by Kenneth H. Hamilton, MD, CM Is today’s physician a healer? Is today’s physician a professional? Is (s)he neither? Or both? The answers to these questions are of vital importance in today’s society. Tremendous societal pressures exist today that ask
by Kenneth H. Hamilton, MD, CM
Is today’s physician a healer? Is today’s physician a professional? Is (s)he neither? Or both? The answers to these questions are of vital importance in today’s society. Tremendous societal pressures exist today that ask us to change the way we think about ourselves. They not only affect us as individuals, but as institutions and professions. Costly technologies have thrust medicine into the forefront of this change and they threaten to break the bank of the United States. Over the past half-century, business, politics, and technology have diverted our attention from medicine as a practice of healing to medicine as a profession of technicians. This diversion has led to a split in medicine that exacts great emotional and physical cost from the population it has served for thousands of years. Healing the split will create a profession of healers trained in and practicing “physicianship”.
Physicianship is a term coined by Doctors Sylvia and Richard Cruess at the McGill University Faculty of Medicine in the 1990s, when Dr. Richard Cruess was its Dean. They were aware that a significant percentage of incoming North American medical students saw themselves as healers; they also knew that the pressures of training the medical student to be able to join the medical profession subjugated the healer.
Healers have been part of all societies for millennia. To heal is to make whole. Those two words derive from a Germanic root that also means holy. The implication that healing is a sacred function emphasizes the importance of the healer in medicine. Healing as a whole implies integrity, which, when coupled with the implication of sacredness, creates a richly psychospiritual appreciation for the whole of medicine.
According to Dean Cruess, the professional is “a means of organizing the delivery of complex services which (society) requires, including that of a healer.” (PowerPoint presentation, Physicianship, Professionalism and Medicine’s Social Contract with Society) Professions, per se, have been a part of Western society since the Middle Ages when society created guilds and universities. “Profession” has come to mean an occupation or calling that requires specialized knowledge, which comes from extensive academic preparation and training. Cruess also says, “(The) members (of the profession) are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. (ibid.)” Codes of ethics that describe governance and commitment comprise the oaths found in all professions, including the medical profession’s Hippocratic Oath (in all of its interpretations). Today, a host of societal attitudes and belief systems that challenge the governance and commitment of the oath create a need to appreciate the value of this clear description of a profession and to preserve it, for without it altruism and care cease to exist.
Doctors Richard and Sylvia Cruess persuaded the McGill Faculty of Medicine to critically examine the concept of physicianship and create a curriculum thereof, citing the need to sustain the profession’s ability to care. They succeeded, and the Faculty’s graduating class of 2009 will have been exposed to the precepts and concepts of physicianship from the very beginning of their McGill medical studies. Whereas these young physicians comprise only 167 new physicians out of a cohort of tens of thousands of practicing physicians, is there any hope for the many already out in practice?
The reader can readily identify the many harmful pressures on medicine and those whom it serves. Of great importance is physicians’ need to spend quality listening time with their patients. To do so reduces risk of malpractice suits; it may also increase the effectiveness of their therapies. Medicine also needs to improve its abilities to serve those with chronic illness. The placebo effect seems to do its beneficial work in people who perceive that their doctors care for them. This all takes time; the question is how to get it.
Two ways stand out for providing that time. First, let computers handle a database that is larger than any physician can possibly put in their own memory banks. In a December 8, 2005, article called The computer will see you now, The Economist pointed out that “Medline, a medical database, indexed 3672 articles about adult coronary-heart disease studies in 2004…. If a physician took 15 minutes to read each article, it would take 115 eight-hour days to read up on this one clinical area alone.” Twelve thousand known diseases comprise the medical database; the reader can draw her or his own conclusion about any one human’s ability to have a good working knowledge of that database and its constant flow of changes. Today’s computers have storage capacity for a database of such size, but do the current database-management programs with their fixed algorithms create the opportunity for anything more than cookbook-style clinical application of the databases? Probably not…. However, this deficiency stimulated the mind of Lawrence L. Weed, MD, who says, “The best medical information must be available to health care professionals through software at the time they perform; it is at the point of integrating knowledge and action that they need help, not in learning the facts themselves.” (From http://www.pkc.com/our_founder.aspx)
In 1969, Doctor Weed, then professor of medicine at the University of Vermont, developed the problem-oriented medical record (POMR). Simultaneously, he created a specialized computer program called the Problem-Oriented Medical Information System (PROMIS) that could bring the information of a POMR up to the information (data) of the PROMIS in a manner that Weed called “knowledge coupling”. Knowledge coupling (“Couplers”) brought a list of possibilities to the physician and the patient that were not simple cookbook, database-managed conclusions. Rather, they presented the clinical pair—patient and physician—with diagnostic and treatment options that, according to a long-time user of PROMIS, Doctor Charles Burger of Bangor, Maine, were the “best fit for that patient.”
Given that a diagnostic accuracy of 80% is acceptable in medicine—as with expert management of virtually all living systems—Burger made a powerful discovery…making that “best fit” with his patients improved his clinical performance beyond the norm. Of couplers, he says the following, “Couplers create a positive environment that is immediately perceivable and (they) give us time to focus on the people-time. Questions of psychosocial nature are built into most of the couplers, (and they) enrich the relationships.” Burger has a large primary care medical practice with a long waiting list and he still has time for himself, his family, his friends, and his hobbies.
Weed could not get the University of Vermont to adopt PROMIS, so he left UVM in 1982 to form the Problem-Knowledge Coupling Corporation (PKC) to bring a continually updated medical database to professionals using the POMR to reveal diagnostic possibilities and therapeutic approaches for any given patient’s symptoms and lab findings. PKC engages patients at every meeting in such a way that the health-care provider—physician or physician assistant— has more time to spend with patients examining (touching) and listening to them— healer functions, all.
Second: Bring patients together in dual-purpose supportive groups “guided” by trained nurses or physician assistants who focus interactively on helping their patients understand and participate in their therapies, and who help their patients put these same therapies in the context of finding that which brings meaning, value, and purpose to their lives. Such groups play a valuable role in the management of chronic disease states. In these groups, both the professional and the healer have active functions. Such groups are not conventional, facilitated, therapeutic support groups; rather, they are guided, intentional supportive groups. They do not concentrate on the medical, professional model that something is wrong (diagnosis), something caused it (pathology), and it can be changed (therapy). Rather, they focus on the healing that comes from finding answers to the most important questions of life: “Who are you?” (…more than what you have, have done, or what others think of you.) “What would you like to have happen in your life?” (Core passion) “How are you going to attain it?” (Success) and “What are you going to do with it when you have it?” (Service) Such groups promise to give both the patient and the physician the time each needs in order to participate in the healing process where the physician can promise the patient that they will do everything in their power to help the patient achieve those aims.
The presence of professionals as group guides enables group participants to help each other to understand their therapies and provide feedback to their guides about the effectiveness of their therapies, their qualitative life style effects, and any desirable changes thereto. Professional guides are ideally qualified to convey that information to the appropriate physicians for the most beneficial adjustments in participating patients’ treatment plans. This group function comprises a vital component of each patient’s therapies. In this way, it becomes a reimbursable service that qualitatively and quantitatively improves the professional aspect of the practice.
Physicianship needs a physician’s time in order to bring the professional function and the healer function into balance. This essay presents two means for physicians to acquire that time. The one decreases the professional’s database management workload; the other increases the healer’s availability to her or his patients. Thus, it is possible for medicine to begin to implement physicianship today, with other means certainly to follow.
Indeed, our society needs physicianship for its own health. Given that the means for taking quality listening and touching time is not a dream but a manifest reality, society needs to demand it and medicine needs to provide it. The result… health care reform.