Healing

Healing – Long Term Relationships

I’m back to my series of posts about healing relationships. Hopefully it will not be necessary to return to posts about COVID, but if new developments happen that require some explanation, I will go back to posting about COVID.

In our dysfunctional health care system, health systems seem to think that clinicians are interchangeable like widgets. Since healthcare is a product, it does not matter who provides the product. Relationships between clinicians and patients are nice, but not really necessary. Many primary care organizations make very little attempt to make sure that patients are scheduled with their own clinician when they make appointments. As we shall see, clinician-patient relationships, the longer the better, are not only nice but essential for both patients and clinicians.

It used to be common for clinicians to stay in their communities for a long time. I started doing family medicine in Batesville, Arkansas in 1979 and stayed there for twenty years. That is distinctly uncommon today. Clinicians (both doctors and nurse practitioners) move every few years.

I am convinced that the healing aspect of clinician-patient relationships takes years to fully develop. In my own experience, I think it takes at least five years for me to begin to develop healing relationships with my patients. It can happen more quickly with patients who have chronic illnesses and need to be seen frequently, but that is the exception rather than the rule.

Abiding

In my research patients and doctors talked about how important it is for patients to feel that they are known by their physicians, that is known as people, not just a vehicle for disease. Knowing someone takes time. We used the term “abiding” to describe these long term relationships. It is a kind of intimacy that both clinicians and patients described as like being members of a family. Here is how one patient described abiding: “I think after years and years and years and years it’s like…a marriage. You and your doctor have a marriage.” Another patient said, “She knows who I am first of all. She knows exactly who I am. She knows my thoughts and my way of understanding things.” One doctor described abiding this way: “There’s being there for the big events, whether that’s birth or death or the diagnosis of something bad, or being there when they need you to be there, pushing other things away in order to be there in a way that’s more substantial.”

Abiding also means not abandoning patients even when all the pills and technology have been tried and patients are still suffering. If just listening to a patient’s story of suffering and having compassion for him/her is all that a clinician can do, then he/she needs to do that. As I discussed before, curing may not be possible, but healing can still happen. As one patient said, “He never gave up on me. And that means a lot.”

Trust

Trust means feeling safe. It means that you can tell your clinician anything and you will not feel judged. It means confidence in the competence of your clinician. It means knowing that promises will be kept. It takes time for trust to develop. As one physician said, “That’s something that you can’t do right away. You have to sort of earn that.”

Earning trust does not meant that trusted clinicians never make mistakes. But when they do make a mistake they tend to admit it. That often actually enhances trust. As one patient said, “He had the courage to say, ‘Well, I made a mistake.’ That endeared him to me forever.”

What to look for in your doctor

If you are lucky enough to have a trusted clinician who has been with you for a long time, then treasure that relationship. Always insist on seeing that clinician unless you have an emergency and your clinician is not available. There is nothing you can do to keep your clinician from moving or retiring, but to the best of your ability, choose someone who has been in your community for a long time, because that clinician is more likely to value long term relationships with patients.

Healing – Understanding Power in Doctor Patient Relationships

It seems to me that many healthcare organizations assume that doctor/patient encounters are transactions between equals. Much of the healthcare organization language reflects this idea. Doctors and nurse practitioners are called ”providers.” That is supposed to be inclusive language, but rather than that, it characterizes doctors or nurse practitioners as providing something (health care) to consumers (patients). While empowering patients is a laudable goal, characterizing the clinician-patient encounter as similar to selling shoes is not. I prefer the term clinician, which includes doctors and nurse practitioners.

I want to be clear that I am not advocating for a return to the paternalistic (perhaps authoritarian is a better word) model of “Doctor knows best.” This kind of relationship, where the doctor decides what the diagnosis is and what the treatment will be without regard for patient’s preferences or values is disappearing (although not fast enough) and good riddance to it.

On the other hand, there is an inherent asymmetry of power in relationships between clinicians and patients and pretending that it does not exist will not make it go away. When patients are ill, frightened that something bad may be wrong with them, they do not comparison shop. They go to a clinician they feel like they can trust to help them. A good clinician provides the best science in diagnosis and treatment tailored to this particular patient; her values, her preferences, her personality.

Empowering patients

Good clinicians empower the patient as much as possible. They do this in several ways. They listen carefully as I discussed in the previous post. They create a partnership with patients. As one patient said in one of my interviews, “one thing I really appreciated with [my doctor] is like we’re a partnership.” 

Good clinicians also empower patients by translating medical jargon into understandable language and by giving them information they can use to manage their own illness. As one patient said, “He explained what I needed to do going forward, the life change it would take, you know the medication, the eating habits, and everything to try and keep it from happening again.”

Using clinician power

Sometimes, clinicians need to carefully use power to push resistant patients to take actions that are important for their health. As one patient with HIV infection said, “…that’s why I really need, someone to push me, tell me you have to do those things. That’s one of the reasons that I’m still here.”

Good clinicians have an intuitive understanding about when and how to push patients based on assessments of patients’ needs and strength of relationships. One physician described it this way: “…sometimes you’re the coach and sometimes you’re the boss and sometimes you’re the sibling and sometimes you’re the doctor.”

What to look for in your doctor

Here are some red flags that suggest you should look for another doctor.

  1. Your clinician has already made up her mind about treatment and pays no attention to your concerns.
  2. Your clinician lectures you about your bad health habits
  3. Your clinician gives you whatever medicine you ask for that you have found on the internet without discussion of whether it is appropriate for you.
  4. Your clinician uses medical jargon that you don’t understand.

There are good clinicians out there that know how to use power appropriately in the context of relationship. Most of the time that means empowering patients, but it also means knowing when to push when necessary for the patient’s benefit. If you don’t have one like that, keep looking.

Healing

My last post about placebo (or context) effects was one example of the innate healing capacity of our body-minds. During my 40 years practicing medicine, I learned that the quality of my relationships with patients had about as much to do with how well they did as the medicines and treatments that I gave them. That observation led me to research into how doctor-patient relationships can promote healing and how people make their journey of healing. This post and the next few posts will explore how healing happens. By healing, I don’t necessarily mean being cured, although that can happen too. The definition of healing that I found in my research was: healing means being cured when possible, reducing suffering when cure is not possible and finding meaning beyond the illness experience. If you would like to read the original research paper you can link to it here

This post will be about one of the characteristics of healing doctor-patient relationships that we call Valuing

Valuing

Valuing means very simply to see every patient as a person of worth. One of the patients put it this way in describing his physician: “Everybody who walks in front of her is the same.… She doesn’t care what kind of insurance you have, what color you are, how big you are, how small you are.”

When clinicians see every patient as a person of worth then certain characteristics of the relationship follow.

Finding ways to connect with patients

The doctors that I interviewed looked for ways to connect with patients, partly to help them care what happens to them. One of the doctors said ”I try to love every single patient. And I especially try to love those I initially hate. There has to be some reason why I want them to get better.”

Presence

People in my interviews talked about how important it was for their doctor to give them his/her full attention during their visit. Presence means not looking at his watch, not looking at the computer for most of the visit and not talking on the telephone during the visit. It means looking directly at the patient, paying careful attention to their story and not interrupting until the patient has finished telling their story of illness. As one patient reported, “…she is totally directed and focused on you when she is with you.… This is your time.”

Sufffering With

Another part of valuing is experiencing the patient’s suffering. This is not quite the same as empathy, but more like compassion. One physician described this as “dwelling for a moment in their pain, in their misery, not letting it float off our backs.”

Relativity of Time

When I talk about this research to audiences of doctors, their first response is ”I would love to do all those things, but time pressure is such that I have only 15 minutes for each patient encounter. There is no time to be present and connect with patients.” My response is that if you give your full attention to the patient in that 15 minutes, they will experience that as much longer. One of the doctors I interviewed felt that staying on time was very important, and most of his visits were about 15 minutes. This is what one of his patients said:  “Well he sat there and he listened. And he never rushed you out of the office. You took as long as you needed.”

One of the things I always did after I listened to the patient’s story was to ask the question ”Is there anything else you need to talk to me about today?” That question frequently led to the real reason for the visit. We might or might not have time to completely address all of the issues at that visit, but patients felt that they were heard, and that was important to them. I learned to ask that question because when I didn’t, often when my hand was on the doorknob to leave the exam room, the patient would say ”By the way doc..” and then I would hear the real reason for the visit after having spent the whole visit dealing with something else.

What to look for in your doctor

Hopefully many of you have a primary care doctor that values you in the ways I have described. Here are some red flags that suggest you might look for another doctor. 1. Your doctor interrupts you to ask questions after a few seconds. 2. Your doctor types on the computer for most of the visit and talks to you over her shoulder. 3. Your doctor stands while he talks to you and does not sit down. 4. Your doctor talks about himself for a good part of the visit. 4. Your doctor keeps looking at her watch.

Unfortunately all these things are much more common than they should be. There are doctors and nurse practitioners out there who truly value their patients as whole people and are present with them during visits. If you don’t have one like that, keep looking.

The next post will be about how doctors and patients manage power in relationships.