Friday, November 8, 2013

The Right Kind of Love Between Doctors and Patients

Yesterday I attended a remarkable educational session at the Brigham & Women's Hospital - "Love Stories: Deconstructing and Learning from Successful Doctor-Patient Relationships."

The stars of the session were Doris Bunte, who turned 80 this year, and Dr. Chuck Morris, her primary care physician. The large audience of medical students, residents, and staff, were transfixed by their description of their first appointment, the building of trust, and Dr. Morris's presence as a "guest of honor" at a large 80th birthday celebration.

Here's how Ms. Bunte spoke about her relationship with Chuck Morris:
I feel something inviting in you that says you are understanding me; you appreciate what I am going through. You rise to the expectations I have for a physician. You are a partner with me in my illness, helping me look at all possible angles and decisions. I feel very blessed by how closely you watch me. I appreciate your candor even about missteps between us. I value our honesty with each other when things are not working well for me. I feel a warmth. We have a mutual understanding and have never reached anger. Any illness is frightening. I must trust the doctor, especially as a patient who is alone. It is a very important partnership. 
I was happy that the panelists used the word "love" to characterize an optimal doctor-patient relationship. That's certainly true to my own experience in practice. Even before Facebook degraded the concept of "friend," I felt that "love" better connoted the attitude of deep affection, cherishing, and strong wish for the well-being of the other, that doctors should feel for their patients in the context of long term caretaking relationships.

Early in my practice I learned a lesson I've never forgotten. I inherited as a patient a man almost twice my age (I was 35, he was in his 60s) who'd suffered from a serious psychiatric ailment throughout his adult life that had impeded his capacity for work and caused suffering for himself, his wife, and his children. By the time we met his condition was quiescent. I met with him and his wife every month or two, gave what counsel I could, and tinkered with his medications. But at heart I felt guilty - I liked him and his wife, and felt I was doing nothing for them.

My wife and I wrote off for tickets to an event. (This was in the pre-internet era.) I received a letter in response:
Dear Dr. Sabin:

There were no tickets left for this event, but when I saw who was asking, I managed to find two. You've been such a wonderful doctor for my parents that I wanted to do something for you.

Gratefully yours

The incident still brings tears to my eyes. At the same time that I was feeling guilty about how little I was doing for my patient, he and his wife had conveyed to their adult child how grateful they were for my ministrations. My "technical" offerings were essentially nil, but the letter I received showed just how much the "soft" element - respecting and caring about my patient and his wife mattered to them.

In retrospect, I'd use the term "love" to characterize the bond between me and my patient, his wife, and even their adult child who I'd never met.

Over the years I've had many discussions with primary care and psychiatry residents about how we can establish clinical relationships that a) allow for the right kind of love, b) don't interfere with our capacity for objective analysis, and c) don't leave us overwhelmed when our patients do not do well. I knew these were longstanding questions in medicine. As a first year Harvard Medical student in 1960 I was in a tutorial led by Dr. William Castle, the eminent hematologist. Dr. Castle, who was 63 at the time, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:
Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel? 
Dr. Castle: I would feel terrible! 
Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)
My current understanding is that there are two key factors in learning how to establish loving relationships within which we are adequately "insulated" so that we can think objectively and withstand the bad outcomes that inevitably occur.

First, role modeling. Dr. Castle was passing on to young medical students what his respected teacher had passed on to him 40 years earlier. Dr. Castle wasn't just a brilliant hematologist. He conveyed to us that he loved his patients. We loved him and wanted to be like him. I repeat his story to students 50 years after I heard it from him.

The second factor is practice. Perhaps establishing the right kind of relationship comes naturally to some. For me it didn't. Sometimes I let my emotions interfere with the needed objectivity. Other times I was too stand-offish. But with guidance from teachers, colleagues, and patients, I believe I did better over the years.

I know from observing students that it's a learnable capacity. This was brought home to me years ago when a resident who erred in the direction of being too stand-offish at the start of his training, described a final visit with a patient who was in a nursing facility, close to death from AIDS . At the end of the visit his patient was too tired to sit up any longer but no staff was available to help. The resident picked up his frail and emaciated patient, carried him to his bed, and said a fond goodbye.

That's the right kind of love between the doctor and the patient!