“It’s Personal”: Reviving the Human Touch in Healthcare
By Dr. Julie Ponesse
In the broad expanse of Canadian healthcare, the personal touch is fading fast. Our medical system is becoming increasingly impersonal and transactional, relying on technologies which promise efficiency, cost-reduction, and scale at the expense of the uniquely human virtues that should lie at the centre of the physician-patient relationship.
Technology isn’t the only factor depersonalizing medicine. Another is the fragmentation of the modern healthcare “team,” which resembles a revolving door of ever-more hyper-specialized specialists, each of whom is an expert in a narrow slice of pathology, but none of whom seems to have the time, and possibly the skill, to intimately understand the person seeking care.
This is a serious problem because, to state the obvious, patients are not pathologies. A heart disease patient does not experience atherosclerosis as a thickening of arteries but as the inability to breath comfortably, to run after one’s grandchildren, to support a friend. An infertility patient does not experience her illness as a uterine abnormality but as disappointment, unworthiness, a future of unfulfilled dreams. A cancer patient does not experience his malignancy as a proliferation of abnormal cells but as a pervading fear of mortality, as the struggle to recognize himself in the mirror. Illness represents not just a bodily disorder but a crisis of identity and meaning, a profound disruption of the life we once envisioned for ourselves.
Technology and biomedical specialization aren’t themselves the problem; the problem is our assumption that they can substitute for the distinctly human qualities which characterize truly patient-centred care. As Sociologist Timothy Hoff points out, “Technology such as electronic health records and mobile health apps can further the depths of an already solid provider-patient bond, but it can't replace it.”
The word care comes from the Old English word caru and the Gothic word kara which refer to “sorrow,” “worry,” and “concern.” At its core, this is what healthcare should be: a concern for and commitment to address the sorrow of others. In seeking to make healthcare more efficient, clinicians must keep the essence of care firmly in view. No matter how advanced technology and biomedicine become, it will always be the distinctly human traits of attention, trust, and compassion which lay the foundation for genuine healing.
Humans Are Not Machines
The depersonalization of healthcare stems partly from the reductionist, biomedical framework which dominated medicine for much of the 20th century. Through a biomedical lens, medicine viewed patients more as machines to be manipulated than humans to be healed.
For all its flaws, this approach led to stunning, liberating therapeutic advances. From antibiotics to pacemakers, organ transplants to gene therapy, biomedical and technological innovations have saved countless lives. But this hyper-focus on the component parts of the physical body, in which physicians act as specialized technicians, has progressively eclipsed the essential role of the physician as a human caregiver. Unsurprisingly, this transition has left many patients psychologically and emotionally unmoored.
We’ve known this for decades. Take, for example, the research describing the factors most likely to predict whether a patient will sue her doctor. It turns out that the more time doctors spend with their patients, and the better their communications skills (i.e., using humour, checking for understanding, asking for the patient’s perspective), the less likely they are to face a malpractice complaint. When it comes to patient satisfaction, it’s not enough to provide good care; it’s integral to make the patient feel cared for.
Becoming Whole Again
The word health comes from the old English word for “whole.” By focusing so intently on treating disease, medicine sometimes loses sight of the deeper essence of health: to become whole. True healing involves much more than the physical body; it also concerns the preservation of less tangible but no less important aspects of a person, such as their well-being, dignity, and integrity.
The suffering inherent in illness does not arise only from the pain of a pathology but also, and sometimes even more significantly, from the meaning patients ascribe to their illness. In fact, recent psychological research suggests that how a person views illness may play a bigger role in determining health outcomes than the actual severity of disease. As psychologists Keith Petrie and John Weinman explain,
“Illness perceptions are frameworks or working models that patients construct to make sense of their symptoms and medical conditions…The major components include how the illness was caused, how long it will last, what the consequences of the illness are for the patient’s life and family, the symptoms that are part of the illness, and how the condition is controlled or cured. Research has demonstrated that patients’ perceptions of their illness along these dimensions vary widely, even between patients with similar illnesses or injuries.”
It is possible, in other words, for two people to have the exact same disease, but an entirely different experience of it. Illness is, therefore, always intensely personal. Given this truth, when the health care system slowly but systematically alienates what allows patients and doctors to foster a relationship, healthcare crises (of unsustainable cost, lack of quality and patient trust in the system) inevitably emerge.
Creating the Conditions for Healing
It is in the clinical encounter that the worlds of the physician and patient meet. In an effective healing relationship these two worlds must somehow interact positively around the common goal of making the patient ‘whole’ again, or, if that is impossible, lessening the impact of sickness. This demands that the physician has compassion (literally “to suffer together”), which is not just a matter of being kind but of making a sincere attempt to comprehend the patient’s experience of illness.
Alfred Schutz called this the “face-to-face relationship” – one in which the participants share time and space in an effort to perceive and understand one another. In the complex dance of the clinical encounter, one of the essential preconditions for feeling understood is undivided attention, a quality that the philosopher Simone Weil aptly called “the rarest and purest form of generosity.”
Physician and bioethicist, Edmund Pellegrino, expanded on Schutz’s ideas when he outlined a “phenomenological orientation” with which to analyze the essential qualities of the healing relationship. It involves setting aside one’s assumptions, listening with genuine curiosity to grasp the other’s experience: what it is like to be ill, what it is like to be healed, and what it is like to promise to heal. One of the assumptions of this approach is that the meaning of illness to the patient is always qualitatively different than the meaning assigned by the physician.
In a famous article about medicine’s blindness to “person-centered care”, Dr. Richard Baron, an internist and geriatrician, captured this distinction beautifully. One morning on rounds, while using a stethoscope to auscultate a patient’s chest, the patient started to ask Dr. Baron a question. He reflexively stopped the patient: “Quiet. I can’t hear you while I’m listening.” Baron felt that this example was emblematic of “a deep confusion in medicine today … It is as if physicians and patients have come to inhabit different universes, and medicine, rather than being a bridge between us, has become one of the major forces keeping us apart.”
Much has changed in health care over the last few decades, and especially the last few years, to exacerbate this disconnect. A prime example is the intrusion of the computer into the examining room. In conversing with, and even examining, the patient, the doctor faces the screen – not the patient – disrupting verbal and nonverbal communication and limiting the depth of the interaction. Add to this the ever-reducing amount of time allotted to the office visit, plus the increasing burden of administrative tasks and electronic health records, and it’s little wonder that physicians don’t have time to pay attention to the most important thing: the patient’s story.
Another effect of these transformations in medicine is the erosion of trust in the healing relationship. In professing to be able to help, the physician invites trust in his knowledge, competence, and moral character. Implicit in this profession is the dedication to use his knowledge for the patient’s benefit—not his own, not society’s or the interests of any other third-party. Given the complex web of interests in health care today, and especially the regulatory capture of the COVID era, it is now more difficult than ever for patients to trust that a physician has the freedom to act without constraint in arriving at a decision about how best to act on their behalf.
Charting a New Course
We must return to the roots of humanism on which health care was originally based.
The history of medicine is characterized by a pastoral approach to care and by the assumption that continuity of care, individual attention, and comprehensive communication should be valued above efficiency and economy. Personalised medicine, which encompasses the tailoring of medical treatment on the basis of individual patient characteristics, needs and preferences should be incorporated. As William Osler said over 100 years ago, we must move from a doctor-centred approach to a patient-centred approach.
We need to understand the difference between facts and values, and realize that no amount of data and technology, by themselves, will substitute for the distinctly human qualities that heal. Then we need to commit to a set of values about what physician-patient relationships should look like, which will become the guiding principles for reframing health care, from the bottom-up. Only with this foundation in place can technologies be integrated in a way that retains the healing essence of medicine.
The path towards patient-centred medicine will be challenging, but the destination – a healthcare system that values and prioritizes people over pathology – is worth every step. We can and must reclaim the personal touch in healthcare. Let's chart this new course, together.
References
https://medicalxpress.com/news/2014-02-healthcare-transactional-impersonal.html
Merriam-Webster. (n.d.). Care. In Merriam-Webster.com dictionary. Retrieved May 19, 2023, from https://www.merriam-webster.com/dictionary/care
Levinson, W., Roter, D. L., Mullooly, J. P., Dull, V. T., & Frankel, R. M. (1997). Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. Jama, 277(7), 553-559.
Patients' Perceptions of Their Illness: The Dynamo of Volition in Health Care Keith J. Petrie and John Weinman. Current Directions in Psychological Science. 21, No. 1 (FEBRUARY 2012), pp. 60-65 (6 pages) Published By: Sage Publications, Inc.
Schutz, Alfred. 1962. Symbol, reality, and society. In Collected papers I: The problem of social reality, ed. Maurice Natanson, 287– The Hague: Martinus Nijhoff.
Letter to Joë Bousquet on April 13, 1942. "Correspondance", published by Editions l'Age d'Homme in Lausanne, p. 18, 1982.
Pellegrino, Edmund D. 2004. Philosophy of medicine and medical ethics: A phenomenological perspective. In Handbook of bioethics: Taking stock of the field from a philosophical perspective, ed. George Khushf, 183– Dordrecht: Kluwer.
Baron, R. J. (1985). An introduction to medical phenomenology: I can't hear you while I'm listening. Annals of Internal Medicine, 103(4), 606-611.