Putting the Patient Back Into Medicine

When Martin A. Samuels was growing up in the suburbs of Cleveland, a house call from his pediatrician J.W. Epstein was a big deal.

Samuels says his mother would make him take a shower and put on new clothes while waiting for Epstein’s old jalopy to come up the drive.

Whether Samuels was suffering from measles or the chicken pox, Epstein was always gentle and reassuring. “It was a very romanticized version of what a doctor was supposed to be,” says Samuels.

“I asked him one day, ‘Can you continue to take care of me now that I’m not a child anymore?’ and he replied, ‘I’ll take care of you until you’re a doctor’” recalls Samuels—now chief of neurology at the Harvard-affiliated Brigham and Women’s Hospital.

For Samuels, Epstein was an ideal physician—skilled in both the scientific and the humane, interactive aspects of medicine.

But that model, he says, is fast disappearing as schools and hospitals increasingly prioritize teaching new medical technologies and clinical guidelines.

Such “evidenced-based” training has been a boon for medical care in a technical sense. But Samuels and colleagues like Medical School associate professor Katharine K. Treadway, who teaches a class at the Medical School called “Introduction to the Profession,” say they worry that the physician’s traditional focus on doctor-patient relationships has been lost amid the shuffle.

“What we don’t do enough of is helping students not just to make a diagnosis and not just to think about the treatment but also to think about what the experience is for the patient in terms of what I’m doing and what I can do to help,” Treadway says.

‘INSPIRED TO ACT’

In an effort to inspire physicians to internalize traditional values of medicine, Samuels used an old form of technology—the radio—to launch a program entitled “Inspired to Act.”

He helped develop the weekly XM Satellite Radio broadcast to highlight more personal aspects of medicine as a response to the heightened pressures doctors face today. Each week, Samuels chats with a guest picked because they “have done something inspiring in medicine,” such as improving clinical care in third-world countries or performing the world’s first kidney transplant.

“It’s just a fascinating program,” says Allan H. Ropper, who helped found the field of neurological intensive care and now serves as executive vice chair of neurology at Brigham and Women’s.

Ropper, who was featured on a segment about the traditional values of medicine, said he believes these values are “immemorial.”

“They revolve around putting the patient first, relieving their suffering,” Ropper says.

What has changed, he says, is how patients are treated.

Because he and Samuels were trained on far more primitive medical technology, Ropper says they benefited from a culture that placed a high premium on the judgment of the doctor.

“One of the ironies of modern technology is that it has made clinical care more expensive and devalued clinical judgment,” Ropper says.

If a patient comes in complaining of a headache, a neurologist who doesn’t find any symptoms after examination can no longer tell the patient, “I don’t find anything serious but you should come back in a few months if you’re still having problems,” Ropper says. Instead, for legal reasons, MRI images are taken to ensure that there really is nothing wrong and then every detail of the encounter must be logged electronically.

A ONE-ON-ONE RELATIONSHIP

Samuels says he worries that this move towards “evidence-based medicine,” in which physicians adhere to pre-made treatment guidelines, will turn doctors into a sort of “functionary, who just sits by the computer and fills in the blanks”—a prospect he considers discomforting for patients.

“The doctor is often not even looking you in the eye, but he’s turned sideways and typing into a computer while you are trying to tell him something very personal, frightening, and important to you,” Samuels says.

When Epstein visited Samuels years ago, he would spend time talking to Samuels and reassure him with a pat on the back that “everything was going to be alright”—a bedside manner that Samuels says he still uses with his patients today.

“You can imagine how a patient would feel if they’re telling you about their husband’s recent diagnosis with lung cancer and you’re looking at the computer,” says Treadway, who teaches “Introduction to the Profession” at the Medical School.

Treadway adds that many medical students and doctors are so focused on diagnosing and treating the problem that they forget what the experience is like for the patient.

She recalls a time when she asked a group of residents who had just delivered a diagnosis of cancer whether any of them had asked the patient, “How are you doing with this?”

One of the senior residents answered that he would never ask that question.

When Treadway asked why, the resident said that he was afraid the patient might go “crazy” and he wouldn’t know what to do.

“The only way you can make the patient feel safe is to make it clear you’re available and you care,” says Treadway.

According to Abraham C. Verghese, a Stanford professor of medicine who has authored books that stress the importance of bedside exams, the doctor-patient relationship is like a ritual: “one individual comes to another and bares their soul and their body,” he says.

Even with the advances in technology and imaging, Verghese, who was featured on one of Samuels’ radio shows, says he believes that the ritual still needs to be taught.

“We have gotten very good at treating virtual 3D patients and rendering them 2D in a sense as a lot of the activity in hospitals centers around computers,” adds Verghese, who coined the term “iPatient” to describe this trend.

Samuels says he continues to carry around a black bag as a symbol of the doctor who sits by the patient and is able to pull everything he needs out of his bag without the patient worrying about issues like the cost-effectiveness of the procedure or whether the doctor is in “cahoots” with a pharmaceutical company.

“I think the danger in medicine is doctors being captured from within and turning into something else, but the patients can’t tell by looking because they still wear white coats and have stethoscopes around their necks,” says Samuels. “When you go to see the doctor, you expect a person who will basically do anything possible to help you, who will listen to you and care about you—you don’t expect a person looking into a computer screen.”

—Staff writer Alissa M. D’Gama can be reached at adgama@fas.harvard.edu.