Meaningful experiences in medicine

I MEDICINE, SCIENCE, AND SOCIETY

Meaningful Experiences in Medicine WILLIAM T. BRANCH, M.D. Boston, MassachusettsANTHONY SUCHMAN, M.D. Rochester, New York

w r hat makes the practice of medicine meaningful to physicians? Surprisingly, there has been little

formal discussion of this important question, despite growing interest in medical humanism a n d in the meanings that illnesses hold for patients. With all the turmoil in medicine today--physician dissatisfaction, patient dissatisfaction, diminishing interest on the part of students it might be useful to explore what fulfills practitioners and reaffirms their commitment to their profession.

In June 1986, we participated in a discussion with a group of clinicians and teachers in medical schools of their most personally meaningful and rewarding experiences with patients. Initially, the discussion was awkward. We spent several hours defining concepts, such as the term "meaningful." Before long, we realized that abstract talk failed to capture the richness of what was important to us. We decided to elicit this richness by telling stories of actual interactions with patients.

Our stories dealt with the human context of medicine, with the life experiences, of taking care of the ill and being ill, that we and our patients undergo. The clinicians in these stories did not separate their roles as doctors, providing diagnoses and treatments, from their personal roles with patients. Each story began with the clinician struggling with a challenging problem. Intrinsic to the solutions that emerged was the mutual understanding and rapport that developed between patient and doctor. What our storytellers described was consistent enough from one story to another to invite close inspection.

In this article, we relate three "stories" with our comments. To retain the voices of the participants, these stories have been edited minimally. We hope that readers, discovering common threads in the stories, will reflect on the personal meaning of their own work.

COMING INTO RELATION "For the past four years I have been taking care of a

black couple whose names are Charlie and Gertie. Both are in their eighties and have a myriad of medical problems including hypertension, cardiac disease, and renal disease. They would occasionally come to our clinic, frequently late because of difficulty in obtain- ing a ride. Approximately a year ago, after moving to the same neighborhood, I began making home visits. Charlie's health was reasonably stable, but Gertie had recurrent bouts of small bowel obstruction requiring admissions to the hospital and resulting in dwindling weight and strength. After a brief hospitalization she returned home but did not appear to recover as quickly as she had before. She remained frail and weak, and

From the Brigham and Women's Hospital, Boston, Massachusetts, and the Departments of Medicine and Psychiatry, University of Rochester, High- land Hospital, Rochester, New York. Requests for reprints should be ad- dressed to William T. Branch, M.D., Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts O2115. Manuscript submitted May 25, 1989, and accepted in revised form September 7, 1989~

56 January 1990 The American Journal of Medicine Volume 88

frequently complained of abdominal pain not relieved by any of my prescribed medications. Eventually she became weaker, and frequently missed her medications. Finally, she lacked even the energy to take liq- uids.

"One evening, as a summer storm approached, my wife, a nurse, and I went to their house after receiving a call from the public health nurse, who believed that Gertie was dying. As we entered the dilapidated cinder block house, it became unusually dark. We were concerned about the sight we met. With the electricity off, there was just enough light to see blind Charlie sitting in his chair smoking a cigar. In another room, we could hear Gertie moaning a lonesome cry of pain. We went to Gertie and found her delirious and crying with ex- cruciating abdominal pain. It was apparent that she had not been eating or drinking. Her mouth was parched, her eyes were glazed, and her sound was the cry of a suffering animal.

"Reviewing the goals that Gertie and I had previously made to avoid hospitalization, I quickly realized that she would die if she did not receive more medical attention than I could give at home. As my wife and I wrestled with the question of whether we should take her to the hospital, the storm grew fierce outside, with the wind rising and rain pelting down on their tin roof.

"I talked the situation over with Charlie, who said 'Doc, do whatever you think is best for Gertie.' Charlie and Gertie had placed all their trust in me. I found this frightening. I knew that if we at tempted to treat her at home, it would be impossible for my wife or me to care for her, because soon I was to leave town on a scheduled trip.

"I slowly made the decision that it would be inhu- mane to allow Gertie to stay at home with the amount of pain that she was suffering. I felt that if her family were more prepared to care for her, or if my wife and I could help, staying at home might be an option. How- ever, under the circumstances, this was impossible. So I called the rescue squad. While waiting for them to arrive, my wife and I sat with Charlie in their dark living room, with faded pictures of their bygone days surrounding us. For a moment, as the storm raged outside and Gertie moaned with pain, my wife and I looked at one another and tears welled in our eyes. We were both aware of the intimacy we shared with this family, and of how deeply Charlie and Gertie had touched us."

COMMENTS: Physicians are often forced to make choices for their patients when the outcome is uncer- tain, and no optimal solution presents itself. As this physician told his story, his tone of voice conveyed his difficulty when forced to choose between keeping a previous promise to Ger t ie- - to allow her to stay at home--and recognizing her medical needs for hospitalization. His choice was made more difficult because his own travel plans forced him to relinquish caring for Gertie at home.

The physician identified this as an especially meaningful experience in his practice. He had worked hard and made special efforts to support his pat ient- - for

MEANINGFUL EXPERIENCES IN MEDICINE / BRANCH AND SUCHMAN

instance, his house calls, setting mutual goals, and bringing his wife. He cared about Gertie. No doubt this contributed to Charlie's trusting him so much. Per- haps what triggered the doctor's feelings of reward in this story was his own realization of how much he did care about these people.

Medicine may at times seem like a lonely profession. The "objective" detachment that characterizes science can contribute to this loneliness. In this story the doctor was not emotionally "detached" from Charl e and Gertie. In the midst of making difficult decisions, whose outcomes were murky, he remained personally involved with his patient and her husband. In return, he received their personal appreciation and positive regard, which triggered his understanding of why this work was meaningful.

TAKING RISKS "An elderly woman, admitted with sepsis, was found

to have metastatic carcinoma. As her condition deteri- orated, her husband was unable to tell her, or agree to have someone else tell her, the diagnosis. I saw her daily in the role of consultant. Failure to tell the diagnosis was against my principles, and this concerned me.

"One day as I stood on one side of the bed, with her husband on the other side, she turned slowly towards me and looked up saying, 'I have cancer, don't I?' I replied, 'Yes, you do.' She groaned and, covering her face with her hands, said 'But he said he got it all.' I replied carefully, 'I know your surgeon thought he had gotten it. He did the very best he could.' She was silent. We stayed with her for some time, me with a hand on her shoulder. Eventually I left the patient and her husband in the room.

"Soon I suffered second thoughts about telling this patient her diagnosis without having an opportunity to explain why this was necessary to her husband or to the surgeon, her attending physician. Caught up in this anxiety, momentarily and unexpectedly, I was able to identify with, and briefly glimpsed for myself, this woman's isolation and suffering.

"Next day, I returned with hopes of talking with her again and redoing, if I could with more compassion and clarity, what was done the day before. I found the patient comatose, and her husband in tears. Not total- ly comprehending what I had previously said, he con- fronted me, choking with tears, 'Did you tell her she had cancer?' I replied, 'Yes, I had to because she asked me.' 'But I don't know what to say to her,' he said. I explained as gently as possible: 'She may want to know her diagnosis at times. At other times she may not want to talk about it. You don't need to talk about it unless she asks you to.' He was visibly relieved. After a little while, he said, 'Thank you very much,' and I replied, 'You've done so much for her by just being with her.' We stood for a while beside the bed, and when I left, I felt that all along, my efforts, though unrealized by me, had worked to help the husband as much as the patient.

"The next day on approaching the patient's room, I heard laughter. Expecting to find that she had died in the night, and that a different patient now occupied the room, I knocked and then went in. What I found was the patient's several sons and daughters and her husband gathered at the bedside. Although she remained comatose, they explained that in hopes of communicating their feelings to her, they were telling

stories about her past. I then told a story of a previous experience I had with this patient. During an earlier admission, she gave me a little white paper plate, on which she wrote around the front, 'This is a TU-IT, a ROUND T U - I T . ' On the back I found wri t ten, 'WHEN ARE YOU GOING TO GET AROUND TO IT.' We shared a laugh.

"The family asked if I thought she could understand us. I said that even though no one knows this for certain, it was my belief that a comatose patient could understand on some level what was being said. After a few moments of silence, during which I felt close to this family, I raised my hand slowly as a farewell ges- ture, and quietly left the room."

COMMENTS: The patient in this story was dying of cancer. The physician felt trapped between doing the "proper" thing--avoiding his patient's question until he could discuss it with the patient's husband and her attending surgeon--versus doing what he believed was right: telling the patient her diagnosis.

To help his patient in this story, the physician had to risk personally experiencing this patient's pain, fear, loneliness, and despair. Doing so made him vul- nerable to feeling acutely anxious and uncomfortable. The physican also exposed himself to blame, guilt, and self-doubt by taking actions that might have disrupted his relationships with the patient and her family, and with his colleagues.

It was probably the doctor's willingness to take these risks--undoubtedly recognized by his patient's husband as being done earnestly and compassionate- ly - - tha t broke through barriers of fear and isolation in this case, and allowed person-to-person contact to oc- cur.

The doctor felt rewarded because working to over- come his personal inhibitions enabled him to make meaningful, therapeutic contact with his patient and her family.

HELPING OTHERS LEARN "When I was teaching family practice residents, I

accompanied the house staff on morning rounds each Tuesday. During one rotation I had difficulty with a particular resident, M, who was friendly but main- tained a certain distance. He always seemed compe- tent, but avoided asking for any input. All the while he was cordial. I waited for an opening but was not at all sure that one would arrive.

"One morning on rounds, M mentioned an elderly woman with severe congestive heart failure, who he said needed a 'code status.' He also mentioned that she was stone deaf.

"I asked if he had been able to go over the options with her, and he said he had not, because she was so difficult to communicate with. I asked if he had ever discussed 'code status' with a patient. When he admitted not, I suggested that this was one of the hardest things to do but also could be one of the most rewarding. I asked M if he would allow me to work with him and his deaf patient. Grudgingly, he said okay.

We went in and sat on opposite sides of the bed. The patient (whose name I have forgotten, though I can still see her face quite clearly in my mind) was a little bird of a woman, hardly noticeable in the bed, except for her intent eyes. M wrote that he wanted to talk with her about her thoughts regarding the future. He wrote that he imagined she had been thinking about it as she had been lying in the hospital for some days.

January 1990 The American Journal of Medicine Volume 88 57


(He was so sensitive in the words he chose.) Instantly she nodded yes and tears began to form. M wrote that he was not worried right now, and she seemed to understand. She wrote that she had had a good life, and that in the event of an emergency, she really did not want to be kept alive by machines. At this point she was crying, though noiselessly, and M looked over to me helplessly, and silently asked what to do next. Be- cause she was deaf, I said softly that he might write to her that she was doing a good job in talking about some tough issues, and that it must be hard.

"M wrote on the tablet, 'You are doing a very good job at talking about all of this. It is very hard and sad and you are brave.' The patient wrote, 'You are doing a very good job too and I am grateful. It has been lonely.' M, the patient, and I all had tears in our eyes. I caught M's eyes and we smiled. It was a wonderfully rich, sad, happy moment.

COMMENTS: The issues highlighted in the previous clinical stories emerge again, but now in the setting of medical education. The experience that the teacher in this story found meaningful involved relationships made possible by her willingness to risk rejection and embarrassment in responding to her resident and his patient. To reach an apparently reluctant learner, she offered to share with him his burdensome problem of discussing resuscitation orders with a deaf patient. Starting with his needs rather than with her goals as a teacher of psychosocial medicine, she gained access to him, just as the expressions of caring by doctors in the previous stories established connections with their patients.

The resident sensitively initiated a discussion of ad- vanced life-directives with his patient, and elicited an important emotional response from her. When he did not know how to reply to this, his teacher gently guid- ed him to give a personal response that arose from his own feelings. This proved to be very effective. The resulting moment of connection between the patient, doctor, and teacher ensured that the resident's discovery of the power of personal responses would not be forgotten; while the mutual recognition by teacher and resident of the intensity and importance of their inter- action with the patient created a bond between them as well. Being instrumental in helping another doctor learn to express the caring and understanding that she felt for the pat ient - -and seeing the patient benefit from this--were meaningful for this teacher.

DISCUSSION With varying skill and success, the physicians who

told the aforementioned stories tried to help their patients. Their humility was evident in their sharing with us their insecurity and doubt about how to pro- ceed in these situations. If there was an aspect of crisis in the stories, perhaps it reflected where these doctors were in their efforts--wanting to help their patients, the patients' families and, in one case, a resident; not always knowing how; afraid at times to try; but eventually succeeding at least in part.

A common scenario emerged in the three stories. There was the doctor's struggle with a difficult decision or course of action, his or her determination to help, then discovery of a solution that often risked more personal involvement and, finally, willingness to go ahead. Each little scenario led to heightened rapport or understanding, or to a sense of connection be-

tween patient and clinician [1]. Often this resultec from the physicians' willingness to take risks that en- tailed giving up some of the security and control of the formal physician role. Practice should make this process more natural and continuous for the doctors, and more reliably useful for their patients and others.

None of this is astonishing or ought even to be un- usual. What we saw--and what was labeled "meaningful" by the clinicians--were ordinary people treating their patients in honest, caring ways. Doing so, how- ever, can be difficult for physicians, when their patients have compelling needs, and when the required medical decisions are difficult to make.

The experiences resulting from these doctors' efforts rewarded them, so much so that several clinicians described lingering feelings of warmth or purposefulness afterwards. The richness of their experience coin- cided with their learning to combine medical expertise with actions that also expressed their caring and understanding for their patients and others. The meaningful events described in our stories encouraged several clinicians to persevere in their less dramatic but important everyday encounters with patients.

IMPORTANCE TO MEDICINE Medicine currently faces many challenges. There is

concern about the humanistic quality of medical care [2-10], about patient and physician discontent [11- 23], and about the attractiveness of medicine as a ca- reer, particularly the attractiveness of the primary care specialties [23-30]. Do our stories help to address these issues? We think so. Neither the doctors nor the patients in our stories were discontent. The reason seems to be that the medical care rendered in these stories incorporated humanistic values such as caring and understanding. Patients benefited from this, and it enabled the doctors to find meaning and satisfaction in their work. Moreover, they seemed to be discovering how to be better clinicians by combining their clinical experience with the capacity to use themselves as therapeutic agents [31-34].

Their discoveries were not made easily; they strug- gled and were unsure of themselves. Yet they ap- peared to believe that they became more worthwhile people to the extent that they could feel and express caring and understanding for their patients. They also discovered the depth of these values in themselves, through working to express them. In this process, the doctors said they found answers to questions about the validity and purposefulness of their own medical careers.

There can be little doubt that for Charlie and Ger- tie, the two dying patients, and others in these stories, it was the doctor, not just the medications or proce- dures, that proved beneficial. Certainly there are objective benefits to patients from patient-physician relationships [34]; for example, in one study, decreased narcotics requirements and durations of hospitaliza- tions resulted when patients received detailed infor- mation about their expected postoperative courses on the evenings before scheduled surgery [35]. But our stories show that the benefits for patients belong to the moral nature of medical practice as well. They show how physicians can relieve suffering in their patients by providing them with a relationship to a caring person, who will stay with them even when they are frightened and in pain.

58 January 1990 The American Journal of Medicine Volume 88


RESTORING BALANCE None of the clinicians in our discussion group had

previously described experiences like these to his or her col leagues. Perhaps they were unsure about whether they were providing beneficial, meaningful human contact, or were becoming emotionally overin- volved, and so did not want to disclose their own insecurity or discomfort. Perhaps they feared ridicule for appearing "unscientific." Most likely, it simply may not have occurred to them that this was something to talk about. After many years spent working in a field dedicated to rational thought and detached observa- tion, one may learn to overlook one's emotional and spiritual experiences entirely. They do not cease to exist so much as they become unnoticed, and as such, never fully developed as therapeutic instruments.

How can we make emotion and spirit more visible in the present, highly technical medical enterprise? As a first step, we can attend to our subjective experiences. By observing, discussing, and comparing our experiences, we can use consensual validation and peer support to shape the knowledge and attitudes we need to become better communicators, and to relate more' skillfully and therapeutically to our patients. A second step would be to increase instruction in interpersonal skills and patient-physician communication. A num- ber of medical schools, residencies, and continuing medical education programs have taken steps in this direction [36-38]. Our last story illustrates how teachers can work at the bedside to help students learn to communicate and relate more effectively. Such oppor- tunities are numerous, but teachers, as yet, are not. Fortunately, many physicians manage to learn on their own, in a sink-or-swim manner, after entering practice; we believe that the hard-won lessons of these physicians, if sys temized and better understood, might be shared with younger colleagues.

CONCLUSIONS Finally, what makes the practice of medicine mean-

ingful for physicians? In the three stories we have related, we saw clinicians struggle to meet their patients' needs. Their actions--ranging from making a house call to a seriously ill woman to making themselves available to people who were sick or dying- - bespoke efforts to do their very best to combine medical care with making human contact with their patients. The clinicians committed themselves fully to being with their sick patients, even though this meant sharing to an extent the patients' loneliness and suffering. The meaning of these interactions for the physicians rested in large part on their mutuality. How fitting and how curious that the patient-doctor relationship was as important to these physicians as it was to their patients.

ACKNOWLEDGMENT We are grateful for the contributions of the following persons who participated with us and gave permission for us to quote the stories of their experiences with patients, as told in a workshop held at the course, Teaching Medical Interviewing, sponsored by the Society of General Internal Medicine, in June 1986 in Lexington, Kentucky: Carol Boudreau, James Florek, Dan Harrington, Phyllis Hiedihy, Gerald TerIep, Sarah Williams, and Penny Williamson.

REFERENCES 1. Suchman AL, Matthews DA: What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. Ann Intern Med 1988; 108: 125-130.

2, Arnold RM, Povar G J, Howell JD: The humanities, humanistic behavior, and the humane physician: a cautionary note. Ann Intern Med 1987; 106: 313- 318. 3. Clouser KD: Teaching bioethics: strategies, problems and resources. Hastings- on-Hudson, New York: Institute of Society, Ethics, and the Life Sciences. The Hastings Center, 1980. 4. Kleinman A: The illness narratives. Suffering, healing, and the human condition. New York: Basic Books, 1988. 5. Subcommittee on evaluation of humanistic qualities in the internist: A guide to awareness and evaluation of humanistic qualities in the internist. Portland, Oregon: American Board of Internal Medicine, 1985. 6. Evaluation of humanistic qualities in the internist. Position paper, American Board of Internal Medicine. Ann Intern Med 1983; 99: 720-724. 7. Glick S: Humanistic medicine in a modern age. N Engl J Med 1981; 304: 1036- 1038. 8. Goflin R, Zucker MD: Physicians' reactions to patients. A key to teaching humanistic medicine. N Engl J Med 1983; 308: 1059-1063. 9. Odegaard CE: Dear doctor. A personal letter to a physician. Henry J. Kaiser Family Foundation. Menlo Park, California, 1986. 10. Project Panel on the General Professional Education of the Physician and College Preparation for Medicine: Physicians for the twenty first century. J Med Educ 1984; 59(suppl): 1-200. 11. Shorter E: Bedside manners: the troubled history of doctors and patients. New York: Simon and Schuster, 1985. 12. Okrent D: You and the doctor: striving for a better relationship. New York Times Magazine. March 29, 1987. 13. Brice JA: Empathy lost: chronic illness sets a psychiatrist in search of compassion and dignity. Harv Med Alum Bull 1986-87; 60: 28-32. 14. Engel GL: The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129-136. 15. McCue J: The effects of stress on physicians and their medical practice. N Engl J Med 1981; 306: 458-463. 16. Ort RS, Ford AB, Liske RE: The doctor-patient relationship as described by physicians and medical students. J Health Hum Behav 1964; 5: 25-34. 17. Vaillant GE, Sobowale NC, McArthur C: Some psychological vulnerabilities of physicians. N Engl J Med 1972; 287: 372-375. 18. Ingelfinger F: Arrogance. N Engl J Med 1980; 303: 1507-1511. 19. Hilfiker D: Facing our mistakes. N Engl J Med 1984; 310: 118-122. 20, Relman AS: The changing climate of medical practice. N Engl J Med 1987; 316: 333-334. 21. Berrien R: What future for primary care private practice. N Engl J Med 1987; 316: 334-337. 22. Alper PR: Medical practice in the competitive market. N Engl J Med 1987; 316: 337-339. 23. Kralewski JE, Dowd B, Feldman R, Shapiro J: The physician rebellion. N Engl J Med 1987; 316: 339-342. 24. Stoeckle JD: Working on the factory floor (editorial). Ann Intern Med 1987; 107: 250-251. 25. NRMP 1987 Results. Evanston, Illinois: National Resident Matching Program, 1987. 26. Scherr L: Decline in internal medicine careers: a foreboding trend. ACP Observ- er 1987; 7: 22. 27. McCarty D J: Why are today's medical students choosing high-tech- nology specialties over internal medicine? N Engl J Med 1987; 317: 567- 569. 28. Graettinger JS: Internal medicine in the National Resident Match- ing Program 1987: the ides of march. Ann Intern Med 1988; 108: 101- 115. 29. Swick T: Seeking the future of internal medicine. ACP Observer 1987; 7: 1, 12-14. 30. Graettinger JS: The 1988 National Resident Matching Program (editorial). Ann Intern Med 1988; 108: 761-762. 31. Cassell E J: The nature of suffering and the goals of medicine. N Engl J Med 1982; 306: 639-645. 32, Engel GL: Physician-scientists and scientific physicians: revolving the humanism-science dichotomy. Am J Med 1987; 82: 107-111. 33. Hilfiker D: The wounded healer and healing the wounds. A physician looks at his work. New York: Pantheon Books, 1985. 34. Novack DH: Therapeutic aspects of the clinical encounter. J Gen Intern Med 1987; 2: 346-355. 35. Egbert LD, Battit GE, Welch CE, etat Reduction of post-operative pain by encouragement and instruction of patients. N Engl J Med 1964; 270: 825-827. 36. Branch WT: Doctors as "healers": striving to reach our potential. J Gen Intern Med 1987; 2: 356-359. 37. Lipkin M, Quill TE, Napodano R J: The medical interview: a core curriculum for residents in internal medicine. Ann Intern Med 1984; 100: 277-284. 38. Tosteson DC: The Oliver Wendell Holmes Society: a new pathway to general medical education at Harvard Medical School. In: Barrows HS, Peters M J, eds. How to begin reforming the medical curriculum: report of a conference, June 14- 15, 1984. Springfield, Illinois: Southern Illinois University School of Medicine, 1984; 94-116.

January 1990 The American Journal of Medicine Volume 88 59

Documents

Meaningful experiences in medicine