‘Speak friend and enter’ – riddle on Westgate of Moria (Fellowship of the Ring)
Recently a patient said to me, ‘Thank you for taking an interest.’ This compliment reveals a whole world of problems. It says, in ascending order of alarm –
- Up until now no-one has been interested
- I’ve been looking for someone to invest their time and attention in my problem
- …because until someone takes an interest in you, things don’t get done
- …and if you don’t manage to find a doctor who is interested in you, you’re on your own
- Will anybody actually engage in my problem if I’m not interesting?
So what role does interest play in the patient-doctor relationship?
A patient enters the clinic room. Another referral, another challenge. But the referral letter includes some tantalising pieces of information, and the patient describes how an unusual symptom developed three weeks after returning from, say, Bolivia. Sparks of interest meet the kindling of barely remembered lectures on tropical disease; you search your memory, plan some investigations. After clinic you make a special effort to expedite a scan or ensure that a special blood test is sent away to another lab. The game is afoot. The game? Is this really a game?
Doctors are problem solvers. There are many problems to solve in medicine, and until you qualify those problems are generally intellectual – a combination of pattern recognition when presented with pathology, and cross referencing disparate physical symptoms or signs with the huge database of information that has been created during your medical education. At his or her purest, the useful doctor is an inspired search engine, able to discard irrelevant diagnoses and focus on the probable, before seeking confirmatory data to back up the initial hunch. In training the focus is knowledge and its application. How many doctors reading this, as students, left a ward full of ill patients in a huff, muttering, ‘No signs, no signs!’?
But the first day on the wards presents very different problems to solve, such as how to prioritise an unmanageable list of jobs, how to persuade a radiologist to perform a CT scan in the desired time frame, how to placate the nurse who needs you to re-write a drug chart while you run off to an emergency. A job that seemed cerebral becomes predominantly organisational, and this can make some young doctors downhearted. Then, if you persevere, learn how the system works and become more senior, the opportunity to make diagnoses and test hypotheses yourself comes around. You admit patients, see, hear and feel the signs that you once read about in books, and start to believe in medicine again! You begin to see ‘interesting cases’.
The high priests
What advantage do ‘interesting cases’ have? By virtue of the clinical features that these patients report or display, they generate energy. They stimulate conversations, the swapping of ideas, the easing open of dusty books (or more, likely, tapping into PubMed), the seeking of multiple opinions…the chase is on to get the right answer and find the right treatment. While such focus is commendable, if not vital in some urgent cases, the price may come when doctors get carried away in the search for jigsaw pieces that fit the puzzle and lose sight of the person before them.
In ‘5 patients’ (available to read for free here) the late Michael Crichton wrote about the game that can play out when a student or trainee and their supervisor spar over the meaning of various clues, and presented an impenetrable piece of dialogue as an example:
Student: “The patient has kidney disease consistent with glomerulonephritis.”
Visit (by which he means a resident or attending, I think-PB): “Was there a recent history of infection?”
Student: “Anti-streptolysin liters were low.”
Visit: “Was there a facial rash?”
Student: “LE prep and anti-nuclear antibodies were negative.”
Visit: “Were there eyeground changes?”
Student: “Glucose-tolerance test was normal.”
Visit: “Did you consider rectal biopsy?”
Student: “The tongue was not enlarged.”
The conversation ‘jumps from mountain top to mountain top’ as both parties demonstrate that they know what the other is referring to without saying what they mean explicitly. They are caught up in a trail of clues and deductions; if the patient were listening (as is often the case on ward rounds or teaching clinics), they would be bewildered. But patients do tend to tolerate such jargon heavy, exclusive exchanges, recognising that they are relevant to their own condition even if they are beyond their understand. In such scenarios paternalism, even sacerdotalism (whereby doctors act as mediators between humans and the unknowable mysteries of the body) rise again.
A seductive game
As non-patients, we enjoy such games. Hence the popularity of TV shows like ER (created by Crichton) and House, where the plot is driven by a race against time to understand the relevance of various medical clues. Despite the human interest, the success of these shows depends on the writers’ ability to find a good medical topic, be it radiation sickness or the clichéd ‘lupus’, and set up a sense of jeopardy. The famous whiteboard, on which House’s photogenic team record their ideas, illustrates how medicine must, when pared down to its essentials, focus on the facts. The working title for House was ‘Chasing zebras, circling the drain’, zebras being rare conditions. House was itself inspired by the work of a New Yorker journalist, Berton Roueche, who wrote up real life cases of medical detection from 1940s until his death from suicide by shotgun in the 1990s. Eleven Blue Men (1953) presents 11 such cases, and is for sale in hardback on Amazon at £143! There is no doubt about it, doctors and non-doctors alike are fascinated by zebras.
The film Bigger Than Life, starring James Mason as a patient with polyarteritis nodosa who becomes addicted to cortisone, is based on Berton Roueche’s work.
It and Thou
Back in the real world the physician Jeffrey Ennis explored this progression from the factual to the holistic explored by reflecting on his own experiences. He presented to hospital with neurological symptoms such as shoulder pain and tongue numbness, which were eventually diagnosed as due to Guillain-Barre syndrome. He contrasted the attitude of the emergency physician, which he found ‘insensitive and depersonalizing’ with that of the neurologist, who was ‘comforting’. Ennis then invoked the philosopher Martin Buber’s categories of ‘I-It’ and ‘I-Thou’ relationships, and concluded his piece with this:
‘The physician-patient relationship is the vehicle through which such care is provided. In an I-It relationship, the patient and the problem are objectified, allowing the physician to collect and analyze data about the patient’s problem in an effort to offer a solution. Taken to an extreme, an I-It relationship can be dehumanizing.
At the other end of the spectrum of human interaction is the I-Thou relationship, where the physician experiences the patient as an emotional being. This allows the clinician to empathize with the individual’s situation and to offier psychological support. Taken to an extreme an I-Thou relationship can result in the clinician becoming confluent with the patient’s emotional state. As a result of this, the physician becomes psychologically paralyzed and is unable to offer objective clinical assistance to the patient.’
There is clearly a place for both, but they lie on a spectrum. In my mind the balance tips towards the I-It in emergency situations, where the jeopardy is greatest and the unknowns are numerous. Then, having achieved a degree of safety and stability, the doctor can move towards the I-Thou end of the spectrum. This approach might seem reasonable, but…it fails. It fails because patients are at their most distressed and vulnerable during that early period of uncertainty, and it is at this time that they need to see human qualities and a willingness to empathise. Traditionally, nurses have been better at recognising psychological distress in emergency situations, and have been able to compensate for doctors’ tunnelled medical vision. However, as doctors, the ability to retain an awareness of the whole patient rather than the just the relevant physical features can soften a potentially petrifying experience. Away from severe emergencies, the ability to keep an eye on the Thou without letting the clues in the It slip through unnoticed remains an important medical skill. Melding the two – forensic analysis and human warmth, always was a tall order.
The essence of satisfaction
Most conditions and presentations are easily recognisable and do not excite a fascinated reaction or the doctor to go to the textbooks. It is not acceptable for this majority to perceive themselves as boring in the eyes of their doctors. To each patient their own ailment is of paramount interest, and the doctor who fails to reflect a sense of uniqueness will come across badly. But for those doctors who derive genuine professional pleasure only from the interesting patients, a career in which the majority are not interesting may prove challenging. How to resolve this?
My advice would be – do your best to work in a field that you find interesting and enjoy the ‘game’ when you are required to play it. However, no specialty or department that I know of is exclusively populated by patients who succeed in creating those intellectual sparks. If it doesn’t come naturally, it behoves doctors to develop ways of deriving interest from patients in a way that does not rely solely on their medical condition. The rewards of making the right diagnosis are fleeting, because once made the process of arriving at it becomes irrelevant. It is treatment and management, which may be long term for chronic conditions (such as lupus, for example!), or barely effective in others, that really matters. Moreover, it is the patient’s wellbeing as a whole person, not a collection of affected organs, that is the true measure success. If we as doctors are not ‘interested’ in that, ultimate satisfaction will be denied.
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