Reclaiming the lost meanings of medicine

FOR SOME TIME, I have taught communication and relational skills to medical students and physicians-in-training in an internal medicine residency program in the United States. What became apparent to me early on was that the humanistic, relationship-centred attitudes and behaviours being fostered in the classroom were not always finding their way into the clinic or onto the hospital floors. Sadly enough, this observation is supported by studies on patient–physician communication.1,2 In discussing this phenomenon with my students and colleagues, a common response emerged. They believe the relational behaviours taught in the classroom are not wholly credible in the “real world” of medical practice. Empathic attitudes and behaviours make little sense in terms of survival in residency training or success in practice. It seems as if these compassionate behaviours are being extinguished by a lack of incentive or reward in the system. Valued and rewarded instead are academic acumen, technical knowledge and skill, business savvy, and financial success. To better understand this situation, I began to study the “real world” of medicine more intently. Based on this examination, it is my impression that the fundamental problem in the current healthcare system is a lack of meaning. For the purpose of this article, “meaning” will be defined as the underlying beliefs, guiding principles, and defining philosophies that make up the professional ethic of medicine. What follows are my observations and thoughts, as well as a brief outline of my recommendations. Over the past century, there has been an insidious decline in attention to the philosophy of medicine. We have become less interested in or aware of the age-old values and ethical traditions of our healing profession. This claim is supported by the many studies demonstrating that medical training and professional socialisation, rather than developing and fostering humanistic attitudes and behaviours, actually erode them.3,4 As a result, the core meanings of medicine have been subsumed by the current, dominating societal paradigms of business,5 consumerism,6 the information age,7 technology,8 and the legal system. Clearly, these paradigms are integral and necessary to world culture and modern healthcare, but problems arise when they control the healthcare system, directing the way we care for patients and relate to clinicians. Patient-care surveys reveal a steady decline in public satisfaction with medical care. Research studies repeatedly demonstrate a lack of communication, empathy, and trust in the doctor–patient relationship.9 Although a significant percentage of patients are satisfied with their individual physicians, they and their families are largely displeased with the overall healthcare experience.10 Escalating discontent and distrust are evidenced weekly in newspaper articles and bestselling books.11,12 This widespread public discontent with mainstream medical care is further evidenced by the large and growing movement to seek alternative avenues of medical treatment by turning, literally, to “alternative” practitioners.13 Dangling on the other end of the stethoscope, physicians and other clinicians increasingly find themselves frustrated and demoralised by a work environment devoid of respect and compassion for its employees.14 Morale within the healthcare work environment is at an all-time low.15 Physicians, emotionally exhausted and burned-out, are claiming disabilities and leaving the practice of medicine in unprecedented numbers.16 Loss of autonomy in medical decisionmaking, burdensome and time-consuming administrative hurdles, fear of malpractice litigation, and financial disincentives threaten physicians’ livelihood and their sense of responsibility and professionalism.17 Clinicians, entering the profession with an expectation of providing humanistic medical care, quickly become disappointed and disillusioned.18 The present healthcare system, embedded in the principles of the marketplace, has become a caustic and dehumanising environment for patient and physician alike. Physicians are reduced to interchangeable “providers” and patients to generic “consumers”. Clinicians, now treated like factoryline workers, are forced to process patients as if they were items on a conveyor belt. And so we find ourselves entangled in the paradox of modern healthcare19 — despite astounding scientific achievements and dazzling technological sophistication over the past few decades, societal satisfaction with the healthcare system is declining.20 The question we return to is why. One of the greatest tragedies of the 20th century is that in developing the means we have forgotten the “meaning”.21 Our society has forgotten that the practice of medicine is primarily a humanistic endeavour, not a scientific one.22 We have forgotten that medicine is a healing profession, not a technological one, and that the contribution of a doctor adds up to more than the sum of his or her knowledge and skill. We have forgotten that the patient, as a person, is far more important than the illness; that the illness is far more than the presence of a disease; and that when the cure of Reclaiming the lost meanings of medicine