The secret of the care of the patient is in caring for the patient.
FRANCIS W. PEABODY, MD
WE’VE PROBABLY all had brief interactions, sometimes with strangers, that leave us feeling better than we felt a few minutes earlier. We may remember those moments as a “breath of fresh air.” Physician and author Rachel Naomi Remen, who has written and talked about living with Crohn’s disease, describes just such an encounter with a nurse that may have saved her life. It was a particularly dark period for her, in the 1960s, when as a young physician in her late 20s she had major surgery at the hospital where she also worked. The surgery involved removal of a large section of her intestine and placement of an ostomy bag. At the time it was considered high risk and experimental. During the long recovery period, colleagues and friends came by to cheer her up. Meanwhile, she was descending into a deep depression, unable to imagine her life as a young woman with a bag containing fecal material extruding from her abdomen. She began secretly hoarding the sedatives placed at her bedside each evening, with plans to take them all at once after she left the hospital to end her life. She’d decided that she didn’t want to do it while she was still there, as she thought it would humiliate the doctors and nurses caring for her.
A chance visit by an ostomy nurse, however, changed everything. Up to that moment, Remen had grown accustomed to being treated in a way that made her feel like a medical specimen. Staff were courteous, but their behaviors betrayed squeamishness. They came to change her ostomy bag extensively gowned. They seemed efficient and courteous, but distant. The nurse who came in this time was different. It was a weekend evening, and she was dressed fashionably, on her way out to a social event. Remen wasn’t in her usual hospital garb either, as she was wearing a colorful outfit her friends had gotten to lift her spirits. This was a setup for a demoralizing encounter: her caretaker living in a world of normalcy and fun, while she, all alone and stuck in the hospital, could only dress the part. But the nurse didn’t see things that way. She conversed as one young woman to another, chatting unselfconsciously about their clothing, things to do in town and so forth, as might two friends chatting at a café. Remen almost forgot her situation.
She also noticed that while the nurse was meticulous at washing her hands so as to avoid infecting the healing wound, she didn’t bother putting on protective garb. In reality, there was no need to do so, as Remen wasn’t infectious. The others may have been acting out of fear, not of infection but of physical contact. This nurse, in contrast, was simply providing a helping hand while having a pleasant time. She was both warmly informal and highly professional. Remen said she never saw that nurse again, but the 15 minutes together literally saved her life. As the woman left, Remen was able for the first time since her surgery to see a place for herself in the world. Someone had regarded the ostomy as inconsequential, simply a practical matter rather than what defines a person. Hope returned and the desire to die receded.
When we are feeling insecure and unsure of ourselves, we are particularly sensitive to how others regard us. It wasn’t the ostomy that had Remen so depressed. It was how people responded to her in her new state. It took just one person who related to her as normal to change everything. Not objectifying her patient also enabled the nurse to enjoy a human interaction. She related to Remen rather than to Remen’s wound. She saw a young woman like herself, so that’s how she related to her. She wasn’t caught up in the fear and “otherness” that infected the rest of the team. As a result, she got to be herself.
Healing interactions are mutually nourishing, because they are based on real human connection. They occur not only in hospitals and clinics but at work, at the gym, or on a bus. A woman I worked with got stuck in an elevator with someone more senior in the organization who tended to be aloof and reserved. This individual, however, suffering from claustrophobia and needing reassurance, let his guard down. Unexpectedly, it was just two people supporting each other in a situation where their status outside the elevator no longer mattered. They were literally and figuratively on the same level. They maintained a friendly rapport after that experience.
Frightening or isolating situations create a heightened need for emotional support, which opens individuals to meaningful human interaction, including those who are typically guarded. Even if temporarily, they also level the playing field. It’s said that there is no racism on the battlefield. When your life is on the line, all you care about is that your fellow soldiers have your back, not the color of their skin. The conditions of life in combat obliterate social constructs that stratify people under normal circumstances.
In the medical encounter, the physician is generally the impediment to such meaningful interaction, which I’ve referred to as engagement. Patients are typically ready or even hungry to engage. They are the ones feeling trapped, on a battlefield of sorts, or simply in need of human connection at a time when they feel vulnerable. Meanwhile, their doctor is having just another busy day at work. The usual justification for not engaging is that there isn’t enough time. But the question is whether they would interact differently if they had all the time in the world. And, more fundamentally, is an openness to fully engage even time-dependent? Or, rather, is it simply a way of relating to people?
An openness to engage is a show of respect. It means you consider the person worthy of your full attention. You are curious about what they have to say because you want to understand where they’re coming from. You presume that however puzzling their behavior may seem, they have their reasons. You regard them as an equal at a fundamental level, neither expecting that you know what’s right for them, nor that you should do whatever they want.
According them your full attention, however, is not the same as according them unlimited attention. Positive engagement must be circumscribed by boundaries. Boundaries demarcate who we are both in the literal sense (that is, our skin) and in terms of our values, preferences, and obligations. Just as physicians should respect patients’ boundaries, they should maintain their own. For doctors, staying on schedule so as not to keep other patients waiting is an obligation. If you’re going to run over the allotted time with a patient, it should be because you have consciously decided it’s the right thing to do, under the circumstances, not because the patient “won’t let you go.” I’ve found that physicians are often uncomfortable telling patients it’s time to end visits, so that they frequently run over. Such behavior reflects a lack of boundary clarity.
One problem with lacking boundary clarity is that physicians are reluctant to engage in the first place because they fear that if they “open Pandora’s box” they won’t be able to close it. When I think a patient may need more time than I have, I’ll mention at the start of the visit that “Unfortunately, the bean counters only gave you twenty minutes of my time today, but if it’s helpful to you, we can schedule another visit or make other arrangements to talk further if we run out of time.” I regard such fair notice as a courtesy to the patient so they can prioritize, and a way to keep myself on track. It also sends a message not to take my ending the visit personally. The point is that there are straightforward logistical workarounds to the common reasons physicians give for not engaging with their patients, including that they don’t have time.
One indicator that a physician is engaging is that they “contextualize care.” As described in the introduction, a plan of care is contextualized when it’s adapted to a patient’s individual needs and circumstances. If you’re engaged, you won’t ignore a comment like, “Boy, it’s been tough since I lost my job” in a patient who may have stopped taking a medication as evidenced by a flare-up of their asthma symptoms. Instead, you’ll ask what they mean. If they tell you that they can’t afford the costly brand-name medication they’re taking, you’ll switch them to a less costly generic. In contrast, ignoring such a comment and simply adding more medication reflects inattention to context. It’s what happens when physicians don’t engage. As a result, one of the practical benefits of engaging with patients is that it enables better care. Physicians become curious about what is going on with the person in front of them. If a patient with previously well-controlled diabetes has a high glycosylated hemoglobin, they are bound to ask, “Ms. Jones, what happened?” rather than lecture her or simply add more medicine.
One of the most striking findings in our research on contextualization of care, as noted earlier, is that it doesn’t lengthen visits. Physicians who take the time to figure out why a patient isn’t doing well save an equal amount of time during the encounter avoiding pointless discussions about adding new therapies and treatments that are ineffectual. Hence, the reasons physicians don’t engage are intrinsic to them, not to the constraints of the medical encounter. Either they don’t know how to engage, or they don’t want to, or some of both. Engaging with patients isn’t going to happen if it’s perceived as additional effort and work—if it’s seen as yet “one more thing I’m supposed to do during a busy, draining day” rather than a refreshing way of relating to people.
I think the notion that interacting with patients is a task, rather than a way of being, is inadvertently reinforced when doctor-patient communication is taught in medical schools. Typically, in the first and second years, there is a “doctoring” course that teaches communication with patients, along with how to conduct a history and physical exam. There are a variety of instructional techniques, including small group discussions, interviews with simulated patients, observing faculty with real patients, role-playing, and videotaping. The classes or seminars generally share in common that they teach communication as a set of skills, often involving steps to carry out during a medical encounter. Trainees are taught to “build rapport,” “demonstrate empathy,” “engage in active listening,” “project calmness,” and so forth. Many communications skills curricula in medical school consist of tasks such as “opening the discussion” or “understanding the patient’s perspective.” Students are given specific directives, such as “allow the patient to complete his or her opening statement,” and “be aware that ideas, feelings and values of the patient and doctor influence the relationship.” You’ll find many such directives in online syllabi and instructional publications.
The whole approach reminds me of learning to paint by numbers. I recall a communication class during my second year of medical school in which it was my turn to interview a standardized patient while the teacher graded me as my classmates sat around and watched. I tried to follow explicit instructions about when to lean forward, where to sit, and when to make eye contact. I had trouble keeping track of these tasks and lost quite a few points. It’s no wonder that students’ communication skills deteriorate as they progress through their training. Rather than be encouraged, whatever intuition they may have about how to relate to people is overridden instead by an approach that is formulaic.
I don’t think that is the intent of those who design and teach communication classes. Rather, I believe it is to provide tools and strategies for enhancing the abilities that students bring with them. The classes are also attempting to address a legitimate need, particularly when preparing students for high-stakes conversations about difficult topics such as serious illness and death. While teaching helpful tips, however, these classes are ignoring the elephant in the room: namely, fear. On the one hand, in a capricious world where illness and misfortune can strike at any time, we all need each other. On the other, in the face of suffering, we are prone to retreat out of a sense of our own vulnerability. Falling back on a scripted set of tactics, beginning with “building rapport,” is better than fleeing in the face of suffering, but it falls far short of what the situation requires. It is a form of hiding.
What is the difference between “building rapport” and attempting to engage? Superficially they may seem similar, but the differences are profound. Engaging is a personal expression of caring. “Building rapport” is a labor. I recall watching my attending physician on the oncology service attempt in vain to build rapport with a desperately unhappy woman whose husband had left her after she was diagnosed with cancer and hospitalized for a bone marrow transplant. She wanted to go home and die. The attending said, speaking in a soft voice, that he understood how bad she must feel and that he hoped she would consider the implications of leaving. He also said he’d like her to meet with a psychologist. She didn’t stay. Something about his approach wasn’t effective.
The incident came back to mind years later—along with an opportunity to think about a more effective approach—when I came across a similar case reported by the physician and philosopher Jodi Halpern in her book From Detached Concern to Empathy: Humanizing Medical Practice, about a 56-year-old woman with diabetes who had developed complications of renal failure, and peripheral vascular disease requiring bilateral above-the-knee amputations. The patient, whom Halpern refers to as “Ms. G,” declined life-sustaining hemodialysis when her husband left her for another woman. Halpern recalls that, as she approached the patient’s room in the hope of talking her out of it, friends standing outside said, “Ask her about her husband, that creep.” When she met with Ms. G, she attempted to build rapport, beginning indirectly with, “Is there anything besides your body that is hurting you?” Ms. G replied, “My husband doesn’t love me anymore. He told me that he’s in love with someone else. He moved in with her while I was in the hospital. He said that with my amputations and other medical problems, he could never be attracted to me.” Relating what had happened to her heightened the women’s pain, which she suddenly directed at Halpern in rage, crying out, “Why the hell did you ask me to talk about this? . . . Don’t ask me any more questions! Get out of here!” Halpern relates how, at a loss, she exited the woman’s room and discussed the situation with several male supervising physicians who concluded that since the woman was mentally competent, they must respect her feelings. She was sedated and died shortly thereafter. For years Dr. Halpern says she has revisited this case, speaking about it and considering whether a different interaction could have had a better outcome.
What might a highly personal, heartfelt response have looked like at the point where Ms. G got angry and demanded her doctor leave? When I asked Simon, he was visibly upset that a woman would let a man run roughshod over her with such dire consequences, and replied, “I’d say: ‘I’ll leave, if you insist. But before I do, there’s something I need to say, and even though it may sound harsh to you, if I understand you correctly, it’s something you need to hear. I hear you saying that you want to die so that asshole who once professed to you his undying love and commitment can walk off with everything you own and give it to that women he’s just moved in with! No! What you need is to get the nastiest divorce lawyer in town who’ll take him for all he’s worth for abandoning this poor, disabled woman—and I’ll help you find that person! Don’t reward the sonofabitch! Make him pay! And see how long his new girlfriend wants him around!’ ” Simon and I proposed this response in our essay “From Empathy to Caring: Defining the Ideal Approach to a Healing Relationship.”
Such an approach to a patient’s rage is unconventional. I hesitated to share it because it could be misunderstood as sanctioning aggressive and vulgar language with patients. But it exemplifies where rapport building and an engaged response diverge. It goes beyond caring for a patient to caring about them. Simon’s objective in expressing his feelings is to convert the patient’s grief and despair into anger, to mobilize and energize her to defend her dignity rather than surrender to an unfortunate situation. What distinguishes this as a professional response, despite its crudeness, is that the anger is directed at her passively allowing herself to be victimized, rather than at her husband. Simon’s intentional use of offensively crude, vulgar language to convey his anger and to exhort a course of action is a caring response, based on a calculated assessment of the situation: That bold actions are needed since the patient’s emotional situation is extremely dire and will soon lead to her death without such an intervention; that she is clearly capable of rage; and that she is not lacking for support in this cause, given that friends are advocating for her. That willingness to step outside of professional norms when it might save a life is a hallmark of engagement and exemplifies caring.
Remen’s and Simon’s examples illustrate radically different ways of relating, each suited to their situation, and reflect the personalities of the individuals and the exigencies of the moment. What they share in common is that they are coming from a person, not a persona.
Engaging with others is the shortest path to caring about them. When you care about someone, you become personally invested in their well-being. I noticed that happening to me as a junior resident when I met a man my age, in his late 20s, on the inpatient service for a flare-up of his sickle cell disease. I learned that Arthur had been admitted dozens of times with sickle cell pain crises, that he would “demand” specific narcotics, then leave against medical advice (AMA), and not follow up at his outpatient appointments. Many of his hospitalizations were serious enough that he required blood transfusions. As a result he developed hemochromatosis—iron overload—which damaged his organs, including his liver. He was advised to start deferoxamine intravenous therapy, a medication that helps remove the iron, but hadn’t followed up with the referrals to hematology. Arthur was considered the worst kind of patient: demanding, unreliable, belligerent, and manipulative. I was warned that he was “drug seeking” and that I should “be on my guard.”
It’s odd, when you think about it, that doctors are frightened by patients. They feared that this slight 26-year-old with a profoundly disabling disease, who’d never finished high school, would push them around. And in a manner Arthur did so, at a small cost to their egos and at a huge cost to himself. One could say he was “messing with them.” In an excruciatingly painful world in which he spent much of his time in the hospital with little or no say about what he ate or how he spent his day, keeping his doctors off-balance might have given him some small sense of control, however dysfunctional the dynamic. While they held him at arm’s length, he took swings at them, pushing their backs against the wall. He was engaging negatively, and they weren’t engaging at all. It occurred to me that if he could make them so uncomfortable, he was probably pretty bright.
What accounted for this dynamic? I suspect his doctors hadn’t engaged with him because they didn’t know how. They weren’t open about what they were thinking, which he resented and exploited. He would say things like, “Are you saying you don’t believe me when I tell you Demerol is the only pain killer that works for me?” and they would respond, “It’s not that I don’t believe you, it’s that I think we should try something else . . .” and he’d tie them in pretzels as he pointed out that they had just contradicted themselves. A more candid response would have been to say that they didn’t know him well enough to know if they could believe him, and that they weren’t comfortable risking their medical license by writing a potentially unsafe prescription. They feared telling him what they were thinking, which he recognized as disrespectful, so he taunted them.
When I first met Arthur, stepping into his hospital room and introducing myself as the doctor who would be caring for him, I was surprised by his personality, given what I’d heard. He seemed relaxed, made eye contact, and although we didn’t talk much, I noticed that he used language with agility. Working in an urban hospital on the South Side of Chicago I’d cared for many patients who were difficult to communicate with because their language skills were hampered by the environment in which they were raised. As someone with a learning disability who had benefited immensely from excellent schools, private tutoring, and parents who read to me as a small child, I was acutely aware that the difference between me and the impoverished men and women who struggled to express themselves was simply luck of circumstance. There but for the grace of God go I. I also appreciated that when I met a poor young man who was articulate and sharp despite a life of severe chronic illness and little education, I was in the presence of someone with high intelligence. As he and I started to talk, I thought, “this is someone I think I can connect with.”
My initial approach with Arthur was to come by his room and show high interest in his health and health care before he was discharged. I carefully reviewed his medical records and wanted him to see that I’d made the effort, asking him about how his condition was affecting his life, what medications he was taking, and so forth. I saw it as a kind of audition, and I wanted to pass. The conversation was only about 10 minutes, but probably more than he was used to. I told him that I thought he needed to continue to use narcotics to control his pain but I believed he should switch from meperidine (Demerol) to morphine, since the former could cause seizures at such high levels and was likely more addictive because of its fast action and associated euphoria, which seemed to be leading to escalating dosages. As I anticipated, Arthur objected to switching to a different narcotic, saying that only Demerol worked to control his pain. I stood my ground, saying I would prescribe an equivalent dose, and explaining that “I am personally not comfortable keeping you on that medication, as I believe it is more likely to harm you, and I’m not prepared to take that risk.” He told me he’d probably need to find another doctor. I responded that he could do that if he thought that was the right thing, but that I hoped that he would stick with me because I was looking forward to getting to know him and seeing if I could be helpful. My comment might have puzzled him, as the usual dynamic had been his pushing his doctors away and their being more than ready to see him look for care somewhere else. He grudgingly agreed to come to my outpatient clinic in a week.
Not surprisingly, he didn’t show up. As soon as clinic was over I gave him a call. He seemed surprised but pleased to hear from me. He said he couldn’t make it because he was watching over a couple of nieces and nephews, and I could hear kids playing in the background. We chatted about his family, and I asked him how he was getting along. He said he was doing okay. I told him I wanted him to see a specialist to get on a medication called hydroxyurea, which could reduce the frequency of his sickle cell crises. He agreed to do that, and I scheduled the consultation.
On the appointed day, I logged into the computer system and saw that he was a “no show.” Again I called him, and this time he didn’t have an excuse other than that he’d forgotten. I said, “Arthur, you’re too smart to forget something this important. What’s going on?” He told me that a friend of his had gotten shot and he was feeling awful about it. We discussed what had happened. He told me that he wasn’t involved with gangs anymore but had been, despite his sickle cell disease. Now he was “an old man” and didn’t get into trouble anymore. We laughed about that.
From then on he began showing for appointments with me, and finally followed up in hematology, where he was started on hydroxyurea, a daily pill that can decrease the rate of painful sickle cell crisis episodes. In addition, the hematologist started deferoxamine to try to remove some of the excessive iron that had accumulated in his body after years of blood transfusions. By the time I met Arthur, it had infiltrated his liver and heart, causing irreversible damage. We tried nevertheless in the hope that, given a chance, perhaps his body could heal itself. Deferoxamine requires a nightly eight-hour infusion using a pump—for a period of months in severe cases like his. That entailed arranging for a home nurse to visit and a social worker to coordinate his care. He accommodated these changes in his life.
Our interactions didn’t always go smoothly. After we had a solid relationship that seemed personal and at times intimate, he started to demand that I switch him back to Demerol, saying he had no reason to see me if I wasn’t going to treat him right. These outbursts were disconcerting and a bit hurtful, although I realized they were an indication that he was struggling. They reminded me of a child having a temper tantrum as a way of releasing pent-up feelings. Rather than saying “What the hell is wrong with you? We’ve been getting along great,” I took each one at face value: “I’m sorry you’re miserable. What’s going on?” He’d see that I asked a lot of questions, was obviously concerned, but wasn’t going to give him Demerol. The outbursts coincided with his growing appreciation that his hemochromatosis was severe and that while we could buy him some time, he was nearing the end of his life. This was something he figured out himself and first brought up with me. As I came to understand that his eruptions were a testament that he felt safe that I wouldn’t abandon him, I took them as a sign of trust rather than as hurtful. Whenever I had the opportunity I shared with him my appreciation for his insight and intelligence, based on something he had just said or done. He would nod appreciatively but never looked surprised. I got the sense that he knew he was smart. On the other hand, he’d probably not often had this part of him acknowledged.
Arthur died one night from complications of the hemochromatosis on his heart, causing heart failure culminating in a fatal heart rhythm. A home nurse notified me, and I called his mother. I recall, a week later, pulling into the parking lot at the funeral parlor in Auburn Gresham, a neighborhood twenty minutes southwest of Hyde Park, where I worked. A lot of people were there, and everyone was dressed up. I was the only white person in sight. No one stared at me, although I felt self-conscious. When I stepped into the parlor, Arthur’s mother spotted me and came over. I clasped her hand. A few minutes later one of the ushers said that Ms. Barnes (not her real name) would like for me to sit next to her. I felt awkward and undeserving of this request—but knew it was what I should do. I sat next to her during the service. There was an open casket, so I had a chance to see Arthur one last time.
For about a year after that I kept in touch with Ms. Barnes, calling her now and then to see how she was getting along. The tragedy of the story is that Arthur might have lived a long life had he started on deferoxamine years earlier. It was already well established at the time that early chelation therapy, as it’s called, prevents iron buildup and organ damage, and our hospital was providing the service to other patients who received frequent transfusions. Arthur’s medical record noted that he was “noncompliant” and therefore not a candidate for a medication that required nightly infusions and close monitoring. He certainly should have been.
The problem was that the doctors lacked the interpersonal competencies to care for Arthur. As noted, they were turned off by his behavior because they lacked boundary clarity and, perhaps as a result, were unwilling or unable to engage. When he gave them a hard time, they took it personally or assumed it was a fixed trait of his character. Reacting based on how one feels in response to a patient’s behavior rather than on the responsibilities one accepts as their physician represents a lack of boundary clarity. Assuming their behavior is a personality characteristic rather than asking them what is going on represents a lack of engagement.
These clinician deficits can be lethal as well as common. Arthur was judged incapable of participating in care that he needed when he was perfectly able to. In fact, the doctors had the problem reversed: They were the ones incapable of giving him the care he needed. By “care” I’m not referring just to the medical services he should have received, that is, the medications to reduce his symptoms and treat the iron deposition. That’s not “care”; that’s technical know-how. To “care” is to “feel concern or interest; to look after and provide for the needs of.” Because of his physicians’ inability to care he wasn’t able to benefit from their technical know-how.
I enjoy caring for patients labeled “difficult” for a couple of reasons. First, one can sometimes break the cycle of dysfunction between the patient and the health care system, leading to unexpected improvements in their health status. This is personally rewarding. If a patient is dying of cancer because every possible drug has failed, there isn’t much one can do to save them. But if their health care is a mess because of conflicted relationships with their care team, there is the potential to make a difference. Second, I find “difficult” patients stimulating because their antagonism is an indication that there is an unresolved backstory. Why in the world is this person behaving in a way that is self-defeating? That’s a challenge to explore.
Unfortunately, not all patients respond positively to an engaged, caring physician. Some are incapable of trust. Their past experiences, often dating back to early childhood, are so fraught with abusive or controlling interactions that they have little reason to believe anyone acts solely in their behalf. They respond to a sense of powerlessness by attempting to bully those they regard as having power, including health care professionals. In my experience, paradoxically, these individuals run from physicians who seek to engage with boundary clarity, despite having badgered others with constant phone calls, e-mails, and complaints. So accustomed are they to physicians holding them at arm’s length and taking offense at their behavior, that they don’t know what to make of one who is calling to see how they are doing and why they’ve missed appointments, while also not acquiescing to their demands or getting upset about them. They may wonder, “Is this person up to something . . . or could they possibly be for real?” Sometimes they will return, when they are capable of accepting help.
As a medical educator I encourage engaging with patients, starting by pointing out to students and residents when they are talking over patients’ heads. When a resident asked her patient if he was having “any abdominal pain,” he shook his head to indicate that he was not. I then asked the patient if he knew what “abdominal pain” is, and sheepishly he acknowledged that he did not. The resident then reframed the question avoiding medical jargon. That’s just a start. When the doctor needs to be shown that the patient isn’t following them, they are not engaging!
Engagement often begins with a feeling of curiosity about another person. When I meet people in social situations I’m often curious about how they think and what’s important to them, but I’ve learned from experience to keep it light. With patients, I have the luxury of inquiring without seeming intrusive, because the information is relevant to their care. I’m often struck, however, by how often residents don’t ask obvious questions. Recently a second-year resident came out of the exam room to tell me about an elderly man in a wheelchair who lives alone, has had a couple of falls, and is not controlling his diabetes. He knew how much insulin the man was taking, and what medical tests had been done to evaluate his falls. But here are things he hadn’t asked: whether the man has family or friends who drop in to see him; what sorts of activities he does during the day; how he manages shopping and cooking; what he thinks or feels about his situation; how he got to his appointment that day; and what sort of work and family he had when he was younger. This may seem like a lot of information, but I’ve found that if you’re curious and hungry for a mental picture of someone’s life, you can get it in a couple of minutes in a way that feels natural.
I am not convinced by arguments that physicians don’t have time to obtain psychosocial information. If you feel pressed for time, you can tell patients up front what you hope to accomplish and how much time you have. While studies of doctor-patient communication show that physicians interrupt patients too soon, I don’t think that means we shouldn’t interrupt at all. Patients rely on our expertise to guide the discussion, and we, not they, know how much time we have. If I’m trying to figure out if an 85-year-old man in a wheelchair who lives alone is managing okay, I’ll ask him to describe how he goes shopping, prepares food, bathes, and so on. Once I’ve heard enough in each of these areas to know whether I should do something or not, I’ll interject if needed, asking him if we can change to a different topic. Being open about the direction and goals of the conversation provides an opportunity to collaborate. If he’s not able to interact this way, that’s useful to know too: Is he distracted? Could he be depressed or anxious? Does he have cognitive deficits? Everything is grist for the mill. As a result, there is little unproductive time during the encounter.
This chapter is titled “Healing Interactions,” rather than “Healing Relationships” or “Healing Encounters,” because it is about a way of relating in the moment even if you’ve never seen the person before and have little time together. My research team and I have listened to hundreds of 15- to 30-minute recorded encounters between doctors and patients, and rarely do we think to ourselves “if only they’d had more time together, they would have connected.” Generally, it is the physician’s behavior that determines whether the interaction sounds like a partnership to figure out what the patient needs, or a doctor trying to get through a checklist of questions and things to do. Many physicians seem to have the impression that only the latter approach is practical in the current health care climate, which judges doctors based on adherence to various care and screening guidelines, documentation requirements, and productivity. Engaging with patients, however, is not an add-on to an already long list of tasks; rather it is a nonlinear way of relating that widens the bandwidth so that more is learned and shared in the same amount of time because less is concealed.
Engaged interactions are also more personal, which is good for the doctor too. Rather than feeling drained, you feel rejuvenated because—just as you are now acknowledging another person’s humanity with your attention—that person, in reciprocating, is acknowledging yours. That mutual recognition is the foundation of all healing interaction.
Questions for Reflection and Discussion
1. Can you think of a time when you felt alienated or alone, like Dr. Remen, and someone interacted with you in a way that was a breath of fresh air—that lifted your spirits and enabled you to feel more connected? If so, what was it about their behavior that had that effect? Can you give an example?
2. Do you see yourself as someone friends turn to when they are in distress or need guidance? If so, what is it that you are able to offer them that enables you to be such a valuable resource? Is that part of you accessible to your patients during medical encounters? Can you think of an example? If not, why not?
3. Have you cared for a patient like Arthur who is regarded as difficult and manipulative? If so, what feelings did that person elicit in you? How did you process those feelings? Based on that processing, how did you respond to the individual? Did the relationship become more or less engaged and trusting? If it did not improve, do you think there is anything you could have done differently?
4. What do you do when you don’t have enough time to ask a question that you think is relevant to figuring out what care and services your patient needs? How do you prioritize getting through what you want to cover versus figuring out what’s really going on with them that has implications for their health? Are you able to communicate openly with them about the time constraints of the encounter so that they are best served?
5. How often do interactions with patients leave you feeling good rather than just neutral or tired? What are the characteristics of those interactions?