Thursday, March 1, 2007

Why Sir William played with dolls, and other thoughts on modern medicine

Family doctors seem to be at the centre of a lot of attention these days. Patients want to have one, towns and cities are on the look out for a few more, hospitals covet them. Where ever you look people are after family doctors. Although family doctors make up about half of physicians in Canada there is clearly a shortage, as I discussed in this post. When someone I meet finds out I'm a real live doctor, the next question is usually about if I am taking on new patients. As a practicing family doctor I could phone any town or city in Canada and have a job within an hour. It's nice to be coveted, but at the same time I think it signifies trouble with the system. Some of the questions it raises are logistical, and some are on the nature of family medicine itself. As I've already discussed some of the logistical challenges around issues of physician supply, I'll focus on the interesting question of what family medicine is really all about.

I went into family medicine with the idea that it was a job that would allow me to do a bunch of different things. Since I was not keen on the idea of doing the same thing day after day it seemed a good fit. It turns out that family medicine is indeed a job where you can do an almost endless variety of things, but I think that definition misses the essence of the thing. At my medical school (Queen's), and probably in most others as well, family medicine was described as a job where you would manage a wide variety of diseases, in a wide variety of ways over the course of a patients lifetime. The emphasis was on the continuity of the encounter, over a patient's lifetime, as the defining factor in family medicine. I hesitate to criticize these definitions, because they do describe in part what a family doctor does. What they don't do is describe what a family doctor is. In fact in my 4 years of medical school and 2 years of residency training discussions of what family doctors did rarely went beyond the party line of 'managing a wide variety of diseases, with emphasis on chronic diseases, in continuity and over the patient's lifetime'.

What I think is lacking in these definitions is the whole point of family medicine. I would argue that as a family doctor I manage and care for people (who happen to have diseases) rather than diseases themselves. Although that may seem cliche and vague, I'll illustrate how it is an important distinction as well as where I think the distinction comes from and what impact it has on patient care.

The notion of what it means to be a good doctor has changed over time in both the minds of the public as well as in the minds of physicians. Here is a picture of the most revered of Canadian (or maybe American or British depending on where you hail from) physicians, Sir William Olser. As usual we see Osler at the bedside, because in his time a good doctor was one who comforted the patient, at the bedside. This was part of the notion of what being a good doctor was all about. Interestingly, what he is doing in the picture (playing with dolls) has nothing at all to do with our modern notion of medicine, but clearly has a great deal to do with making this sick little girl feel better.

So how could a busy, famous, doctor like Sir William find the time to play with dolls with one of his sick patients? Couldn't his time have been better spent finding some other sick people to cure? Of course the reality of his time was that cure was rare. Of course this is a man whose stated goal was “cure rarely, relieve suffering often, and comfort always”. In this picture he is comforting the patient, and therefore relieving suffering. We are left guessing when it comes to the cure. In Sir Williams mind what he is doing (again, playing with dolls) is medicine, by virtue of effect.

Over the intervening years medicine has changed a great deal, with added technologies and increased ability to treat disease. Although medicine is still mentioned as being both a science and an art, the emphasis is now clearly on the science side. With increasing technology came increased specialization within medicine, increasing focus on pathology and physiology, and increasing focus on the treatment of disease, rather than the treatment of people. Within both medicine, and within society an increased ability to cure has resulted in an increased expectation of cure. As Dr. Jack Berger writes, Sir William's old axiom has shifted: to “cure always, relieve suffering if one has the time, and leave the comforting to someone else.”

In fact the idea of suffering has been much lost within medicine. For most doctors suffering equates with pain, and while pain certainly is a cause of suffering the two are not the same. Indeed, suffering has many causes that go far beyond pain. In his excellent book "The Nature of Suffering and the Goals of Medicine" Eric Cassell discusses many of these ideas. Suffering, he states, is caused by threat to the integrity of personhood. What threatens anyone's integrity is a deeply personal matter, yet in order to relieve suffering it is a matter which begs to be understood.

The rise of technology driven medicine has also created the rise of the physician-scientist. The ideal modern physician is not a hand-holder like Sir William, but instead is part time clinician, part time scientist. Busy and important, active in research, this perfect physician is as concerned with discovering the next, best-thing, as with care of the patient at hand.

This new ideal-physician didn't sit easily with family doctors (or GPs) as with less specialized knowledge, less technology, and often not involved in research, they clearly failed to hold their heads above the waterline of the new ideal. And thus a new inferiority complex was born. Family doctors have responded by increasing their science, adding evidence, and participation in clinical trials to their practice, and by endlessly discussing where the expertise and specialization of family doctors really is. Of course there has been a cost to the process, and unfortunately it is not a cost paid by the physicians themselves. In fact the cost has been paid by patients. When family doctors choose to prove their science (and thus deny inferiority), they all too often do so at the expense of comfort and relief of suffering for their patients.

The nature of what specialist physicians and family physicians do is very different. Specialists provide specific answers to (hopefully) specific questions. They focus on a specific problem and a specific system, and as a result often see the patient in the context of that disease. This seems not only rational based on the mode of practice they engage in, but probably facilitates patient care. Family doctors, on the other hand, see that patient first and the disease second. By knowing the patient as a person, a family doctor is well positioned to determine if an event, an injury or a disease is causing suffering to that particular patient, and to relieve that suffering, sometimes without curing the disease.

Family doctors need to be well trained and excellent at making diagnoses. They need to keep abreast of science and research and incorporate it into their practice. Some family doctors need to participate in research themselves to advance family medicine as a science. However, all of that should occur within the context of treating patients as individual people rather than as diseases.

The inferiority complex carried around by many family doctors has caused great harm to the profession. It has shifted focus away from where it belongs, and made family medicine an unpopular career choice. When we can say again that family medicine is a profession about offering excellent care, curing when possible and relieving suffering often I suspect family medicine will feel like a more rewarding job, and will be a more attractive career choice.

I'll end with a case that illustrates some of the above points. The patient was an elderly woman who didn't speak english, and I had a translator in the room to help me. It went something like this:
Dr J: What brings you in today?
discussion between patient and translator
Translator: She says things at home are hard. She doesn't have her strength anymore, and her husband is sicker than he used to be.
long discussion between patient and translator
patient starts crying

Dr J: listening closely, understanding nothing
patient stands up and hugs me
Translator: She says to tell you thank you, you are a good doctor, thank you for listening, she feels better now.

I left the room totally perplexed with no idea of what had gone on. I felt I had done nothing at all to help this lady, and yet I got a hug and lots of thanks out of the encounter. In reflection I think this encounter was mainly about this patients suffering with her loss of Independence, and the fact she had no one to talk to about it. I think she was comforted by talking to me (in spite of the fact that I understood little of the conversation, and most of the conversation was untranslated), and felt better as a result. In fact 'doing nothing' is really the medical term for 'not curing'. I didn't cure this patient, but I did help her to feel better and that seems a good goal to me. To me, that is what taking care of people is all about.

1 comment:

david said...

I hope more people read this blog especially student doctors and current physicians. I feel sometimes that we as students are "bred" to be heartless and be quick and efficient with our patients. However, at the same time we are preached to over and over that compassion is everything.

This essay is refreshing and inspiring. Keep up the good work and good luck in northern Canada.

"The young doctor should look about early for an avocation, a pastime, that will take him away from patients, pills, and potions...No man is really happy or safe without one, and it makes precious little difference what the outside interest may be - botany, beetles, or butterflies - anything will do so long as he straddles a hobby and rides it hard." ~Sir William Osler