Remaking Medicine Whole
The quagmire of our business model of caregiving
Tom Hutchinson鈥檚 new book, Whole Person Care, is timely especially for us in the United States. It diagnoses with precision the quagmire we face in the American medical profession as a result of years of thoughtless genuflection at the feet of our business model of caregiving. Our mess has been created by an unholy alliance between the crusading business experts charged with 鈥渂ending the cost curve鈥� and reducing the percentage of GDP we pay for health care with the most reductionist aspects of modern medical science.
Guess which essential part of human caregiving has been given short shrift? Yes, you guessed right鈥攖he human part. Hutchinson masterfully gives voice to the absolute necessity to call a halt to the demise of our vocation. Our vocation is to fully care for our fellow human sufferers by employing the best of modern science in an effort to cure AND the best of our interrelatedness in order to heal.
The saga of the oversold world class billing tool
Take the saga of the vaunted role of the electronic health record (EHR) in solving the problems of medical care as an example. The EHR represents an advancement in our cognitive capacity that has been oversold as an answer to modern medicine鈥檚 problems, perhaps because what it does best is perform as a world class billing tool.
In 2001, the Institute of Medicine鈥檚 鈥淏etter Care at Lower Cost鈥� Report listed the 鈥渄igital infrastructure鈥� as their No. 1 recommendation. We now realize how ludicrous this was, and in 2017 even IOM鈥檚 successor organization, the National Academy of Medicine, acknowledged that the EHR is not our No. 1 need. But still, certain healthcare organizations will spend more than a billion dollars to install the EPIC EHR system in their hospitals.
In 2015, Lisa Rosenbaum, MD, wrote an NEJM article on the EHR and the disruption of medicine. She mentions the disruptive transitions of moving from volume based to so-called 鈥渧alue based care,鈥� the overreach of 鈥渕eaningful use鈥� metrics, the fact that physicians are administrators now and not doctors, and the fact that you can accumulate a lot of data that has very little clinical meaning at the end of the day.
Rosenbaum quotes Robert Wachter, MD, author of The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine鈥檚 Computer Age:
Medicine is at once an enormous business and an exquisitely human endeavor;
it requires the ruthless efficiency of the modern manufacturing plant and the gentle hand holding of the parish priest; it is eminently quantifiable and yet stubbornly not.
Hutchinson鈥檚 book focuses on the very real power of the 鈥済entle hand holding鈥� tradition in medicine to heal human suffering even when we have no curative answers. This is what he means by integrating the very best medical science with what he calls 鈥渕indful clinical congruence鈥� in addressing the vocational vow we鈥檝e taken as physicians to provide care of the whole person who comes to us with hope and trust.
The gulf between doctors and their patients
Hutchinson also refers to Wachter in his chapter on 鈥淭he Digital Doctor.鈥� There鈥檚 growing recognition that while the EHR has a lot to offer in terms of data sharing amongst physicians, it also comes at the cost of intimate connectedness between patients and their doctors.
Hutchinson achingly laments the gulf that has opened up between doctors鈥攃hained to their necessity to meet RVU requirements by writing their billing notes with sufficient CBT coding elements鈥攁nd their patients. As a result, many doctors today face the choice of neglecting their patients by looking at the computer screen and feverishly typing their templated notes during the patient visit, or spending an extra week per month on average catching up on their notes at home.
Is this what is meant by 鈥渧alue based care?鈥� 听Perhaps the answer is not 鈥渢he ruthless efficiency of the modern manufacturing plant鈥� after all, especially when the system now being put into place cuts the hand off the parish priest!
Hutchinson addresses the double-hit such a system delivers to the face of medicine鈥攑atients feeling uncared for, and doctors becoming burned out. This is an unsustainable condition with a very poor prognosis for the healthcare system.
Hutchinson has a prescription鈥攚hole person care.
Remembering our heritage as healers
In eighteen superbly written and succinct chapters that read like meditations, we鈥檙e reminded about our heritage as curers and healers and are taken on a journey that illuminates how we鈥檝e come to this pivotal point in our profession鈥檚 history. We鈥檙e bequeathed the scientific tradition of Hippocrates as well as the equally important tradition of Aesklepios, the Greek god of healing.
One of this book鈥檚 great strengths is that Hutchinson pours his soul into personal narrative. We learn of his maturation as a doctor, his poetic Irish sensibility about life, and his experience as a nephrologist caring for very sick end-stage renal disease patients.
Hutchinson also reveals how his decision to pursue training in palliative care led to his insights about how the crucial role of healing in patients with terminal illness has the potential to inform a renaissance of caregiving in all of clinical medicine. In palliative care, the doctor strives to bring his or her full self to the clinical context. This is in recognition of the suffering patients experience when an illness represents a potential separation threat to themselves.
Here, physicians can provide whole person care with four steps:
1.) Clarify the diagnosis.
2.) Clarify the prognosis from the patient鈥檚 perspective.
3.) Treat the disease.
4.) Create a healing relationship.
Moving towards mindful clinical congruence
Mindful practice requires focus on the patient as a whole person through attention to the connections that make the person unique and separate from their disease. This leads to radiance鈥攁wareness of the patient as a whole person. Physicians through the ages have been honored for their ability to provide the solace of attachment solutions for their patient鈥檚 separation challenges.
This 鈥渕indful clinical congruence鈥� means bringing our full selves as doctors to the clinical context. This is enabled through the learning and practice of mindfulness meditation and the enhancement of resilience in all its dimensions as buffers against burnout.
Hutchinson, with the inspiration of the wise founder of palliative medicine in North America, Balfour Mount, MD, has created a remarkable four-year medical school curriculum at 平特五不中 in mindful medical practice. Let鈥檚 hope it catches on in other medical schools.
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Whole-person care 鈥� the antidote to physician burnout?
CMAJ 鈥� March 21, 2018 鈥� by Kirsten Patrick, Deputy Editor at CMAJ
Rising awareness of the toll that physician burnout is taking on our profession and our healthcare services has inspired numerous organizational physician wellness initiatives and resilience courses aimed at individual physicians. Yet, as experts discuss the relative merits of the system-level approach vs. the individual-wellness-training approach to addressing burnout, one key element seems to be all-but ignored: the healing power of the relationship between physicians and the patients they serve.
Dr. Tom Hutchinson, in his book, Whole Person Care: Transforming Healthcare (Springer International Publishing AG, 2017), suggests that we have lost touch with 鈥渢he interior processes of healing and growth in the individual patient and the practitioner that give meaning to illness and to healthcare,鈥� and in so doing we have created healthcare systems that fail us all. If you are looking to rediscover some meaning in your medical career, read this short but powerful book.
Before physicians become medical students it鈥檚 likely they are asked, more than once, 鈥淲hy do you want to become a doctor?鈥� I was asked this question in my medical school interviews. Many would-be physicians are required to write lengthy personal statements outlining their reasons for wanting to join the medical profession. I鈥檓 sure most of us say something virtuous yet heartfelt about wanting to heal/help people who are sick.
Yet in the process of learning the science and practice of medicine, and often because of the culture of our profession, we start to lose sight of what it means to be a physician and what is truly required of us. We confuse knowing with evidence, practice with treatment, and healing with curing. Aligning ourselves with guidelines, targets, algorithms performance expectations and hierarchy, we forget that much of what supports the healing of others comes from within us and must be discovered rather than learned. We burn out. And as we give our all, trying to rise to all that is expected of us, we wonder why patients don鈥檛 seem to appreciate our efforts. 鈥淭he increasingly external focus of medical practice and teaching has displaced a complementary internal focus,鈥� writes Dr. Hutchinson.
In Whole Person Care, Dr. Hutchinson draws on his decades of experience as a nephrologist and palliative care physician, as well as a decade and a half of co-developing and teaching the 平特五不中 medical school鈥檚 program in Whole Person Care. He begins with a brief history of the evolution of the medical profession, pointing out that healers have long existed in many cultures and our pivot towards a focus on the biomedical model, evidence-based decision-making and health care efficiency are relatively modern developments. He doesn鈥檛 dismiss these important advances, but readers are encouraged to examine how they have affected the quality of the relationship between physician and patient that is essential to healing.
Healing. A key focus of Whole Person Care. But what is it? According to Hutchinson, healing 鈥渂egins with getting people in touch with what gives their life energy, hope鈥︹�� because 鈥渢o deal with illness, or indeed life, we鈥eed the sense of our own value as persons鈥︹�� We need to deliberately see the patient behind the disease. As physicians, working to meet targets and standards, it鈥檚 all too easy to see only the illness and not how it affects the patient. Yet, cure or no cure, patients are deeply affected in ways non-physiological by their experience of disease. There may be a cure but there is not always healing.
I entered medical school when I was 18 years old, in a country where you apply straight from high school and the training is a run-through 6 years. Anticipating second year was all about anticipating meeting the body: the cadaver that we had to dissect. But in the year before I went in to second year, the Department of Family Medicine was given the go-ahead to offer an elective course aimed at helping students understand early in training that patients have context鈥hat they are people, not just bodies with diseases. I applied to be in the first cohort to try the new touchy-feely course, which many looked down on because it meant we got to do a slightly reduced physiology course with the physiotherapy and occupational therapy students as a trade-off to create the time. In hindsight I see that this course taught something akin to whole person care as defined by Dr. Hutchinson in his book. One exercise involved the course facilitators taking video recordings of us conducting mock consultations, after which we critiqued our approach. They compared these videos of us second-year, non-clinical students with videos recorded during an identical exercise undertaken with fifth-year students on their family medicine rotation. It was clear to anyone who watched those videos that the second-year students with relatively little medical knowledge were 鈥榖etter鈥�. Lacking clinical information, we relied on our inherent humanity to talk to the 鈥榩atients鈥� we were faced with; we had empathy in spades while the fifth-year students were mentally distracted by their desire to 鈥榳ork out the diagnosis鈥�.
No, I鈥檓 not implying that it鈥檚 better to be a nice doctor than a well-educated one. But genuine empathy and its value in the service we provide as physicians has come to be underrated. We鈥檝e started to fear having too much empathy. Some might even suggest that, while showing empathy is good for patients, being emotionally empathic may be risky for physicians鈥� wellbeing. Articles about 鈥榗ognitive鈥� empathy 鈥� learning to see things from another鈥檚 point of view 鈥� have suggested that if emotional empathy is too risky then cognitive empathy may do the job just as well. Whole Person Care makes a good case for turning again to true empathic engagement as an antidote to physician burnout and lack of professional fulfillment.
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