that few possess».
For me empathy means entering the other person and feeling things as if I were that person.
A patient came to see me in a very distraught state. She was a young single mum and she wished to have an abortion immediately. She had just been to see the gynaecologist and following a scan, she had been told that her baby had a “hole in the brain”. I looked at the patient and looked at my never-ending patient list. Surgery had been very busy that day and I was running late. I tried to quickly weigh up the situation. She was determined to terminate the pregnancy and as I do not refer patients for abortions, she had the right to see another doctor in my place. I also knew her fairly well. She often attended the surgery with her children for minor complaints and seemed to struggle with simply looking after a cold. She always needed a lot of reassurance. How on earth would she be able to cope with a handicapped child? I realised that even though the patient was so determined to have an abortion and would probably end up seeing my colleague, I still had to try to “enter her”. I put to one side the thought of all the patients waiting outside and said to myself that she and her unborn baby in that moment were the most important people. I phoned the gynaecologist who told me that the baby had an encephalocoele but that the patient need not worry because «we will offer her a termination immediately in 2 weeks if it is any bigger in her repeat scan». I asked him how sure he was of the diagnosis. He commented that the doctor who did the scan rarely makes mistakes. They were 99% sure.
I proceeded to explain to the patient her baby’s problem looking for the right words – words said in a language that she could understand. She still wanted to have a termination immediately because she could not live with the suspense over the next two weeks. I told her to go home and give herself time to think about her situation. I also told her to keep in touch with me whatever she decided to do. She came to see me a few days later before she had the repeat scan. She had talked to her boyfriend and they both had decided to go ahead with the pregnancy. He had assured her that he would support her, even if the child were born disabled. At the end of the pregnancy, the patient delivered a perfect little girl without any sign of an encephalocoele.
However, communication is not just made up of words but of pauses, gestures and the unspoken. Once a patient – an old woman who lived alone – came to see me and it was soon obvious that there was not very much wrong with her. The symptoms, which she offered, were so trivial that at the end of the consultation I really could not understand why she had come. Since we had finished she got up to leave. It was only as she was approaching the door that I realised, glancing through her case-notes again, that her birthday coincided with that day’s date. I wished her «happy birthday». She beamed a huge smile and then left. It was only as she smiled that I realised why she had come: she had wanted someone to wish her Happy birthday.
7. The art of medicine
The term “art” has been removed from its RCP definition of medical professionalism. I think it is something we should retrieve. Chauncey D. Leake in 1936 writing in a time when medicine was witnessing increased “science” and specialisation said that «most of the science of medicine may be learned in the four years of medical school, but the rest of a physician’s life may still find him deficient in the art». He goes on to describe this art beautifully when he says: «no musician, not even Beethoven, is a greater artist than the physician who develops a harmony of adjustment from the dissonances of a psychotic personality; (…) no dramatist or actor is a greater artist than the physician who daily plays his role in the everlasting and thrilling drama of the lives and deaths of his patients (…) All good physicians are artists» 2.
I have to admit that I did not find anything particularly earth-shattering in the RCP report. Primary care physicians, at least in the UK, have to learn skills of leadership, can only function in teams and appraisal is now established practice. Other health professionals are probably streets ahead of doctors in this respect and we can learn from them. (slide 12) The report fails to encourage doctors to see themselves as part of an ever smaller world community with the “moral imperative” to address global health issues, it does not address the inconsistencies of medical practice (of 1393 new chemical entities marketed between 1975 and 1999, only 16 were for tropical diseases and tuberculosis 3 – diseases where we can safe life – while instead money is ploughed into “lifestyle” drugs of often dubious value), it does not respond adequately to the ethical issues stemming from sophisticated technology and genetic manipulation not address the dissatisfaction patients feel because our fragmented rationalist approach.
Finally communication is fundamental in the art of medical practice. It is not learnt in a textbook or manual but by putting ourselves in the patient’s shoes. It is an art within an art. Communicating is a two-way thing because not only do I give, but I have to be prepared to receive and learn. The American author and playwright William Saroyan wrote: «Doctors don’t know everything really. They understand matter, not spirit. And you and I live in spirit. [In the Human Comedy] We do not really begin to communicate with patients and with each other unless we communicate with the spirit within».
by MABEL AGHADIUNHO
1. Mercer SW, Howie JGR. A new measure of holistic interpersonal care in primary care consultations. British Journal of General Practice. April 2006; 0960-1643: 262.
2. Leake CD. Pratica Medici Moderni, December, 2936, California and Western Medicine, vol 45, no. 6.
3. Trouiller P et al. Drug development for neglected diseases: a deficient market and a public health policy failure. Lancet 2002 Jun; 359(9324): 2188-94.