The Distance Between Us

Feb 25, 2013 | Articles

As some of you know, I spent many years teaching medical students at the School of Medicine in Chapel Hill. There was an interesting phenomenon I observed over and over again. When the students entered School in their first year they had what I’d call patient-centered values by and large. They were sympathetic and sensitive to the feelings and needs of patients and these values didn’t need much encouragement. They were good patient advocates. Somewhere along the way there was a switch. As they became more focused on their roles and the heavy responsibilities of becoming a doctor their sympathies often migrated too. As stories would go around of patient encounters that involved some level of conflict or disagreement, they were much more likely to want to defend or justify the needs of the physician.

Growing into the role of the physician is difficult. It involves learning many skills, and an almost impossibly large amount of knowledge. The risks in making mistakes are as high as they come. As a student takes on these responsibilities it is not surprising that their sympathies for the patient might wane. Sympathies lose out in favor of the importance of facts.

In this landscape of the doctor-patient relationship, one earth-shaking consequence of the digital revolution is the patient’s access to facts.  No longer does the doctor own them all. And I observe that this shift is not necessarily bringing a kind of balance to the nature of the interaction that might occur. On the contrary, the new access to good information on the web may and can raise the defensiveness of both roles. I think I see in some of my patient relationships a tendency to hold the cards close to the chest.  An ‘I’m not going to show you my cards (what I know) until you show me yours (what you know)’ kind of dynamic.  Or worse, the initial relationship-negotiating may seem to center on who knows the most. If I know more than you do, I win and call the shots. Not so good I think.  I guess this is not unexpected since so often in the past, the physician and patient have both assumed that how much you know is the most important thing.

If the egoic need to know more than the other can be dismissed, perhaps this new level of knowledge by each patient might introduce a wedge of mutuality into the equation. An equation might be created where facts are recognized as important and relevant but one where other factors take on more value; factors such as the experience of the physician, the values of the patient and a kind of mutual regard. I value your facts, values and want to help. You value my facts, values and want to help. We are in this together. Colleagues! Too much to hope for?

As I work on my patient relationship skills I am increasingly appreciating the importance of another aspect of what lies between us: Kindness.

Have you been hearing or reading about the importance of Adverse Childhood Experiences (ACEs)? This is a large study begun 17 years ago to study the effect on the health of individuals who had been exposed to abuse, neglect or other trauma. The findings of this study are mind-blowing to me. The more ACE’s a person has had, the unhealthier they will be as they grow up.  It is perhaps not so surprising that these children will have more trouble with their emotions, learning, addictions and relationships. But  they will also have problems of their heart, digestion, sleep and autoimmune diseases. The more ACE’s, the more health problems.

Having observed the difficulty of the medical student to maintain the patient’s perspective I am sensitive to this issue in my own practice and as I write this column today I am reminded about the complexity of the doctor-patient relationship. As I think back over the years of my practice I realize again how the distance between us can interfere with not only communication and understanding but also the quality of the care and the effectiveness of the outcomes. I’ve known of and observed the importance of mutual respect as in important factor in this relationship and now as I think about the effects of trauma on my patients I begin to realize the importance of kindness. Here’s to kindness.  Let us all embrace it as a key to our wellbeing.

To Your Health.