Oct 2006 Table of Contents

THE LAST WORD

Comfort Always



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Our most important role as a physician is being a comforter to the sick.

Fam Pract Manag. 2006 Oct;13(9):74.

What a just plain awful day. After an early-morning call from the nursing home about an elderly lifelong smoker who was sick again with pneumonia, I reached the office and found the death certificate for a patient who had just died of a stroke despite perfectly anticoagulated atrial fibrillation. Over the course of the day, I had to tell one man he had pancreatic cancer, another he had lung cancer and a woman that her colposcopy showed cervical cancer. The day ended as I battled with an insurer whose paperwork errors had interminably delayed a patient’s medical coverage.

Driving home after fighting an uphill battle against chaos, sickness and death, I pondered what we can do when the usual “doctoring” doesn’t work. I was reminded of the aphorism “To cure sometimes, to relieve often, to comfort always,” which originated in the 1800s with Dr. Edward Trudeau, founder of a tuberculosis sanatorium.

For centuries, it really was only “sometimes” that physicians cured disease and just a bit more often that they relieved suffering, but they still had a role in comforting. Today, we think of medicine primarily in terms of the interventions we can perform. “To cure sometimes, to relieve often, to comfort always” is a reminder that our role as comforter must provide the basis for our care regardless of whether we can relieve suffering or cure disease.

How do we fulfill our role as comforters?

1. Seek to understand our patients’ agendas. Studies have found that physicians typically interrupt patients after only 23 seconds1 and many patient concerns commonly go unvoiced during visits.2 While it is easy to focus only on what we can or can’t fix with our wealth of procedures, drugs and information, we need to stop and reassess whether we really know what a patient’s agenda is. We can uncover this by learning not to interrupt, by asking first about the emotional and then about the biological, and by asking “Is there anything else?” after the patient explains his or her primary reason for the visit.

2. Stand in their shoes. Recently I went with my father to the emergency department after he collapsed. Fighting the urge to jump in and take over his care, I realized I was seeing things from the patient’s perspective, whereas I was used to seeing things from the doctor’s perspective. This led me to consider how often we really try to understand things from the patient’s perspective. We promote “self-management” and “self-efficacy,” but then we assume patients won’t do anything unless prodded, we label anyone asking for a narcotic by name as a “drug seeker,” and we call patients who disagree with our advice “difficult.” How would our care be different if we tried daily to see the world in the context of our patients’ fears, needs and struggles?

3. Strive for “I-thou.” A patient took me aback at the end of a recent visit by asking, “So, Doc, how’s the marriage?” As I began sharing my joys over being newly married, I realized how much of a psychological barrier I had maintained during the rest of the visit. While we don’t need to be “best buddies” with our patients, we do need to stop hiding behind the professional “doctor” role and taking refuge in an “I-it” relationship, with our patients as objects, rather than striving for an “I-thou” authentic human encounter.3

Whether we can cure disease or relieve suffering, the most important thing we have to offer our patients is ourselves as comforters. That’s hard work, as it requires going the extra mile, being vulnerable and facing the limitations of science and technology. Nonetheless, patients trust us with their vulnerability, and it is our job to provide a person-to-person healing encounter.

About the Author

Dr. Cayley is an assistant professor in the University of Wisconsin Department of Family Medicine, teaching at the Eau Claire Family Medicine Residency and the Augusta Family Medicine Rural Training Site and practicing at Sacred Heart and Luther hospitals in Eau Claire, Wis. This material was initially presented as the Marc Hansen Lectureship at the University of Wisconsin Department of Family Medicine statewide meeting in Madison in September 2005. Dr. Cayley dedicates the article to MH, HB, PM, MC, TC and WC, and to his wife, Adrienne.

Send comments to fpmedit@aafp.org.

1. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281(3):283–287.

2. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320(7244):1246–1250.

3. Buber M. I and Thou. New York, NY: Scribner; 1970.

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