The treatment works just fine. It's the patient who screws it up. This kind of thinking has clouded our minds, probably for centuries. And it has clouded everybody's minds — physicians and patients alike. It has led physicians to think they have efficacious treatment modalities when they don't. At the same time, it has led patients to think they would be well except for their inadequacies. “All I have to do is lose a few pounds, exercise more and take my pills regularly. Why can't I make that work?”
The problem is that patients — and physicians — are only human, and we can never seem to fully appreciate the human element in medicine. We can acknowledge that patients and physicians are human. We can see the joke in “The operation was a success, but the patient died.” But we still fail to grasp the extent and depth of humanity — of what it means to be a person and, especially, what it means to be someone else. Despite our best intentions, we can't help thinking in reductionist modes that dehumanize the people we deal with to some extent and thereby hobble us in our dealings with them.
The dawn of power sharing
How else can we explain the slow and painful migration of the power center in the physician-patient relationship from the physician toward the patient? The evolution of that relationship from what might be called a “doctor's orders” model to a compliance model to an adherence model reflects the ever-so-slow dawning of a realization that Martha Funnell articulates well in this issue's cover story: “You can't get patients to do anything. The motivation to change one's behavior … is largely internal.”
What has held the dawn back is partly, of course, the age-old social tendency to elevate physicians to the status of priests. While patients have found it comforting to have physician-priests who can unilaterally cure what ails them, the resultant relationship is hardly what a transactional analysis guru would have described as “adult-adult.” But a large part of the problem lies deeper than that: It is the difficulty we all have in seeing the person we're talking to — in seeing beyond the face, in seeing through the haze of our own projections and assumptions — and in talking to that person rather than talking to ourselves.
Want proof? Think about the times you've caught yourself (or not caught yourself) talking to a patient in technical terms the patient doesn't begin to understand. Think about the times you've been frustrated because a patient doesn't see things your way. (And ask yourself whether, deep down, you think of patient education as a process of getting the patient to see things your way.) Think about the times you've explained carefully how this or that lifestyle modification could benefit the patient, knowing that you weren't getting through. Think about the times you've acted on the erroneous assumption that you know what the patient's priorities are.
If you find in retrospect that you haven't always granted your patients their full “personhood,” don't feel bad; you're only human. Besides, they've been busily reducing you to your role as physician — or rather, to their misconceptions of that role.
What's particularly encouraging about the approach advocated by Ms. Funnell in this issue is that it is predicated on the assumption that the relationship between a physician and an adult patient is a relationship between two sentient beings, each of whom brings something to the encounter. It's encouraging not because it's something patients and physicians have been clamoring for; I don't know that they have. Rather, the fact that it seems to work may be a sign that doctors and patients are finally ready to treat each other like human beings.