Friday, August 3, 2018

The Enduring Wisdom of Franz Ingelfinger

On May 5, 1977, Dr. Franz Ingelfinger, editor of the New England Journal of Medicine, delivered the George W. Gay lecture on medical ethics at Harvard Medical School. I was in full time practice at the time and, alas, was not at the lecture.

Dr. Ingelfinger, one of the world's experts on esophageal cancer, had developed the disease he had taught so many others about. Here's what he tells us 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...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."
Yesterday I spoke with a dear friend whose spouse is suffering from a profoundly serious medical condition that calls for complex clinical, psychosocial and financial decisions. My friend reported "if I had a dollar for every time I was asked - 'what should we do about XYZ' - there would be no financial problems to deal with!" My friend described feeling "you are the doctor - what do you think we should do?"

My friend was encountering a common medical ethics dilemma. We physicians are taught to provide "patient-centered" care, to "respect patient and family autonomy" and to avoid "paternalism." But as Dr. Ingelfinger described so poignantly, in the context of serious illness, patients and families also need support and guidance. Physicians need to develop communication skills that allow us to thread between respecting autonomy and providing structure and guidance.

There's no single right answer as to how to do this. I often found it helpful to (a) elicit the patient's goals and values, (b) give my view of what course of action these goals and values called for, but then (c) check on whether, from the patient's perspective, I'd gotten it right.

Over the years with medical students and residents I've often quoted Muhammad Ali's philosophy of boxing: "float like a butterfly/sting like a bee." Ali's eight-word formula conveys the need to embrace and integrate ostensibly incompatible components. Doing this takes experience. It also takes time.

I don't know if my friend's physicians felt rushed. My brilliant colleague Dr. Amy Ship recently wrote about how limited time constrains us in our efforts to be the best we can with patients and families. But whether or not time was a factor for my friend's physicians, Dr. Ingelfinger's guidance from his own experience as a patient holds true forty-one years after his lecture.

(Dr. Ingelfinger's lecture, published in 1980 after his death, is available here. "Physicians as counsellors," a previous post on a related topic, is here. )

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