It may not surprise you to learn that I love stories and storytelling.
I have always learned and thought and taught medicine through stories. These days there seems to be an explosion of medical storytelling everywhere. Everyone is watching ‘The Pitt,’ The Nocturnists podcast is extremely popular, even the Globe and Mail is getting into the act with stories by Nick Pimlott. I have been contemplating why this surge of interest is happening, and I think it is because the very foundation of medicine is under threat and both health professionals and patients are trying to protect it.
“Wherever the art of medicine is loved, there is also a love of humanity” – Hippocrates
The art of medicine begins with the doctor-patient relationship. When we first learn how to conduct histories and physicals and construct a differential diagnosis we are engaging in a complex interaction with the patient in front of us. We listen, we look, we hypothesize and probe. We look our patients in the eyes, explain our ideas to them and see if these ideas resonate with their understanding of what is happening to them.
“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” – Hippocrates
“The good physician treats the disease; the great physician treats the patient who has the disease”- William Osler
“A physician does not treat a disease, he rather treats a sick person” – Maimonides
Human beings do not exist in a vacuum. Particularly in a country as large and diverse as Canada, we need to understand the context of the patient and who they are in their lives. Medicine, particularly family medicine, is the surgical arm of epidemiology. Epidemiologists collect data on disease patterns and their probabilities. Family doctors apply that information to their patients’ lives, where they live, what their life stage is, what work they do, their income, their sexual life, their risk factors and lifestyle choices, and where they come from. A chronic cough in downtown Montreal is not likely to be tuberculosis unless the patient is from a high-risk country, but in Nunavut, TB must be high on your differential diagnosis when someone is coughing, sweating and febrile.
“Listen to the patient. He is telling you the diagnosis.”
“Medicine is a science of uncertainty and an art of probability” – Osler
Once we have put this all together in our minds, we co-create our differential diagnosis with our patients and use our diagnostic tests to confirm our ideas. Then the trick is to get the patient to understand and agree to this diagnosis because, as Michael Balint discusses in his book The Doctor, His Patient and The Illness true healing can only happen when the doctor and the patient agree on the diagnosis. This is especially true when the patient is not actively suffering from the disease or the treatment is not easy. This again depends on the bonds of trust between the patient and the physician. We should also refrain from what Balint called “the doctor’s apostolic function” which is demanding that the patient change more than they want to, e.g. “why are you still smoking, I told you to stop!”
“To be a healer is to help patients find their own way through the ordeal of their illness to new wholeness.” – Ian McWhinney
Then, we use the bonds of trust that we have formed with our patient to move them towards health. Our job is to heal in whatever form this takes. In the Jewish tradition we refer to a Refuah Shlaima a true healing of body, mind and spirit.
“To cure sometimes, to relieve often, and to comfort always” is a maxim, often attributed to Hippocrates or 19th-century physician Dr. Edward Trudeau
So, you might ask me, why have I taken you on this historical tour of the medical process and smart people’s ideas about the doctor-patient relationship over the centuries? I will finally get to my point.
Funders of health are institutions, be they provincial governments in Canada or healthcare corporations and hospitals in the U.S., hate the idea of relationship-based healing. It seems to me they are invested in the idea of physicians as commodities, as interchangeable parts of a plug-and-play medical machine. Any doc can substitute for any other doc at any time. There is all kinds of talk about access, after-hours care, team care etc., all of which are important but are a poor substitute for the true healing that can happen within an ongoing continuous relationship.
I have recently met a few docs around my age who are hanging on to their primary care practices despite wishing to retire. Here in Quebec, it is next to impossible to find a physician to take over your practice, particularly for doctors outside academic or GMF practices. They feel unable to abandon the patients they have been bonded with for 40 years. They soldier on, weary but committed because this is more than a job.
I gave up my continuity of care practice a long time ago when I moved back to Montreal from Toronto, and I stopped doing clinical medicine in September, but I still miss the magic.
That is why I am joining the storytelling movement. I started a medical storytelling event in Montreal called: Histories and Physicals.
Stories about medicine are deeply compelling. Every health professional can tell you about the encounters that made them who they are. This show is about the heart of medicine by those most deeply affected: doctors, nurses other health professionals and most importantly, patients.