“Let me warn you before we go into the next room,” the physician whispered, “this woman is crazy!”
I stood in the hallway of the rheumatology clinic with a well-respected physician and was intrigued by his comment. As a third-year medical student, I was excited to have the opportunity to spend one-on-one time with this specialist. We were about to see a patient with severe rheumatoid arthritis. She was the last patient of the day, and I had already learned much from this physician.
Without further explanation, the physician strode into the examination room. I followed and was introduced to a normal-appearing woman in her late 30s who was sitting calmly in a chair in the corner of the room. I did not understand the physician's comment made earlier about the patient until I noticed an extremely large, black three-ring binder on the patient's lap, which she quickly opened as we sat down. The physician's eyes shot to the binder and then to me, indicating without words that the notebook was the source of his warning. Within this giant volume, the patient kept meticulous records of her illness—every blood test result, every radiograph finding and, seemingly, every word the physician had uttered. Without looking up, the patient grilled the physician for her recent laboratory results. What was her erythrocyte sedimentation rate? Rheumatoid factor titer? Complete blood count? Reluctantly, and with annoyance in his voice, the physician surrendered the information she requested.
The rest of the visit continued in the same manner, with the patient furiously recording information in her notebook and frequently interrupting the physician to ask questions. As we concluded the visit and left the room, the physician complained, “See, I told you she was crazy! And that notebook has started driving me crazy, too!”
The physician and I parted ways with a chuckle about the big black book and its obsessive owner. That night as I reflected on the encounter, I began to realize why maintaining the notebook was so important to the patient. The rheumatoid arthritis that she had was severe, and it represented a significant loss of control in her life. Using the notebook was her attempt to regain some of that control. There was not much she could do on her own to combat this disease, but she needed to feel that she was doing something. Chances are that she was not crazy; more likely, she was a normal person reacting to fears that anyone would face in her situation.
Illness does not occur as an isolated physical phenomenon in a person's life. In a broad sense, disease is not simply a disorder of bodily function or structure—it has far-reaching effects on the whole person. Disease can change relationships, alter priorities, challenge faith, raise fears and crush dreams. An illness like rheumatoid arthritis does not just erode joint and serosal surfaces, it encroaches on the spirit and soul as well.
Good and effective medical care goes beyond treating the physical aspects of disease. An old proverb notes, “The purposes of a man's heart are deep waters, but a man of understanding draws them out.” The physician and I did not attempt to enter the deep waters of this patient's life to try to understand her loss of control or any of her feelings. We stayed on the shoreline of medical piety and called “crazy” what we did not take the time to understand. But there is more here than just an interesting empathic exercise for the psychologically inclined. A physician can actually achieve significant therapeutic benefit for a patient by addressing the manifestations of an illness that no stethoscope or laboratory test can detect. Simply put, there is healing power in words.
Stuart and Lieberman, in their book, The Fifteen Minute Hour,1 write, “By being able to engage the person psychologically while laying on hands in the process of examining the body, the physician is in a unique position to help the patient correct whatever disturbance in homeostasis has precipitated the visit to the doctor.” I can often provide as effective a therapy for my patients by acknowledging the feelings of isolation and loss of control that accompany illness as I can by enrolling them in the latest study protocol.
During my residency, I have found these truths to be challenging but never more crucial. As I develop habits and perspectives that will likely last my entire career, it is easy to hide from patients behind biotechnology and medical jargon. Sleepless nights, busy schedules and unread journals make venturing into the deep waters appear inefficient and unproductive. Yet, is it? Do I not ultimately impede my own therapeutic recommendations by ignoring some of the more serious manifestations of my patient's illness? “Physicians are increasingly distancing themselves from the bedside,” writes Dr. Bernard Lown in his introduction to Norman Cousins' book, The Healing Heart,2 “[they] are abandoning the power of the word as a therapeutic tool, and manifesting indifference to the patient's psychological and spiritual needs.” All too often, the concept of the biopsychosocial model of medicine has remained just that—a concept.
|What is going on in your life?
|Affect (the feeling state)
|How do you feel about what is going on?or What's your mood?
|What about the situation troubles you the most?
|How are you handling that?
|That must be difficult for you.
How does a physician go about improving his or her ability to care for the whole patient? The BATHE mnemonic technique (see table),1 is an excellent and efficient method of engaging a patient on an emotional and psychologic level within the confines of a busy schedule. Begin with an initial background question (“What is going on in your life?”); move efficiently into a question concerning affect (“How does that make you feel?”); focus the patient on what is most troubling (“What bothers you the most about the situation?”); assess how the patient is handling the situation (“How are you dealing with this?”); and finally provide an empathic statement (“That must be difficult for you.”) that enables a physician to convey to the patient that he or she has been heard and understood. As Stuart and Lieberman1 note, this feeling of simply being understood is intrinsically therapeutic for a patient.
Yet, the core of these concepts is not just another skill to be mastered but rather a perspective to be maintained. We treat people, not diseases. We should not lose our patients' humanity in the stacks of telephone messages and insurance forms crowding our desks. We should not allow our patients to become a list of ICD-9 codes in our computer databases. We should, instead, have the courage and insight to lift our eyes from their charts, take off our shoes and get our feet wet.