What kind of doctor do I need to be for this patient today?
—MICHAEL BALINT, The Doctor, His Patient and the Illness1
It was a routine Tuesday, and the clinic at the University of Wisconsin in Madison happened to be busy. I was part of a team of nine physicians and twenty-eight other health practitioners, and all combined, we saw about 325 patients a day. We faced time constraints for each visit, and we did our best to keep people from waiting too long. On this particular day, only two hours into the schedule, I was swamped. With a steady stream of patients ahead and multiple tasks still to address for those I’d just seen, the day already had the feel of an avalanche about to give way.
Move efficiently, don’t linger, had become the morning’s mantra. In the first exam room, a woman in her midfifties was waiting to see me about a pain in her shoulder that had been nagging her for two months. Walking down the hall, I began listing for myself the questions I would ask her and mulling the range of tests she might need. Next door, a young man, a new patient to the clinic, was eager to have me look at an itchy, scaly rash that had surfaced on his arms and down his legs. I hoped, for the sake of time, it would be run-of-the-mill eczema that I could treat with a steroid cream. I paused at a computer to enter an electronic prescription for the patient I’d just seen, a shy teenager with a long history of asthma, when the clinic nurse informed me that the person waiting for me in exam room 3 was Martha. I felt my chest tighten.
It wasn’t personal. From the first time I’d treated Martha more than five years earlier, I’d always liked her. She was a good-natured, rosy woman in her early sixties who had come from the same part of the country where I’d grown up, and we often chatted about the changes we’d faced and the regional dishes we’d each missed after moving to the Midwest. She and her family lived in one of the more affluent neighborhoods in town. I had met her husband, who had accompanied her to several appointments, and her son, who was now in graduate school. Martha and I had an easygoing rapport, which was fortunate because she tended to visit the clinic often. She just happened to be one of the more challenging medical cases in my practice.
Martha’s health issues were the type that don’t fit easily into the typical fifteen-minute appointment. For several years, she had been suffering with rheumatoid arthritis, a complex autoimmune disease that occurs when the body’s own immune cells attack the joints. The flare-ups cause swelling, joint disfigurement, and terrible pain. When we treat patients who have rheumatoid arthritis, we rarely rid the body of the disease, but merely knock it into remission by controlling the inflammation. Martha had been on several anti-inflammatory medications, including the steroid prednisone, which helped reduce the swelling, but also came with significant side effects like weight gain. In fact, she had put on so many pounds, her blood glucose was elevated and she now needed to be on diabetes medication. The prednisone had also led to gastritis, an awful stomach irritation, so she was taking an acid-suppressing medication. On top of all that, the condition had severely affected her ability to cope with daily life and resulted in depression. So I put her on the antidepressant Prozac. At her last appointment, we had even added a sleeping aid to her medication regimen because she was having trouble staying asleep through the night. Prednisone, in particular, can trigger insomnia.
This kaleidoscope of complex health problems is not as uncommon as one might think. Many people have medical conditions whose treatment leads to weight gain that then produces a surge of other diagnoses: heart condition, diabetes, back pain, knee injuries, depression, and sleep apnea. Or they have syndromes—chronic pain, lupus, fibromyalgia, or inflammatory bowel disease—with mysterious causes that aren’t fully understood for which we can only address the symptoms. These days, a health issue might not be one isolated illness, but a complex tangle of disorders.
When people have so many diagnoses, treating any one of them is like approaching a tower of stacked grapefruits in the produce aisle: you address one aspect of their condition, but then scramble to stop a cascade of others. Managing each problem as a separate entity results in multiple treatments and the risk of the person having to take a wide array of medications. This dangerous situation, an all-too-common occurrence, is called “polypharmacy.”2
The major concern of polypharmacy is that the medical community has no idea how all of these chemicals interact with one another. Indeed, one drug may even counteract another’s reason for use,3 and the drugs can cancel each other out, as I’ll explain more fully in Chapter 2. But perhaps more importantly, taking multiple medications like this greatly increases the risk of medical error, which has now been predicted to be the third leading cause of death in the United States, behind heart disease and cancer.4 How can caregivers evolve beyond the dangerous “find it, fix it” pharmaceutically dominated medical culture they live in? My primary care colleagues and I believe they can do this by developing insight into patients’ unique lives to see how their conditions are often interrelated and not separate entities that require a “pill for every ill.”
So with all of these issues buzzing around in my mind, I braced myself as I entered the exam room where Martha was waiting.
“Hey, Doc, I see you’re running a little late,” Martha said in her jovial manner.
I greeted her and asked what had prompted today’s appointment. She began to list her latest concerns. They weren’t significantly different from the ones she’d had before, though each seemed to have become more onerous. Then she added a new symptom to the mix. With the pressure of time and the enormous complexity of her interlocking disorders and treatments, my mind reeled into a reactive mode: What’s the new diagnosis? And what new medication does Martha now need? How will it interact with her other meds and create another layer of problems? Was she really going to be any better off after this visit?
I meant to maintain my composure, but she must have seen a shadow of frustration dart across my face. It was hard to conceal that I was feeling angry with myself—and even a little annoyed with her. Here was an individual who needed something from me, but whose medical problems, all interconnected and seemingly snowballing, were becoming insurmountable. I didn’t feel helpful in the least. In fact, I felt that I was failing. Each time she came back to see me, the new solution worsened her status. Was I supposed to send her off with an additional prescription that might present other side effects? On the one hand, I could treat the most recent symptom and deal with the fallout. On the other, I could encourage her to “just live with it,” which would leave her feeling as though she had come to me for no reason at all. My sense of powerlessness was devastating.
One thing was clear to me: The problem was not Martha. Rather, it had to do with the focus I was supposed to give to the individual symptoms instead of the big picture of her health. I was expected to “patch” but not to heal, even though what Martha needed was far more than stop-gap fixes. How could it be, in this day and age, that with all my training and the time I had for the appointment I could provide only piecemeal help? At that moment, I realized I wanted to change the way I engaged with all my patients. If I was going to help Martha and other people like her, I would have to learn to understand their disorders in a new way. In fact, to be effective and offer meaningful help, I had to find a way to get closer to the source of the illnesses.
ON BEING OF SERVICE
In the Descent of Man, which was published twelve years after On the Origin of Species, Charles Darwin had argued that when it comes to human beings, the survival of the kindest is most important—not necessarily the survival of the fittest. He called sympathy the “foundation-stone” of our social instincts.5 This question of how to be a helpful person—and even more importantly, how to be most helpful—has captivated me since childhood. Like most other kids, I first was taught that being helpful meant being kind. Share toys. Give hugs. Be respectful. All good advice. I wouldn’t quibble for a second about the importance of treating other people kindly. As I grew older, however, I began to wonder whether there are more nuances in what we can offer as individuals. Kindness can go a long way—and the world we live in certainly needs plenty of it—but I also hoped the service I could provide wouldn’t be just a fleeting gesture.
I aspired to be caring in a way that could make a difference. For years, I was so gripped by the idea, I began to see the imperative everywhere. “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime,” was a proverb that turned up in middle school on a wisp of paper in a fortune cookie and stayed with me for a good long time.
All of this got me thinking about how one person could be the vector for positive change in another. When I chose to become a family doctor two decades ago, I had soaring ambitions along those lines. I had grown up with great role models. My dad is a doctor. In fact, he’s one of the founders of the field of family medicine that began in 1969. For years, I was awed by him and my mother, who worked as a nurse. What caught my attention, even as a child, was seeing their warm interactions with patients outside the office. People would greet them on the street with a bear hug, expressing emphatic gratitude, and often adding the most recent development in the personal story of their health—the story in which my parents had played a role. I witnessed remarkable tenderness in these moments and an awareness that something important had transpired because of my parents’ assistance. Their involvement had an enduring effect on me. That was what I wanted in a career—the opportunity to offer that magnitude of service, to be honored with the invitation to enter the intimacy of another person’s life.
Sure enough, being a family physician is a job that offers ample opportunity to do good. After residency, I became one of two family doctors in a fourteen-bed hospital in the small town of Driggs, Idaho. I felt awe and euphoria when, in a single day, I delivered a baby, treated a heart attack, placed a cast on a teenager’s broken arm, and then supported someone who was suffering from depression. How amazing—and what a privilege—it was to participate in such important moments in people’s lives. The job put me in contact with patients of every age, from infancy to great-grandparenthood. As they came to see me over the years for regular checkups as well as illnesses, I got to know them for their individual personalities and for their connections in the community, not just for their health problems. I began to build those long-term relationships I had observed in my parents’ careers, and to experience the warmth—really, being of service to others—that is the heart and soul of the job.
But the experience wasn’t without a few bumps. Some people who came into my office left with the correct medication, but no greater health overall. We would have a pleasant interaction, and I would offer the best medical advice at my disposal, but little would change in their lives. That bothered me. The longer I practiced medicine, the more I began to pay attention to my interactions with my patients and to wonder about those situations that seemed less than fruitful. Even though a person might have gotten a solution to an immediate problem, I still wondered: Could I have done more? Had I really made a difference for the man with chronic pain? Had I really gotten through to the woman with abnormally high blood sugar? The day-to-day experience of helping was one thing, but was I really doing the meaningful, enduring kind of good I had hoped to do?
As I became interested in learning about other ways to influence health and healing, I moved on from Driggs. I had heard of a fellowship originated by Andrew Weil, MD, at the University of Arizona on teaching physicians about complementary therapies such as acupuncture and botanicals. At the time, those foundational, health-influencing therapies, as well as nutrition and stress reduction through meditation and spirituality, were considered “alternative” and not mainstream approaches. But Dr. Weil had developed the new field of integrative medicine to stress the importance of incorporating the best of these modalities into our conventional systems of care.
What is integrative medicine? According to the Academic Consortium for Integrative Medicine and Health, it “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare and disciplines to achieve optimal health and healing.”6 Much of the information I had absorbed during my fellowship constellated around how to stimulate self-healing mechanisms within my patients’ bodies. This is part of what I like to think of as the “mystery and awe” of medicine.
I completed the two-year fellowship and then moved my family to Madison to start an integrative medicine program at the University of Wisconsin where I also continued a medical practice. Like the hospital in Driggs, the clinical care here also offers the opportunity for long-term relationships with patients, but I could also use some of my newly learned skills. Many of these came from self-reflective insight that was encouraged during my fellowship training. This helped me understand that there was more to this healing work than simply prescribing drugs, herbs, or a referral for body work. I learned the importance of the therapeutic ceremony and how the actual process of delivering care can dramatically enhance the effectiveness of what is prescribed.
Research now shows how this is possible—that is, how personal interactions can actually have physiological effects on patients. As I will explain more fully in ensuing chapters, the mere presence of others can heighten a person’s response to a treatment. For instance, a team, led by neurophysiologist Luana Colloca at the University of Turin in Italy, compared how people fared after surgery when they received pain medication in two distinct scenarios. For some, a nurse entered the room postsurgery and announced that the patient would be getting a powerful analgesic that would make the pain subside in a few minutes. A clinician then arrived and administered the treatment. For a second group, there was no announcement and no one to inject the drug. The patients received the same dose of medication by way of an IV injection from an automatic infusion machine and weren’t even informed when the infusion was begun.
Dr. Colloca found that patients receiving the drug by machine needed a 50 percent higher dose of painkiller than those who anticipated feeling better and received the drug from the nurse. In addition, one hour after treatment, patients on the drip described their pain as “much higher” than those who were given the drug by human hands.7 The expectancy created (“We are going to give you a pain medication to help you feel more comfortable”) and the actual presence of a person giving the medicine significantly enhanced the effect of the medicine. The lived experience is related to much more than just the intrinsic effect of the analgesic. Recent research has shown that positive expectations regarding pain reduces its severity by 28.4 percent, which is the equivalent of an average-size adult taking 8 mg of morphine.8
After comprehending more about the power of the interactive process, I started to ask myself fresh questions about how I could more effectively influence healing in another. Have I been patient enough? Have I been insightful about my patients’ circumstances? Have I been imaginative about possible solutions? And then, there have been cases like Martha’s that have been so complex, I’ve wondered how a merely interactive process could ever contribute to improving such a challenging medical situation.
ALOOF OR EMPATHIC?
The prevailing wisdom in the medical literature for most of the twentieth century asserted that doctors needed to keep their distance to maintain a position of emotional detachment from their patients. In 1912, Sir William Osler wrote in his famous essay “Aequanimitas” that doctors should neutralize their own emotions. That paradigm has held for decades. It was thought that physicians could “study” a patient’s inner life by attaining cognitive clarity, a state of sustained emotional divestment. In fact, the topic of disengagement appeared prominently in the New England Journal of Medicine and the Journal of the American Medical Association in the 1950s and 1960s where it was affirmed that clinical empathy should be based in “detached reasoning” 9—that is, in order to be most effective in caring for patients, doctors should not get too close to them or connect emotionally to their problems or suffering. In addition, the idea has long held that this so-called objectivity would act as a personal shield. Doctors who were emotionally distant could protect themselves from burning out.
As a result, medical schools taught students how to take a detailed history but didn’t always teach them how to connect with patients. That’s why, for generations, there’s been great tolerance on the medical side for clinicians who are brusque and distant.
This belief has been changing in recent years. Increasing numbers of medical schools are now teaching compassionate care. In particular, they want doctors to learn how to be more connected healers. Having compassion for others doesn’t necessarily mean becoming a mess of raw nerves, nor does it entail losing the objectivity to make sound and well-reasoned recommendations. The essence of the compassionate encounter is being able to listen deeply in order to say, “I understand your needs because I see and feel where you’re coming from.” With compassion, in fact, caregivers can better understand how others interpret their own “health” and how illness affects them. They can better grasp the sources of meaning and purpose in patients’ lives.
CAN COMPASSION HELP PEOPLE HEAL?
I believe the answer to this question is yes . . . and that health may ultimately lie in the quality of the compassionate connection that two people create. When individuals perceive a person as caring about them, they may be more willing to open up and express their inner secrets. They may be more available to listen to advice and make changes in their lives.
When we review approaches used by all types of healers throughout history, whether they were doctors or shamans, one consistent pattern stands out. No matter the technologies or medicines available, the healing visit or therapeutic ritual itself has always been critical in an individual’s care. The interaction involves elements of hope, trust, wisdom, caring, gratitude, and often, mutual respect. We humans are capable of making each other feel better, even if we have little to offer except reassurance, or sympathy, or merely hand-holding. The surprising thing is that—even before offering any medications or therapies at all—we’re capable of improving each other’s health.
Look back through medical writing in any era and you’ll find evidence of the vital power that humans have—the power of connection. Even in the first-century AD, Hippocrates, known as the father of modern medicine, noted, “For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” Nearly two thousand years later in the late 1800s, the esteemed physician and teacher Sir William Osler, laying the groundwork for twentieth-century medical care, described the fundamentally healthful role of the doctor’s bedside manner. Medicine, he wrote, “is an art based on a science.”10 It’s that art, he continued, that doctors should cultivate just as much as their stores of medical knowledge.
In 2011, the game show Jeopardy pitted their two all-time greatest money winners against IBM’s Dr. Watson, a supercomputer that listened to the question and responded just like a human. The contest wasn’t even close. Dr. Watson annihilated the two human geniuses. Wellpoint Health Services has now contracted with IBM to place Dr. Watson in many of its outpatient clinic settings. The computer, once as big as a small car, is now the size of a pizza box and is twelve times faster. In the future, I suspect that physicians will no longer be required to remember the various causes of a symptom or abnormal blood test results because they will have these supercomputers to do it for them. But these machines have limitations. How do you program them with the art of connecting?
The funny thing is that even though wise people over the ages have written about this fundamental aspect of healing, we tend to ignore it. Our society doesn’t put much stake in the power of the human connection. At least, we don’t concertedly and rigorously incorporate connectedness into medical care. Instead, we tend to focus our healing hopes elsewhere. Every day, the newspapers trumpet a new device on the market, or a new drug that appears to work better than any previous concoction. We have great interest in technologies that can visualize the interior of the body, like MRIs that reconstruct organs in three dimensions and functional MRI scans that show how areas of the brain light up in real time. We’ve become a society thirsty for these developments.
Without a doubt, technology has afforded us excellent diagnostic capabilities and treatments. It has given us great appreciation for the complexity of the disease process. Thanks to molecular biology and genetic studies, we now think of various cancers as distinct diseases, each with its own signature and progression. In recent years, we’ve become more aware that one-size-fits-all treatments are no longer the standard of care, and that medications may need to be fine-tuned for each individual’s genome. We know, for example, that people of different races, ages, and genders metabolize drugs differently, and we’re even moving toward a time when we can routinely test a person’s genome to guide the most effective prescription and cancer treatment, a process referred to as “personalized medicine.”
All of these developments are important, and I’m not downplaying their worth. I’m grateful that my patients can benefit from them. But at the same time, given what we know about our own internal powers of healing, our society can do much more than simply provide an ever-expanding array of technologies and drugs. We can utilize the powers we have, and that means we can engage the connection as part of treatment and care.
It’s not that people have forgotten about the human connection. It’s just that when they’re ill, they fail to consider it as part of their healing tool kit. Most, even when they have a choice, don’t seek connectedness as a central component of their treatment. They’ll pick high-ranking hospitals and clinics with great reputations (because great reputations are capable of instilling hope). Yet I’m always amazed when I hear patients describe how they’re willing to endure doctors with terrible personal skills or clinics where they feel uncomfortable. I’ve heard people say, “So-and-so surgeon is the best. I want the best doctors in the field. I don’t need them to be nice to me.” But research reveals, that yes indeed, patients do need their doctors to be nice.11 And they need them to be engaged, because a physician’s compassion helps reduce complications.
WHAT WE SAY AND HOW WE SAY IT
What do I mean by “human connection?” It’s fair to say that the definition is bound to vary. In some cases, a connection may simply mean more effective conversations. Studies have looked at that connection—when doctors and patients spend more time talking—and found that it can alter medical care. When patients and doctors have the opportunity to connect with each other, the treatment plan tends to require fewer high-tech diagnostic tests and interventions. One study of one hundred primary care practitioners in Rochester, New York, for instance, found that when doctors took the time to initiate a conversation, establish a positive relationship, and spent longer than usual with each patient, all of the expensive, intrusive aspects of care—from tests to repeat office visits to hospital treatments—were needed less frequently.12 When an active therapeutic process was initiated, there was less need for passive treatments or diagnostic tests.
I experienced this on a personal level while conducting consults during my integrative medicine fellowship at the University of Arizona. I would first meet with patients to listen to and document their health histories. I asked them to come back two weeks later, after I’d had a chance to research their case so that I could give them a health plan with therapies based on what I’d discovered. That meant I didn’t make any therapeutic recommendations until the second visit. Astonishingly, most of the time the patients would return with stories of how good they felt . . . even before I’d prescribed anything!
A more intense level of connection occurs when doctors show higher degrees of caring. Several studies are now looking to quantify the effects of empathy on patient outcomes. Researchers at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, for instance, surveyed doctors about their own ability to be empathetic.13 These responses were grouped into categories of high, medium, and low empathy scores. The researchers analyzed whether any of the groups were better able to reach their patients with diabetes. Specifically, they wanted to know whether patients of doctors with different degrees of empathy impacted the control their patients had over blood sugar by measuring tests known as the hemoglobin A1c score as well as LDL cholesterol scores, which can be risk factors for heart disease if not properly managed.
The study revealed that people who were seeing doctors with the highest empathy scores were most likely to have good control of their A1c levels because they were more likely to monitor their blood, take medication appropriately, and improve diet and exercise. Those seeing doctors with the lowest empathy scores fared much worse in managing their disease. When it came to the control of cholesterol, which involves making significant lifestyle changes, the differences between the two groups were even more pronounced. Taking into account other statistics—patients’ and doctors’ ages and genders, as well as socioeconomic factors like health insurance—the researchers concluded that physician empathy played a very significant role in how motivated patients were and how adept they became in managing their own health. Knowing that someone cares helps people help themselves.
LESSONS FROM TREATING THE COMMON COLD
Because I found all of this research compelling, I put the connection to the test in my own clinic at the University of Wisconsin. My colleague and friend Bruce Barrett, a family medicine physician, gifted researcher, and human rights activist, was awarded a large grant to explore the best possible treatment for the common cold. Typical colds are caused by viruses, and even with all of our modern pharmaceuticals, we haven’t yet found a highly effective cure. Barrett’s study compared a range of treatment approaches, including the herbal remedy echinacea, which was compared to a placebo.14
I was particularly interested in whether the quality of interfaces between clinicians and patients could affect recovery, and I took the lead on a related study that compared the results of different types of physician-patient interactions during office visits. I wanted to explore whether various levels of engagement during a doctor’s appointment could alter a cold-sufferer’s rate of recovery. To do so, we enrolled 350 patients over the age of twelve with common colds. We found those people by putting out a questionnaire and asking them, quite simply, whether they thought they had a cold. They had to be suffering from the usual symptoms: a runny nose, stuffiness, sneezing, or a sore throat that had started within the previous forty-eight hours.
Then we randomly selected patients to receive one of three types of office visits. A sealed envelope designating what kind of interaction the clinician should conduct was inserted in the patient’s chart. In the “no visit” group, the patient did not see medical personnel at all. If the envelope designated that the patient was to have a “standard visit,” the doctor or nurse practitioner would carry out a formal, impersonal, if slightly unfriendly, evaluation. But some envelopes would assign a patient to receive an “enhanced visit.” In this case, the clinician would embark on engaging the patient in a warm, personal, and highly interactive way.
In fact, we trained our participants with the help of an acting coach who taught several easily reproduced techniques. In the case of the standard visit, clinicians were to have a cool, businesslike, standoffish demeanor and to engage in minimal personal interactions. The coach even suggested that they think of the word “disconnect” before entering the exam room. With the enhanced visit, however, they were trained to think of the word “connection” and aim to establish a bond with the patient during the appointment.
In addition, during the enhanced visit, the clinician would take the time to provide five key elements. For one, the patient would receive a positive prognosis—in other words, be reassured that she would get better soon. Second, the clinician would show empathy and compassion; he fully understood how badly she was feeling. Third, the clinician would give the patient a sense of empowerment over the illness, putting her in control of her own recovery. Fourth, the clinician would make a personal connection with the patient. During the exchange, he would acknowledge that the patient is an individual with a unique history, life circumstances, and worldview, not simply a “case” to deal with or a collection of symptoms to address. Last, the clinician would provide education about the cold and what patients could do therapeutically to recover faster if they chose to. We labeled these steps PEECE, an acronym for positive prognosis, empathy, empowerment, connection, and education.15
The clinicians didn’t know what type of visit would take place until they opened the envelope just before entering the exam room where the patient was waiting. In the computer-selected, randomized shuffle of names, I sometimes opened standard and other times enhanced-visit envelopes and had to then proceed as directed. Personally, as you’ll see in Chapter 3, I found it excruciating to conduct an aloof, formal exam, without smiling or involving the patient at all.16
After the office visits, the patients filled out a questionnaire about their appointment. They were asked, on a scale of 1–5, what they thought of various elements of the clinician’s behavior and how the behavior made them feel. Did the clinician put them at ease? Did the clinician allow them to tell their own story? Did they feel that the clinician really listened? Was the clinician interested in them as a whole person? Did the clinician have a positive attitude? How well did the clinician understand their concerns, show care and compassion, and explain the illness clearly? And finally, did the clinician help them take control and create a health-based plan of action? A “perfect” encounter resulted in a score of 50.
In the study, 84 of the 350 enrollees gave their clinicians perfect scores. Most of those giving the perfect assessment had received the enhanced visit (although some with a standard visit gave a perfect score, too). But the real measure was to determine whether enhanced visits affected patients’ recovery. So, in addition to the survey, our researchers also took biological samples from the participants. With a nasal swab, they were able to measure levels of nasal neutrophils (a white blood cell that fights infection) and an inflammatory cytokine, the protein interleukin 8, which surges as part of the disease-fighting process at the beginning of a viral respiratory infection and then ebbs during the following days to weeks. The presence of neutrophils and IL-8 correlate well with symptoms and can be reliably measured to determine how strenuously the body is fighting the cold.
Following the appointments, surveys, and sample taking, patients went home. During the next two weeks, our researchers called them daily to ask, “Do you think you still have a cold?” At follow-up visits, approximately forty-eight hours after the initial appointment, our researchers remeasured the patients’ IL-8 and nasal neutrophil levels.
What we discovered was quite impressive. When we correlated the survey results with the patients’ recovery rates, we found that the people who experienced the enhanced visit were the ones whose colds resolved most quickly. In fact, they recovered more than a day sooner than those who had had standard visits. But there was a fascinating finding within those results: The speedier recovery time was strongly associated with those who had rated their enhanced visit a perfect score of 50. There were a scant few who underwent a standard visit, gave the doctor a perfect score, and got well sooner, too. But the most impressive trend was that the first group not only had shorter and less severe colds but their IL-8 and neutrophil measures rose faster to attack the cold virus. The molecular change suggested their bodies were working harder to fight the infection.17
These results provide another peek into how human interactions may have a distinct and measurable physiological effect on the body. Moreover, that effect may be profound enough to kick a person’s own disease-fighting mechanisms into high gear. Making a connection may not bring about a cure, but it may prompt better, faster recovery. This is what I mean when I say that a connection can stimulate self-healing mechanisms within a patient’s body.
However, the association of the perfect score was of utmost importance. We found that people who experienced an enhanced visit, but gave the clinician a less-than-perfect score, showed little improvement in their recovery time. This provided a fascinating piece of information. We postulated that a perfect score resulted when a “connection” occurred between clinician and patient during the office visit. That connection—something more than “kindness” or “good bedside manner”—may be the necessary condition to really impact another person. In other words, the connection is not merely experiencing someone being nice, but an “on or off” phenomenon. Patients either feel that a person really hears them and is really responding to them or they don’t. When they do, they can gain the emotional and physiological benefits of that interaction.
As a side note, the patients who saw no clinician at all recovered slightly faster than those who underwent a standard visit and rated the doctor low in empathy. This finding affected so small a segment of the participants that it was not deemed of statistical significance. But the tiny quirk in our data made us wonder whether people may be better off staying home with their dogs than seeing a grumpy doctor who doesn’t make the effort to establish a connection!
Taken together, all of these studies suggest the potential power of the mind in the course of recovery. This is not to say that caregivers can put the burden on people who are sick to gain mental control over their bodies or even that they can always hope their interactions will have the effect they want. Sadly, the mind and body don’t always work that way. However, the studies underscore what we’ve long known. Caregivers, whether professionals or family members, have another approach available to them when serving others. The more they understand the function the mind plays in recovery, the more they can focus on it as a routine element of care. As connected caregivers, they can play as important a role as medications. Indeed, the concerted engagement with another person can provide the first, essential nudge toward healing.
As evidenced in the pages of this book, when caregivers apply a few specific strategies, they can make meaningful connections with others. In these connections, they offer the opportunity for people to feel they are being heard completely, and they create space to feel respected and understood. They affirm that the others’ perspective is meaningful, even when it differs from their own. In building trust in that interaction, they can encourage the people they’re caring for to bring the most useful information to the conversation, which helps everyone glimpse the big picture. They can then offer their own skills in service of people in need.
LISTENING HELPS CREATE THE CONNECTION
In my circumstance with my complex patient Martha, aware of my frustration and disgusted by my own sense of futility, I took a deep, steadying breath that helped me recall the power of connection and an interactive exchange. I thought about Martha’s out-of-control symptoms, how she was navigating one after the next, and the various side effects of the drugs that were supposed to be helping her. The next thought came with utmost clarity. I would not be as helpful to her if I revealed my frustration. Nor would I be effective if I continued on the same course. It occurred to me that perhaps I wasn’t the one who should determine which solutions she most needed. She had come to me for help and to give her some answers, but in actuality she would know best what kind of help would feel like a “success” to her.
At that moment, what I had learned from my research on the cold seemed particularly relevant. How could I use all the resources at my disposal—not just medical information, but my presence—to be of help to this person? I could recognize the limits of what I could do for Martha, but I could also appreciate how to be of service most effectively. My best approach wouldn’t be to provide answers, but to connect with her in such a way that we would both gain insight into her health. As a clinician, I needed to hear and understand how she perceived her illness and what she believed she could do to change its course. Importantly, in engaging in a compassionate conversation, I could help her feel in control.
Instead of telling her what I saw in her symptoms or analyzing the latest one, I decided to pose a question. “Martha,” I asked, “rheumatoid arthritis has been so hard for you for so long, and it has had so many different and difficult effects. What do you feel is at the bottom of all this?”
To my great surprise, the question opened up a conversation. She told me about how hard her condition had been on her family, and how her inactivity had impinged upon their lives. “I hate to disappoint my son and my husband,” she said, “but I don’t think they fully understand my constant pain.” Then, her eyes welled as she told me about a part of her history I’d never known. Several decades earlier, long before she’d had any symptoms, she had gone through a time of terrible financial distress. In order to support her family, she had briefly prostituted herself. For years, she’d been harboring feelings of shame and remorse about this regrettable period in her life and had told no one. As she cried, I listened. It was a profound moment for me, taking in her emotional release. Her tears provided an insight into the great well of feelings she connected to her sense of being ill. In the conversation, she put words to her desire to get better and also to the negative emotions she felt were hindering that goal. She also linked her disease and its effects on her daily activities to her view of her family that she loved deeply and that gave purpose to her life.
Our conversation didn’t present a cure, but it certainly provided a major shift in the course of Martha’s treatment. It gave her an opportunity to share various elements of her experience that she was holding inside as “unhealthy.” Her disease might have had specific physiological components, but one’s emotional state matters, too. In the conversation that evolved between us, she was the one who described the illness, its effects, and its impact on her relationships. I listened, and an important change took place. Suddenly, we had a new framework to discuss her very difficult situation. And we had fresh strategies regarding what she could do to address it. It was a beautiful moment.
Though the rheumatoid arthritis didn’t disappear, Martha’s overall condition improved considerably following that appointment. As part of her medical treatment, we discussed the merits of her seeking help from a therapist to deal with the unresolved feelings about her past, and she did. She continued to see me for medical treatment of her condition, but over time, her symptoms ceased spiraling out of control, and we were able to decrease several of the medications she was taking. Our connection grew, and we both gained insight about the complexity of emotions, life events, and chronic disease.
For me, the experience with Martha underscored the observation made nearly a century ago by British psychiatrist Henry Maudsley as he linked a person’s emotional state to their health: “The sorrow that hath no vent in tears, may make other organs weep.” When caregivers help others, particularly those who are suffering, they have more resources at their disposal if they consider a patient’s well-being. Martha’s situation also showed me that even one brief conversation can have significant results, and that there are ways to have that interaction that can be used strategically to enhance outcomes. Compassionate listening changed the dynamic between me and Martha and set her on a course that not only validated her experiences but also allowed her to design the next steps in her recovery. The conversation may even have inspired her to have hope, which can be a critical boost, especially when problems have persisted for a long time.
The dialogue also changed my perspective of myself as a person who serves others. In place of frustration, it brought about calmness—and also fulfillment. The positive emotions I’d cherished about my career returned. I felt less like I’d done a patch job and more like I’d offered meaningful help, the kind of assistance that could carry Martha into her future. Our interaction recharged my sense of purpose and gave me clarity about my own potential. Although I had imposed myself and my worldview less on her situation, I had managed to achieve more.
But even more surprising was the sense of uplift that stirred inside me. The brief connection that Martha and I shared was invigorating. I had more focus and better energy to give to the rest of my day. When I went home that night, I felt that something meaningful had transpired, and I was honored to have been a part of it.
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Although most of the research in this book is based upon investigations within the medical community, it is applicable to everyone committed to making a connection happen between two people, whether doctor/patient, husband/wife, parent/child, teacher/student, boss/employee, or anyone in a relationship in which one person is charged with supporting another. I have no doubt that people can do their best work—in fact be of greatest service—when they focus on the steps of connectedness. The process involves understanding themselves first and being intentional in their presence with others. Making the connection takes practice, but the rewards are palpable. Not only does it foster good health and healing in others, but practitioners of this modality can also recharge their own stores of energy and infuse their experience with a sense of joy.