The Sacred Patient-Healer Relationship

I recently had the honor and pleasure of sitting in on a broadcasted conversation with Faisel Syed, MD on the Sacred Patient-Physician Relationship. (Faisel and Friends) That discussion got me thinking more about the special rapport needed between the Person we call the Patient and the Healer in order for healthcare to be effective and to optimally create value.

Sacred means to be set apart from the typical things of the world. In my opinion, this appropriately describes the patient-doctor relationship. To be effective, the connection needed between patient and healer must be set apart from the mundane and profane things of the world, like counting and cost. Not that these things don’t need to be considered in the business of medicine, but healing transcends business. In fact, without healing, there is no “healthcare business,” only snake oil sales and cynical bill-dropping.

Too many times in today’s world, we have allowed numerous interlopers to get between the patient and the healer, fracturing and sometimes rendering powerless the sanctity of this relationship. These intruders include but are not limited to insurance payers (commercial and governmental), financial production (fee-for-service, volume-based care), non-collaborative team members, the depersonalizing use of technology, and our own self-serving processes.

Commonality and Connection in Healing

In a short Lancet article in 2012 entitled “The Art of Medicine - Caregiving as a moral experience”, Harvard’s Arthur Kleinman wrote

Economic rationality with its imperative of containing costs and maximizing efficiency has come to mute the moral, emotional, religious, and aesthetic expressions of patients and caregivers.” (I would add that instead of assisting our caregiving, we have often allowed the incorporation of technology to participate in this muting - especially in discrete field data collection, documentation, and diagnostic testing.) … Caregiving is one of the foundational moral meanings and practices in human experience everywhere: it defines human values and resists crude reduction to counting and costing. … Acknowledgement of the personhood of sufferers and affirmation of their condition and struggle have long been recognized as the most basic and sustaining moral acts …. (And I would further add that this is only possible through conversation and relationship) 

Presence is central to care-giving and the sense of feeling cared for is a vital component both in creating value and (more importantly) in patient outcomes. Healers must be “present” with their patients - the people they are trying to care for. To do so means to make and maintain a connection with the people we serve and heal. The commonality of our human condition and experience can be a good foundation upon which to build.

In my book Value in Healthcare I write about a coat with two pockets, one containing dust and the other gold. Dust is a reminder of our shared humanity and mortality, and that realization is needed to keep us humble and grounded enough to see the need to engage patients on a personal level. Gold is to remind us of our purpose - not only making our wages but also creating the treasure of a healing presence in the world.

Remember the Why - Caring vs Treating

To adequately render care, we must remember the “why” in our choice to deliver that care. For the vast majority of healthcare providers, we entered this space to ease the pain and suffering of the world and make people’s lives a bit better. Generally, feelings like these are based in compassion. We need to transcend conceptual compassion, though, if we want to be effective healers. For a person in the role of patient, applied compassion by the healer leads to an awareness of “being cared for” rather than merely being “treated.” This is much easier for the physician to do from an empathic position of recognizing one’s own imperfection, frailty, and weaknesses.

Acknowledging the humanity of the individual patient has long been a challenge in medicine. Four of my favorite physician-writers address this topic quite plainly. 

Sir William Osler, often described as the father of modern medicine and a pioneer in medical education during the late nineteenth-century, once said that physicians should “care more particularly for the individual patient than for the special features of the disease.”1 A few years later, in the early twentieth century, writer and physician William Carlos Williams observed how the people that come to see a physician are not merely hearts or livers or kidneys; they are one person with a unique problem.2

More recently, Stanford medical educator Abraham Varghese channeled Osler when he noted, “Disease is easier to recognize than the individual with the disease.”3 Last but not least, Atul Gwande, in his book Better, wrote, “In the work against sickness, we begin not with genetic or cellular interactions, but with human ones.”4 (I would include not solely technical or technological connections, either.)

Electronic medical records, digital questionnaires, remote patient monitoring, discrete points of data, and AI patient touchpoints can all be valuable tools in rendering treatment. However, without meaningful, interactive human relationship, the provision of care and the sense of being cared-for is easily lost. The solution is an appropriate application of relationship and technology

Cohorts vs Individuals: Processes vs Plans

A major principle in Population Health is that processes are based on common needs of a cohort but plans of care are based on individuals and their unique needs. We need to analyze cohorts and their associated data to find patterns that can inform our process building. But if we value the individual patient, we must go a step further and discern their individual needs and how to best apply our resources to help them. 

Un-valued people will simply be pushed through a standard process, whether or not it meets their specific needs. We accentuate people’s value when we engage them in conversation, and that is how we truly learn of the needs and priorities around which we need to build our plans.

Intentionally Nurture and Maintain

In this world of interdisciplinary (IDT) approach to patient care - a much needed and overdue method of rendering care - the physician also owes it to the patient to be collaborative and communicative with the other team members. Sometimes it is through the other IDT members that the Patient-Healer relationship is nourished and maintained, even in the absence of direct contact with the primary care physician.

We must be intentional in our efforts to maintain the “sacred relationship” between the patient and physician/healer. The healing art of medicine is very much like a royal priesthood, since we are allowed into the private spaces of our patients and their lives, both figuratively and literally, and optimization of health and well-being are impeded when the sanctity of this relationship is not nurtured and maintained. Whenever we allow payers or technology or financial pressures or non-collaborative team members to get between the patient and the physician, the benefits of that relationship are compromised, and appropriate healing care turns into ineffective treatment. 

Find the ways to engage patients in conversation. You’ll be surprised both with what you learn from them and with their improved results.

References

1 William Osler, MD. “Address to the students of the Albany Medical College. Albany Medical Annals,” Journal of the Alumni Association of the Albany Medical College, vol. 20 (1899): 307–309. Accessed on https://archive.org/details/albanymedicalann2018medi/page/n319/mode/2up

2 Krista Tippett, “How Do You Want to Be When You Grow Up?,” On Being podcast with Abraham Varghese and Denise Pope, May 23, 2019.

3 Tippett, “How Do You Want to Be.”

4 Atul Gawande, Better (New York: Picador, 2007), 82.