When I was admitted to medical school, a close friend of my parents gave me a reproduction of a profoundly moving painting called The Doctor, which was painted in 1887 by Sir Luke Fildes and is currently hanging in the Tate Museum in London. The image shows a child lying on two chairs in a humble home. The doctor sits nearby, looking at her intently. On an adjacent table are a mortar and pestle, presumably used to create a medication. The mother sits at a table behind the child, her head down in her hands, probably sobbing. The father stands beside her with his hand on her shoulder, offering her comfort.
The power of the painting is the gaze of the doctor on his patient. Now is the place, the time, the person – he has no other thoughts or concerns except to assist her back to health if he possibly can. We do not know the medical problem, but we can infer it is serious. And we do not know the outcome, although there may be a clue because through the window comes a faint ray of light.
I did not fully appreciate the implications of this work of art when I first received it, but I came to understand that this physician was a healer. He had listened; he was nonjudgmental; he had earned trust. He has done his best but understood that he alone would not be her cause of cure should a cure ensue. He understands that he is but a humble person entrusted with the most important of all missions – to assist others in finding health. He has done his best and, in doing so, exemplifies the characteristics of a healer.
My maternal grandfather, Leonard McClintock, MD., was a general practitioner in New York state. He graduated from Albany Medical School in 1898. He set up his practice in what was then a small town on the Hudson River, Beacon, N.Y. He built a room on the side of their home to serve as his office and used the large wraparound front porch as the waiting room. There were no appointments; you came and sat on the porch until it was your turn. Office hours lasted until the last patient had been seen.
Initially, there was no hospital, and he cared for all patients in the office or at home, although later in his career, he helped to establish a hospital directly across the street. In his day, a physician had relatively few tools to treat someone, so the skill was to make a diagnosis and inform the patient and the family what the situation was and what the course of that illness would probably be. Yes, he could do some things, including treating pain with morphine, removing an inflamed appendix, sewing up lacerations, and delivering babies much more safely than could have been done without the assistance of a trained clinician.
But during the course of his practice, which ended with his death in 1936, medicine began to change toward a much more scientific basis. To a large degree, this was propelled by the influence of Johns Hopkins University School of Medicine and Hospital in Baltimore, MD. Founded in the late 1800s, it instituted the concept that medicine was and should be a science. Therefore, Johns Hopkins would teach a science-based medical practice during four years of medical school. In addition, Hopkins established what we know today as the standard residency training program following medical school.
This was a dramatic change in medical education and training and, as a result, dramatically changed the way physicians thought about medicine and patient care. During my grandfather’s practice, he began to see the beginnings of those changes. For example, insulin was discovered in the 1920s, and the first antibiotics in the 1930s. After his death and the completion of World War II, the National Institutes of Health began to develop, grow and place large sums of money across the country in various medical schools and within its own walls to conduct basic biomedical research.
The result is that today our ability to repair, restore to function or replace an organ, tissue, or cell has moved ahead at a dramatic pace and will do so even more quickly in the coming years. Concurrently, the pharmaceutical industry also became scientific, resulting in a continual outpouring of new drugs that can relieve suffering, reverse harm and cure many diseases while extending our life span. In addition, with the advent of the science of genomics, it is increasingly possible to predict the onset of illness before it occurs and thereby create a preventive approach for the individual patient.
Soon we will have immediate access any time, any place to our medical records, which will be fully digitized, and the safety and quality of medical care will dramatically improve. All of this is because of the science base of medicine, which was introduced over 100 years ago.
Something else has happened, but it has not been appreciated. In the past, illnesses tended to be “acute,” meaning that they occurred, were treated, and got better, or the individual died. For example, if your child developed “strep throat,” the pediatrician gave an antibiotic, and it got better. If it was an inflamed gall bladder, then you were referred to a surgeon who operated, threw away the gallbladder, and you were cured. But today, most illness is chronic and complex as well. For example, if a person survives a heart attack, he may still have some damaged heart muscle and so develops heart failure. This will be with him for life and will need multiple treatments, many medications, probably multiple hospitalizations with an ICU stay or more, and might even get to the point of a heart transplant.
Now that is chronic, and that is complex! So it is also with diabetes, rheumatoid arthritis, many cancers, chronic lung disease, kidney failure, and many other diseases are frequently seen today.
This is a major shift and enormously impacts how we should [but mostly do not] organize the treatment of the patient and their disease, how we should [but mostly do not] organize the payment system for that care, how we should [but mostly do not] use technologies wisely for maintenance, and how we should [but mainly do not] assure quality and safety in patient care.
This is a profound change, but most of the “healthcare reform” approaches do not address the implications of this change to chronic, complex lifelong illnesses. Although aware of the change toward more and more chronic diseases, physicians also tend to want to preserve their current practice patterns developed over the years to handle acute illnesses, even though the current chronic, complex diseases require a different approach.
But in that same time frame of scientific advancement and the rising frequency of chronic illnesses, we also began to lose something in medicine. That loss is the genuine “connection” between the physician and the patient. Most of us feel we do not have enough time with our physician; the physician seems busy and distracted, often by the computer, and not able or willing to listen to our story in full.
From the physician’s perspective, they feel that there is not enough time to spend with an individual patient; not enough time to learn about the family and the environment in which that patient lives, and therefore in which the patient’s disease has occurred; that there is not enough time to focus on preventive instructions or to even talk thoroughly about the plan for the care of a specific illness or problem. But all too much time is spent following mandates, filling out forms, often repeatedly, and then being paid by the insurer well under what the time and effort were worth. Physician burnout has reached epidemic proportions.
Today we need to preserve our newfound skills and techniques, drugs, and devices but also remember that patients are human and need empathy, caring, and attention, not just technology. Equally, providers need the ability (time) to give the care they were trained to provide, the care most wanted to give when they first decided on medicine as a career.
Unfortunately, rather than a true healthcare system, we currently have a dysfunctional American medical care delivery system. We need a healthcare system, but the cards are stacked against it. That said, it can be changed. Probably not by Congress, nor by the insurance companies but only by the unique interaction of doctors and patients demanding what is and could be the very best. Concurrently, one of the best ways to change the system is for companies to realize that they can secure better medical care for their employees while augmenting health and wellness, which will dramatically reduce the company’s and their employees’ costs. That is a win-win all around.
In later articles, I will outline further what patient and their doctors can do to improve care and what employers can do to create true healthcare for their employees.
