LIKE MANY aspiring physicians, I felt called to a career in medicine yet knew little about what I was getting into. My first medical school interview was with an amiable rheumatologist in a charmless office at a large, run-down, urban hospital, on a corridor tucked behind an industrial-sized kitchen. As I came in the main entrance, wearing a new suit, I noticed the peculiar corrosive smell of hospital disinfectant, saw elderly patients on gurneys, and felt sad and confused inside. At the time, I couldn’t articulate why. The interview was relaxed, friendly, and seemed to go well, which put me in a better mood. Getting to this point had been a long and difficult road for me, so I had every reason to be excited. As I headed home, I was able to push out of my consciousness the unease—bordering on dread—that I’d experienced before the interview. But I sensed it would return.
I’d actually had more experience with health care delivery than many aspiring physicians. In high school, I trained and worked as an emergency medical technician on a rural volunteer ambulance squad. I once performed CPR on a farmer who had aspirated chewing tobacco, pushing hard on his chest while trying to keep my balance in the back of the van as the driver, with sirens blaring, whisked us to the emergency department. Shortly after we got there, the man was pronounced dead. I wondered if maybe I could have saved him if I had known more. In college I observed and studied health care in the developing world, spending the summer after my junior year shadowing physicians at clinics and hospitals in Nepal. Throughout, I strategized about what I needed to do to become a doctor. Getting into medical school became an obsession.
Yet, once on the threshold of entering the profession, I wondered silently if I was making a mistake. What hung over me was the feeling that I didn’t know if I would be happy with my chosen vocation. I recalled going to see my pediatrician in high school, in a nice office where he saw kid after kid coming in with colds and for school physicals, and feeling a disconnect between what I imagined his job was like and the excitement of being a doctor. His demeanor, which seemed fatherly but distant, may have contributed to my misgivings. It was a trepidation that felt shameful to articulate, as I had already embraced the identity. After all, being a physician is supposed to be a “privilege,” as one acquires the knowledge and skills to cure disease and alleviate suffering and becomes privy to the intimate lives of patients. While I could exude confidence and enthusiasm about where I was headed, inside I felt like someone who sensed they might be marrying the wrong person.
It’s taken me years to understand the source of the ambivalence I felt at the time. Joy in medicine requires more than idealistic aspirations; it requires a capacity to see past the “otherness” that separates the well from the sick, the old from the young, the professional in a white coat from the disheveled patient in a hospital gown, and fully embrace their shared humanity. And at that stage in my career, I didn’t have that capacity.
When one is unable to bridge the divide between doctor and patient, medicine becomes a career rather than a calling. Medicine as a career is about advancement, status, fitting in, making money, finding job security, and working reasonable hours. For some it’s also about the intellectual rewards of learning new procedures, guidelines, and research related to patient care. In addition, most physicians enjoy the human interaction with patients and consider it a central part of their professional identity. But how many are capable of relationships that are mutually nourishing?
Few are, it seems. The irony that premeds are often the last people you’d want to turn to in a time of need became evident to me in college when I first learned about the selection process for a peer-to-peer support program. The campus counseling center ran an off-hours service where students could meet with other students to talk about loneliness, depression, relationship problems, or anything else on their minds. At the orientation meeting, premeds were cautioned against applying for the purpose of buttressing their résumés. Such careerism was widely recognized. The prospect of would-be physicians serving as peer counselors was something people joked about. Premeds were satirized as the students who would break your pencil during a chemistry exam if given the chance.
What are the ideal characteristics of someone with whom to share personal matters? The peer counseling program looked for certain qualities. First is unselfconsciously giving others one’s undivided attention, without predisposition to making assumptions, and without pretension that one is somehow superior. In the screening interviews, the program’s leaders sought students who were comfortable acknowledging and talking about their own problems. A mentor, Simon Auster, who came to play a central role in my development as a physician, described those behaviors, collectively, as “a capacity to openly and fully engage.” One could say they were looking for people who are “real.”
The second characteristic is that they have interpersonal boundary clarity, meaning they can distinguish what’s them from what’s the other person. When you talk with someone about your problems, you want to know that they are not confusing their needs and wants with yours. Parents often frustrate their young adult children, for instance, when they regard them as extensions of themselves, coloring the advice they give. A young woman trying to make it as a writer is not going to get good counsel from a father who is dismissive and tells her she should go to law school, as he envisions her taking over his practice. A patient considering whether to stop chemotherapy near the end of life is not going to get good counsel from a physician who believes that—as one of my research oncology professors put it—“everyone should die on a protocol.” Whose interests are these individuals representing? Without respecting—or even recognizing—interpersonal boundaries, they disregard others’ values and preferences when they differ from their own.
Engagement and boundary clarity are the yin and yang of every healing interaction. If one is missing, the other may do more harm than good. To engage without boundary clarity is intrusive. When an angry couple lose their tempers and yell at one another, they are most definitely engaging, but without respect for boundaries, the interaction is more likely to wound than heal. Conversely, maintaining boundaries without engagement fosters alienation. Acting friendly while not really being interested is a prevalent aspect of American culture that does little to alleviate loneliness. At the supermarket checkout counter, when the cashier asks, “How are you today?” and you respond without thinking, “Fine, thank you,” no boundaries are crossed, but neither is there a meaningful connection. In the doctor’s office, the vulnerable patient seeking human connection may attempt to engage, but all too often the physician is on autopilot, focused on writing their notes, as in: “So sorry to hear about your loss. . . . Any bowel or bladder problems?” There is a sad pattern here: In our personal lives we are prone to engage without respecting boundaries, and in our professional lives it’s the other way around—that is, we maintain boundaries but often fail to engage. Neither is healing.
Unfortunately, those entering medicine often have trouble with both. Many come from family and educational environments where boundaries are crossed. They have experienced hurt and humiliation, which makes them habitually guarded. In non-intimate relationships they learn to skillfully keep a distance: in lieu of engagement, they acquire a professional persona that is unassailable but somewhat heartless and insincere. While primarily self-protective, it is also secondarily protective of their patients. If you are not clear about boundaries, it is probably better not to engage, as you may unwittingly say things that are hurtful. Pleasantries and small talk are preferable to disrespectful interaction.
Joy in medicine, however, does require open and full engagement with a wide range of individuals, often from very different backgrounds and life experiences. When I walked into that hospital for my first medical school interview, I had not yet learned how to engage in the professional sphere. When I gazed at an elderly, ill woman in a wheelchair, it never occurred to me that she and I were on the same journey called life, except that she was further along. When I saw a homeless man, I didn’t appreciate that this was a person who had mastered a whole set of survival skills that I knew nothing about. Seeing patients as “other,” I held them at arm’s length. This generated cognitive dissonance: in theory I valued connecting with patients and saw it as an attraction to medicine, but in reality I didn’t know how.
Medical training makes it difficult to confront the emotional issues that often surface in young adulthood. College is over, yet school is harder and more regimented than ever. Persevering requires single-minded focus. Inner pain is suppressed and self-awareness underdeveloped. Like many, I came to medicine with both strengths and challenges. I had wanted to be a doctor for years but struggled with a learning disability that made science courses particularly onerous. I took chemistry during the summer before college prior to matriculating. Working nearly every waking hour, seeking out the teaching assistant daily for tutoring, I earned a C. Then I took it again, this time freshman year when it went on my transcript, and managed to get a B. I got okay grades in the rest of my premedical courses by working really hard to digest just enough knowledge to make it through most of my exams.
During my first year of medical school, I felt especially alone. Whatever strengths I had were not the ones valued by the institution. After a few months I figured out how to play the game—at least well enough to pass exams. It involved memorizing the professors’ handouts even if I didn’t understand what I was memorizing, reading concise outline-style review books, and then taking lots of old practice tests. This required skipping lectures, which I couldn’t follow anyway, to free up the time. While an effective survival strategy, it was also demoralizing, as I did not feel anything approaching a sense of competency, let alone mastery. It felt more like fakery. It occurred to me that some others were probably in a similar boat, but it also seemed as if quite a few people were getting along just fine.
I began to think that the particular qualities that characterize a good physician may not be the same as those required of a first- or second-year medical school student, but that was not much comfort at the time. Struggling through courses had a corrosive effect on my self-esteem. Looking for relief, I became preoccupied with a young woman with whom I had shared an on-and-off relationship starting in undergraduate school. I felt that if she wanted to be my girlfriend, that validated my worth. At the same time, I recognized that we were not compatible or, at least, that our dynamic was not good for me. During the brief period when the relationship was back on, I felt euphoric, and when it was off, I attributed all of my misery to that loss. One evening I found myself pacing the narrow hallway on the first floor of my townhouse, sobbing so loudly that the neighbors called and asked me to come over. They were a couple in their fifties. He could be brusque, as I had learned early on: the first day I moved in, I dragged a washer-dryer I had purchased across our shared lawn, flattening the grass, and he came out and yelled at me. But we had since started to get along, after some friendlier chance interactions. I’ve not forgotten their act of kindness—summoning me to join them for drinks and a card game, no questions asked—at a time when I really needed it.
It was at this low point that someone uniquely capable of helping me stepped in. My parents had designated Simon Auster as my godfather shortly after my birth. We were already close before I entered medical school, but only as close as I was capable of being at the time, owing—as I came to appreciate years later—to a limited capacity to trust. Simon, who was trained as both a family medicine physician and a psychiatrist, said to me on one of our occasional weekend phone calls, “You know, Saul, I think it might be helpful if you and I started to talk regularly.” I accepted the invitation and entered what would be a combination of therapy and mentoring that would last decades. We’ve spoken nearly every Saturday for thirty years.
Simon encouraged my desire to form personal connections with patients and families at a fundamentally human level rather than to adopt the persona of a physician—in other words, he promoted engagement. He also helped me set appropriate boundaries, such that my unscripted self was therapeutic rather than unfocused or self-indulgent in patient encounters. This sort of emotional support and guidance enabled a trajectory that was likely quite different from that of most of my colleagues.
Most are taught what is often referred to as “good bedside manner.” Instead of learning to keep it personal, medical students acquire a set of scripted behaviors, that is, “manners.” I remember in my second year of medical school conducting a practice medical interview while my peers watched and a physician faculty member observed and took notes. I lost points for forgetting to sit at eye level with the patient and reach out sympathetically to touch her on the arm when I was supposed to. The problem was that I was too absorbed in the conversation to remember these “rapport building tactics.” I was able to articulate my frustration to Simon during one of our Saturday morning calls when I said, “Bedside manner seems to be a set of rules for people who don’t know how to care.”
Another example of the socialization process is from my pediatric clerkship, a year later. I was assigned to a team caring for a fourteen-year-old girl with lupus, who I’ll call Lorrie. An array of specialists visited Lorrie daily, arriving at her bedside at different times and not communicating much with each other. This was a source of frustration for her parents. I recall meeting with them several times in a small, private room where they poured out anxieties and concerns about her care. I was able to schedule a meeting of all the doctors to arrive at a plan. While I formed a connection with her parents, I don’t recall spending much time with Lorrie. Her friends came and went as she endured kidney biopsies, dialysis, and episodes of internal bleeding. At that stage in my life I was more comfortable relating to adults than to an adolescent girl.
At the end of the rotation I received an evaluation from the director of the pediatrics clerkship in which she expressed concern about my relationship with Lorrie’s family. Her evaluation was based on feedback she got from the residents I worked with every day. She wrote that my level of “overinvolvement was likely, if it continued, to lead to burnout.” She also raised concerns that I was overstepping my bounds as a medical student, acting as if I were the senior doctor in my interactions with the parents. For me, however, my role in Lorrie’s care had sustained me. It was hard and sad at times, but I felt useful and connected. Also, rather than supplanting a more senior doctor, I felt I was filling a void. No one else was coordinating Lorrie’s care. Nevertheless, the feedback I got felt humiliating and left me with doubts. I wondered if I had been some sort of an imposter who took advantage of Lorrie’s parents’ vulnerabilities to feed some inner need for validation. That was the message I was getting. Talking with Simon provided a critical counterpoint. He challenged me to reach inside and answer for myself whether I thought my behaviors were appropriate or not, so that I could become my own compass. Over time that led to greater self-trust.
Some months later I heard that Lorrie had died. I don’t recall reaching out to the parents or sending a note of condolence. I hope I did, but it wouldn’t have been something we were taught to do. On the contrary, when you left a month “on service,” you moved on. Decades later, as the father of a grown child, I feel anger at the disconnect between medical school teachers’ fretting about a student’s “overinvolvement” and the heartbreaking struggle of a family to keep their daughter alive, desperately dependent on an emotionally distant health care team.
Without someone to talk with about what I was going through during those years, I might have stopped engaging with patients. I might have become more like the residents who were uncomfortable with their “overly involved” medical student. Such a state of mind stunts personal growth, as the self retreats into a shell. Safely encased, the emerging physician adopts an assured manner of handling any situation, whether it be an angry parent or a struggling patient. But what they are doing is just that—“handling”—rather than engaging with another person who may be frightened or suffering, in need of real human connection. I recall my awe as a student of a particularly confident senior resident who effortlessly put out any fire. When called to the bedside of a disruptive patient on the psychiatry ward, he slipped in an IV, infused Haldol, and returned the patient to a state of medicated calm. When I related the encounter to Simon, he wondered out loud what we might have learned if we’d asked the patient what he was upset about instead. That got me thinking: is it okay to stick a needle in someone just because you are a doctor and you think you know what is best?
Over the years, it became increasingly apparent to me that physicians are remarkably incurious about the life circumstances and behaviors of their patients. When they don’t take their medications correctly, we lecture them about how they have to do a better job rather that asking them what happened. When they get angry or anxious, doctors often get defensive or try to calm them down rather than first asking questions to better understand where their patient is coming from. To what extent does this lack of interest affect care?
I decided to explore that question after a particularly memorable patient encounter when I was a junior attending physician. Ms. Dawson (not her real name) showed up in the presurgery assessment clinic that I was staffing with a couple of residents whom I supervised. After seeing her first, one of them explained to me that Ms. Dawson was scheduled for bariatric surgery to treat her obesity. The resident presented the patient’s medical history and test results, concluding that everything was in order for her to proceed to the operating room. As we headed into the exam room together, the resident offhandedly mentioned that “Ms. Dawson’s looking forward to having the surgery so that she can better care of her son”—sharing the comment, it seemed, as further evidence that surgery was the right way to go. Before entering I asked, “What’s wrong with him?” The resident shrugged and said, “I don’t know,” with a look that seemed to convey impatience. Perhaps she wondered why the son’s health care problems mattered. After all, he wasn’t our patient.
I could appreciate where she was coming from because I recalled that when I was in her shoes, I just couldn’t seem to please my attendings by knowing enough. However prepared I was on hospital rounds in the mornings, they’d ask me for some obscure factoid about the patient to which I didn’t have a response other than “I don’t know.” The blank stare I’d get left me feeling like I’d let them down. At the same time, I’d wonder why the information was relevant. I didn’t ask, and they didn’t tell me. I thought it might just be a game of one-upmanship.
When I asked Ms. Dawson about her son, I learned that he was a young man in his early twenties in the advanced stages of muscular dystrophy, with muscle atrophy and contractures. She was his sole caretaker, lifting him each time he needed to be transferred to his bath, bed, or a chair. She also parented a younger daughter and lived with an alcoholic husband. If she went ahead with the surgery, she wouldn’t be able to do any heavy lifting for several weeks. While she’d considered how losing weight would ease caring for her son, she hadn’t thought about the long recovery. Because she’d previously had her gallbladder out and had scar tissue in her abdomen, her surgery would require a large incision. This meant that if she lifted her son during the first month after the operation, she risked opening the surgical wound. Once all this came out in our discussion, Ms. Dawson canceled the procedure. She concluded it wasn’t at all what she wanted or could tolerate at the time.
After seeing the consequences of disinterest in patients’ life situations, I started to work with a research colleague named Alan Schwartz, who is a cognitive psychologist interested in how physicians make medical decisions. This was a time when studies were exposing high rates of medical error. A national report showed that between 50,000 and 100,000 people die in the United States each year because physicians prescribe the wrong drug or the wrong dose of the right drug, operate on the wrong limb, overlook necessary steps to prevent drug-resistant infections, and so forth. Each of these errors was given a name, such as “medication error,” “diagnostic error,” or “treatment error.” I decided to call errors that occur because the physician doesn’t know something critical about the patient’s life situation “contextual errors.” Sending Ms. Dawson to the operating room would have been a contextual error. And it could have had serious consequences. Out of an overriding need to care for her son, she might have had a major setback in wound healing if she’d lifted him before she was medically ready.
Alan and I have been studying contextual errors for over a decade. Ascertaining whether a doctor is overlooking critical information about patients’ life situations that is relevant to their care requires listening in on the visit. We’ve adopted two strategies: training actors to show up in doctors’ offices with a concealed audio recorder while portraying patients who drop clues that they are facing a life challenge, and inviting real patients to record their visits. We then listen for whether the physician notices the clues, asks about them, and addresses contextual factors where feasible when planning care. Participating physicians have agreed not to know when they are interacting with a fake or real patient who is collecting data. Our book Listening for What Matters: Avoiding Contextual Errors in Health Care describes this work and what we learned.
What does contextualizing care have to do with engagement? I think it’s fair to say that a physician who is missing clues that a patient is struggling with a life challenge that affects their care is probably not engaged in the interaction. To assess physician attention, we instructed one actor to sigh and say, “Boy it’s been tough since I’ve lost my job” during dozens of visits portraying a patient whose asthma flared up when they could no longer afford an expensive brand-name medication. The actor was told not to reveal their financial problems unless asked. All too often distracted physicians would nod and respond to the comment, absentmindedly, with something like, “Sorry to hear that. . . . Do you have any allergies?” while they typed and looked at a screen. The minority of physicians who were giving the patient their full attention would ask, “How has it been tough?” and typically follow with, “Are you having trouble affording your medications?” When physicians were distracted, they tended to order more medications that the patient couldn’t afford, as well as additional pointless tests and referrals. When they were engaged, they simply switched the patient to a less costly generic.
Remarkably, we discovered that contextualizing care doesn’t lengthen the visit. The time spent learning about patients’ life challenges was offset by time saved on the back end of the visit, by skipping unhelpful discussions regarding additional testing and medications that weren’t warranted. These findings should be reassuring to physicians who worry that if they start delving into life issues as they pertain to care planning, it will take too long and they’ll keep other patients waiting.
Doing research on physician-patient interaction has further inspired me to write this book, not only because we learned that contextualizing care need not be time-consuming but because it has measurable value: attention to the context of patients’ lives favorably affects health care outcomes. We saw repeatedly, for instance, that patients who had diabetes were more likely to get control of their blood sugars if their physicians identified and worked with them to address underlying impediments to medication adherence than if these were overlooked. Discovering that these more substantive discussions don’t even take longer was “icing on the cake,” as it debunked the argument that physicians don’t have time to form therapeutic human connections.
Why are doctors disengaged? One reason I hear is that they feel that asking personal questions is like “opening Pandora’s box” and that they’ll never get out of the exam room. As noted, research indicates that is not the case. Another possibility is that they don’t have a lot of patience for human nature. I’ve seen how patients are subtly blamed for their problems with phrases like “she is noncompliant” or “he is drug seeking,” when they are just being, well, human! Sadly, it seems that it is in those situations where patients are struggling the most that physicians are most inclined to keep them at bay. The dynamic isn’t good for either party. Patients are left unsatisfied, and physicians become cynical and susceptible to burnout.
Medical students tend to adopt the same attitudes about patients and patient care. While I had someone to guide me during my medical education, few physicians-in-training are so fortunate. Without help finding their way, they are socialized to the norms of the profession, modeling their behavior on what they observe. I was fortunate to have someone challenge me to follow a different course. With Simon’s unsentimental grounding, I came to see that doctors hide behind their white coats while patients want to connect with a real person who cares about them.
With Simon’s mentorship I also learned that good doctors are comfortable not having all the answers, because they know the visit is not about them. They appreciate that if they take advantage of the opportunity to form human connections with their patients, those connections, combined with their expert knowledge of the health care system and what it can and cannot offer, will nearly always bring value to the patient. This perspective has guided me to engage with patients as who I am rather than to adopt a script, confident that doing so is best for both them and me. Admittedly, I don’t think I could have acquired this self-trust on my own. It took coaching from someone who didn’t hesitate to challenge me—and it took quite some time before I was fully receptive to being challenged. First I had to learn to trust Simon, and then, from there, I was gradually able to learn to trust myself.
While this book cannot substitute for one-on-one mentoring, it systematically lays out a number of ideas and concepts that took me years to appreciate. I’ve added questions at the end of each chapter to foster reflection and discussion. On Becoming a Healer speaks to those with an open heart who have not yet found a way to harness such a powerful resource in the service of healing.
Another reason I decided to write this book is that the lessons I learned from Simon have helped me outside of the medical setting as well. A former student of Simon’s, who later became his physician, put it succinctly: “You practice medicine the way you live your life.”
If this book has a single message, it’s that you can’t be remote and controlling with one set of people and a kind and thoughtful healer with others. Engaging with boundary clarity is a way of being in relation to other people that is intrinsically grounded in an appreciation of how we all share a common human experience, with vulnerabilities and interdependencies. No one escapes misfortune, illness, and death. Nearly all rely on others for stability, security, and well-being. Living with this appreciation as a guide to action isn’t just for professional healers. The most effective and contented managers, leaders, parents, teachers, and citizens are healers.
The impact of this book will depend largely on my gaining your trust that there is nothing exaggerated or romanticized here. That way, hopefully, if certain arguments don’t initially make sense to you, you will give them serious reflection nonetheless. I do not sugarcoat aspects of my job that I find tedious and unrewarding. In the settings in which I work as a physician, I struggle with nearly everything except patient interaction. I am stressed by the computer systems, billing requirements, the challenges of accessing resources my patients need, and more. I don’t pretend otherwise. That way, when I tell you that I relished seeing a patient who arrived with two police escorts after a prior physician refused to see that patient, who had threatened to kill him, you won’t be so incredulous as to tune out the discussion that follows about why that encounter and the relationship that ensued were particularly rewarding.
The chapters are organized around topics that I found essential to my own development as a healer. The book begins with a description of the task-driven, all-consuming, hierarchical culture of medicine that marginalizes the patient and values—despite the rhetoric—only technical competence. Doctors learn to do stuff to people rather than with them, with few opportunities to see how it could be any other way. Chapter 1, titled “Physician or Technician?” illustrates the indoctrination process and how it molds the physician’s mindset into that of a task completer rather than a thoughtful professional. It explores the countercurrents to becoming a healer, both in the training environment and in the larger society, that shape the people who go to medical school. Those countercurrents foster compartmentalization between the personal and professional, in addition to stymieing curiosity, self-trust, humility, and a capacity to engage.
Following the first chapter’s exploration of the social forces that direct young adults, particularly those who enter medicine, to disengage and lose their curiosity, the second chapter, “Healing Interactions,” begins with a discussion of the characteristics of a healer. A unifying theme is that healers exhibit an openness across their personal and professional relationships, combined with a high degree of self-awareness—often at odds with the prevailing culture. Hence, subsequent chapters explore the process of developing personally as well as professionally into a healer, especially during the formative years of becoming a physician, despite living and learning in an environment that frequently stifles that process.
Chapter 3, “Your Personal Journey,” considers the personal growth entailed in becoming a healer. How do you take honest stock of where you are developmentally? Are you able to trust others, as reflected in being open with them about what you regard as your vulnerabilities? Do you trust in your own basic goodness? When things don’t work out as you wanted, can you accept that you’re not in control? Once, after I had my first panic attack in college, I commented to Simon that I didn’t think I could turn to friends if I was having a panic attack as I feared they would think less of me. To which he replied, “Then what are friends for?” Learning to be vulnerable and trustworthy—which is to say nonjudgmental—immeasurably increases your value to your patients, particularly when they are suffering. You become someone who can be fully present for them and who is safe.
After having established the basic premises—that healers exhibit a set of personal qualities, that acquiring them is a personal journey, and that it requires overcoming countercurrents—three subsequent chapters explore the paths to “Overcoming Judgmentalism” (chapter 4), “Engaging with Boundary Clarity” (chapter 5), and “Caring” (chapter 6). The proposition of the first is that when we judge others we presume to know why they are behaving as they are, which shuts down curiosity. If you think you know why some of your patients don’t take their medications—for instance, that they aren’t taking your medical advice seriously—you have little motivation to explore what’s really going on. The second describes how open and full engagement with boundary clarity is the foundation of any healing relationship, inside or outside of the practice of medicine. The terms engagement and boundary clarity are explored in depth, with an emphasis on examining what the terms mean and how they enable healing interactions. The chapter on caring also begins with a discussion of definitions, this time comparing the terms caring and empathy, which are often used interchangeably but warrant distinction. When you unselfishly care for someone, you’ll take whatever actions you conclude will help them. To empathize has more to do with what one feels than how one acts. While empathy is widely assumed to increase caring behavior, that notion is challenged. However one defines the terms, what ultimately matters is not what you feel inside but what actions you take to elicit and address your patients’ needs.
Eliciting and addressing patients’ needs is the focus of chapter 7, “Making Medical Decisions.” Unfortunately, medical training focuses too narrowly on diagnosing and treating disease. Care plans often look good on paper but fail because they don’t take into account the circumstances or priorities of individual patients. This chapter introduces a practical framework for incorporating patients’ life context and preferences into care planning without adding to the length of the clinical encounter. It applies concepts introduced in the prior three chapters, particularly the importance of replacing judgmentalism with curiosity so that you ask the right questions rather than make assumptions about patients’ motivations and behaviors.
Chapter 8, “Healers Are Realists,” explores how idealists become disillusioned in the face of messy reality, whereas realists work within it. There are various definitions of idealism, and I’m referring to this one: the practice of forming or pursuing ideals, especially unrealistically. The unrealistic part is often what idealists think they can accomplish, imagining they can swoop in and save the day. When the world doesn’t respond as expected, disillusionment and then burnout set in. We hear people say things like, “I used to be so idealistic,” with a rueful look of disappointment. Yet if idealism has its roots in unrealistic expectations, is it any surprise that it goes away? Disillusionment is often born of arrogance about what we thought we could accomplish. In contrast, healers live in the real world, doing good work in harmony with their own lives. Chapter 8 introduces three physicians who are both pragmatists and healers, each in different ways.
Chapter 9, “Physician or Technician? (Revisited),” considers the problem addressed in chapter 1—why many physicians fall into a routine that is inattentive to patients’ individual preferences and needs—from a different vantage point. Whereas the first chapter explores how the training experience constricts their capacity to relate to patients as individuals whose complicated lives complicate their health care, chapter 9 acknowledges that it’s not always the physician who is the problem: In some practice environments, physicians are expected to see patients so fast that even if they engage, there’s just no time to do more than order routine tests and institute care plans that look right on paper but may be ill-suited for any number of reasons that go unidentified or ignored. Physicians who find themselves in a situation in which they can’t provide what they consider to be good care may ask themselves: Is this consistent with my principles? If the answer is no, it’s time to make a change.
Chapter 10, “Healing as an Organizing Principle,” explores what it means to approach every interaction as a healer, in a country that lately showcases meanness and bullying at the highest levels. Simon quotes the ethicist William F. May, who described the fully actualized physician as one who “eats to heal, drives to heal, reads to heal, comforts to heal, rebukes to heal, and rests to heal.” Many might regard this way of life as exhausting and unrealistic. But they miss the point. What’s exhausting is the inauthenticity and guardedness that characterize so many other ways of interacting. Healers let go of pretensions and posturing, which is liberating—and empowering. In a world with brutes, healers are resilient. As they know where they stand, they are not easily knocked off balance. Absent inflated egos, they are less prone to blindness born of self-deception. And, because their generosity does not go unnoticed, they accumulate friends in unexpected places who look out for them.
Unlike my previous book, Listening for What Matters, which is grounded in empirical research on interactions between patients and professionals who care for them, this one is based on what I’ve learned from a wise mentor and gained from experience. My conversations with Simon were almost always driven by questions I asked him, often about myself, as I wondered why I might be feeling or reacting to particular situations in particular ways during my training, or how I might better respond to something I encountered. Simon often responded by asking me what I thought and then guiding me to my own answers. The questions at the end of each chapter reflect these discussions.
I hope that as a reader you will find relevance to your life from much of what you come across in these pages, and that it will challenge you to grow personally as a healer such that your interactions with those who may be struggling or in pain—whether they are patients or not—are more comforting for them and fulfilling for you.