Recently I saw an article describing the tension between a patient and her oncologist when considering a follow-up appointment during this coronavirus pandemic. On the surface it posed simple questions. Should they meet and risk cross infection? Could they accomplish their goals through telemedicine? Below the surface it underscored the value of medical ritual and human connection. And, it reminded me of an article I offered (unsuccessfully) to the Washington Post last fall and updated here in the shadow of Covid-19.
Before I get to that, here is the full title I wanted for this post: The Ritual of Medicine: An Art Form Formerly Threatened by the Business of Medicine and Currently Threatened by the Rise of Telemedicine. Debbie informs me that this is too long for the blog and for social media. But there you have it, so you know where I’m going.
Cure Sometimes; Treat Often; Comfort Always
My article began with an old medical adage, frequently attributed to Hippocrates but more likely an aphorism from the Middle Ages, that goes like this: the art of medicine is to “cure sometimes, to treat often, and to comfort always.”
Then, as now, this holds a great deal of truth.
The original meaning was that cures were exceedingly rare and treatments were largely ineffective, but comfort was something that the responsible physician could always offer. Even if such comfort was only in telling the patient that there was nothing more that medicine could do.
In today’s world this adage has been turned upside down. Cures are expected, generally through progressive technologies. Treatments are ubiquitous; indeed, so ubiquitous that they have become transactional (“we can try this, or this, or this…) and are frequently addictive (think opioids). And, the comfort of the medical ritual – the laying on of hands for the physical diagnosis – has been replaced in a variety of ways.
Transactional Treatments: Business Quotas and Telemedicine
In the pre-coronavirus era, the ritual has been replaced by condensed office or hospital visits, a devotion to satisfying computer algorithms, the scheduling of diagnostic X-rays, and the emailing of prescriptions. In the post-coronavirus era, the need to isolate Covid-19 patients has placed physical barriers between patients and their doctors and nurses and telemedicine is being heralded as the next frontier, further distancing doctor and patient from physical contact.
The destructive reality of these transactional treatments is largely ignored. The scene of a primary care physician comforting a patient by reassuring them that there is nothing more that can, or should be done, has become virtually extinct. Such a scene has been replaced by that of a specialist offering one more marginally improved treatment for heart failure, chronic lung disease, cancer, or dementia. Or by another scene of a specialist reflexively intubating a terminally ill elder because no one has had the conversation that could forestall that cruel, ineffective treatment.
What does the loss of medical ritual mean to the practice of medicine and how might a reliance on telemedicine compound this? It means that treatments lose efficacy, patients lose trust, and health professionals suffer more burnout. This is because medical ritual creates and fortifies the doctor/patient relationship. This, in turn, makes patients feel better (belief in a treatment improves the response to it) and doctors more committed to their art.
Medical Ritual: Starts with the Laying on of Hands
What is the definition of medical ritual? Physician author Abraham Verghese believes that medical ritual starts with the laying on of hands in the form of a good physical examination at regular intervals. Too often, an X-ray now replaces this human contact. But the ritual is played out in many other ways. It should include routine eye contact and a concerted effort to avoid getting lost in a computer screen. It must include every opportunity to make appropriate physical contact between a doctor and patient such as personally taking a blood pressure or placing a hand on a patient’s shoulder or forearm before performing a procedure or when walking them into the waiting room.
And in the context of such physical contact, ritualizing caring can be as simple as a follow-up phone call to check on a patient’s progress or an invitation to receive a call if things are not going well. It can be as demanding as an extra, uncompensated, visit to see a hospitalized patient and to hold their hand at the end of the day, to let them know that you are there for them. But these things don’t happen enough because commercialized medicine’s allotment of 7-15 minutes per patient visit is inadequate for the patient and overwhelming for the physician.
The Hard Conversation: Ritual and Responsibility
The ritual of medicine should also include a frank discussion of disease and prognosis, because when a patient knows that a physician is there for them, that physician has earned the right to advise them when nothing more should reasonably be done. Knowing that a doctor is speaking the truth, about the good and bad of a difficult situation, is the most comfort that one can receive.
And trusting them when they say, “nothing more can be done,” is better than suffering the side effects or complications of treatments that are not actually prolonging one’s life and improving its quality.
Television/Telemedicine or Truth Telling
James C. (not his real name) was a 75 year-old man and long-time patient with diverticulitis, diabetes, and stage IV heart failure, who came to see me during the last few months of my practice even though his gastrointestinal symptoms were negligible. He had been hospitalized four times in the prior year and had become unable to bathe or dress himself. Based on this, he sensed, and I knew, that he was in the last chapter of his life. In fact, based on published data, his life expectancy was less than six months no matter what medical treatment was attempted.
Yet his cardiologist had offered him the “newest” treatment, saying something to the effect of, “Here, take this new medication. You might have seen it on TV. It suggests that you will be twenty percent less likely to die. Come back and see me in a week.”
But he preferred a discussion with me that went something like this, “James, I have known you a long time and the situation is difficult, but let me try to help. There is a new medication on TV that wants you to believe it cuts mortality by twenty percent but that is only relative to other treatments with limited follow-up. The absolute benefit is less than three percent. So only one in 36 patients truly benefits and that is only briefly. I am happy for you to try it but I think it is time for you to check that your affairs are in order and emphasize spending time with your family. If you are willing to consider hospice care, we can protect you from futile, potentially painful, hospitalization.”
Emotional Comfort: A Lesson for the Ages or The Result of Ritual
In the current moment, coronavirus represents an existential threat to elderly patients. Those who survive are still subject to chronic illnesses, where cure is impossible, treatment options are limitless, but treatment benefits are limited. Under these circumstances, isn’t emotional comfort the lesson of the ages?
The rituals of medicine are designed to bond doctors and patients. Physical touch informs the doctor about disease progression and supplies emotional comfort to the patient. Such a bond helps to minimize futile treatments and to reassure the patient that the doctor is there for them.
What could be more comforting than that?