Monday, February 8, 2016

Physicians as "Counsellors"

One of my favorite moments in music is the spectacular chorus in Handel's Messiah:
For unto us a child is born, unto us a son is given,
and the government shall be upon His shoulder;
and His name shall be called Wonderful, Counsellor,
the mighty God, the Everlasting Father, the Prince of Peace.
Within the chorus, I find the word "Counsellor" especially moving. An article I recently read in JAMA - "The Physician's Counsel" - helps me understand what moves me so powerfully.

The author, Donald Misch, tells how at the end of his mother's life, he was the decision-maker for whether to prolong treatment or "pull the plug." He felt an intense need to talk with his physician, who was also a friend, about the decision:
 I did not need another physician to assess the situation intellectually and medically, and yet it was clear that my [physician] friend’s words were critically important to me. I needed a physician’s counsel to let my mother die. This was true even though I was, and am, a physician, dually trained  in internal medicine and psychiatry, and I had on many other occasions helped other families struggle with similar decisions. I needed a physician—not simply other family members or friends or advisors (although all of these were helpful as well)—to tell me that under the particular circumstances of my mother’s situation, my conclusions were reasonable. Because all decisions about significant others in one’s life are laden with emotion, conscious and unconscious meaning, and history, I needed to be sure that my motives for making this irrevocable and lethal decision were not contaminated by my longstanding conflictual relationship with mother. I needed a physician to assure me that my judgment was consistent with my mother’s wishes and her best interests.
I've often written about health care as a "calling." (For examples, see here, here , here, and here.) I think the need Dr. Misch felt reflects the patient's side of what "calling" means. When we're feeling vulnerable we long for a "Counsellor." In Christian faith, it's "the mighty God, the Everlasting Father, the Prince of Peace." In health care it's the caretaker who we trust and rely on.

Many years ago a religious couple from another state came to see me. A friend who they trusted had been my patient, and gave them my name. Their daughter was involved with a man who was less religiously observant than they were. They asked me - should they cut off contact with their daughter?

I was startled. This wasn't the kind of issue I was accustomed to dealing with in my psychiatric practice. I asked why they didn't consult their pastor at home. They said, "he's new, and we don't respect him." After a moment of internal debate I decided to accept the "Counsellor" role they had given me. Was their daughter's potential spouse an honest seeming person? Yes. Was he a drug user? No. Did he treat their daughter well? Yes. Was she happy? Yes. After some more discussion I gave them my counsel. They should not sever ties with their daughter. The family relationship was more important than their views of proper religious practice.

The woman in the couple jumped up. "See - that's what I told you!" Her husband looked a bit crestfallen, but accepted my advice. I never saw them again, but 10-15 years later I heard indirectly that their daughter was happily married to the man I'd been told about.

Dr. Misch's article reminded me of another - Dr. Franz Ingelfinger's 1977 medical ethics lecture, unfortunately titled "Arrogance." Dr. Ingelfinger, editor of the New England Journal of Medicine and one of the world's experts on esophageal cancer, developed esophageal cancer. He tells us that with regard to the difficult question of whether to undergo chemotherapy and radiation after surgery:
I received from physician friends throughout the country a barrage of well-intentioned but contradictory advice. As a result, not only I, but my wife, my son and daughter-in-law (both doctors), and other family members became increasingly confused and emotionally distraught. wise physician friend said, "What you need is a doctor." He was telling me to forget the information I already had and the information I was receiving from many quarters, and to seek instead a person who would dominate, who would tell me what to do, who would in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief."
Medical practice has its mundane moments, but at it's best it embodies what the chorus in the Messiah is singing about. What a privilege it is to be allowed to be a "Counsellor"!


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