Armand Trousseau stated Medicine is both an art and a science.1
Science gets its due from physicians; artful medicine, highly valued by patients since antiquity, is often neglected. What physicians may not realize is that implementation of the art of medicine will enhance the effectiveness of scientific medicine. I will review some time-honored, easily implemented strategies that will increase patient satisfaction, trust, compliance and reduce the risk of malpractice claims.
Establishing a Human-To-Human Connection
In artful medicine the powers of touch and listening cannot be over-emphasized. What patient could doubt their physician’s humanity and concern after hearing, “I will see you through this, I will not abandon you, I am sorry this happened to you.” Shaking a hand, or reassuring pat on a shoulder makes a connection and meaningful progression toward the act of healing.2 Touching a patient must be in the appropriate context of the exam. Just listening to the patient is therapeutic.3 These caring rituals are transformative; they are at the heart of the patient-physician relationship. In general patients believe physicians are well-trained and capable. Their assessment of physicians is often based on intangibles such as perceived care, concern and listening skills. This traditionally has been called “bedside manner.” A physician with average medical and surgical skills that projects compassion and concern may have a better reputation than a superlative clinician or surgeon that projects a haughty, non-caring, non-listening persona.
Another powerful tool in the art of medicine and communication is eye contact. One increasing dilemma spawned by electronic health records is looking at the monitor as though it were the most important thing in the exam room.
Positioning of the patient, the computer and the physician is important. The physician and staff must look away from the monitor and frequently make eye contact and acknowledge the primacy of the patient not their electronic health record. The conundrum is to create a thorough EHR and a mutually satisfactory patient encounter.
Other important skills to develop are: a look of benevolence, an empathetic attitude, appropriate tone of voice, conveying a high degree of professional competence, being informative, instructive and enlisting the patient as “co-therapist” in their disease treatment plan.
Placebo Effect
The ‘placebo effect’ is profound and poorly understood. The word “placebo” comes from the Latin for “I shall please.” Studies have shown that about 30% of the time, the use of placebos is effective.4 Scientifically, the purpose of a placebo is to serve as an inactive control for randomized clinical studies. However, placebos are not completely inactive.5 It has been demonstrated by neuroscientists using functional MRI that a placebo can produce anesthesia in the pain centers of the brain.6 Words, symbols, and meaningful rituals are active in shaping the patient’s brain. The mind can fool the body - a secret healers and charlatans have known for millennia. Shamans, witch doctors, priests, and medicine men have used placebos with rituals to heal. The ethical use of placebos is outlined in the World Medical Associations Declaration Helsinki.7
Alternative Medicine
Rudyard Kipling said, “The East is east and the West is west and never the twain shall meet.”8 However, today we are incorporating healing therapies from both oriental and occidental worlds. Some alternative medicines, now called Complementary Alternative Medicine (CAM), have been shown scientifically effective.
Acupuncture from Chinese medicine has been a useful adjunct for fifty medical conditions, including stress.9 The National Institute for Health is endorsing acupuncture as a potential treatment for migraines, menstrual cramps and addiction.10
Eastern medicine has taken a more holistic approach. In China, the early stages of medicine and magic were indistinguishable. The harmony of nature - Yin and Yang - a balance. Disease is the result of an imbalance of Yin and Yang. Many medical centers and schools are now adding CAM as part of their curriculum for medical students.
Theology
The history of medicine is interlinked with theology. Faith and superstition are twins.1 Humans have always prayed for help and healing. If their prayers are answered, an offering is given - an “ex-voto,” or a gift in gratitude for fulfillment of the pray-a just as in ancient times. The power of prayer is controversial. A well-constructed scientific controlled investigation The Coronary Bypass Study did not show any difference between the controls and the patients who were prayed for.11 Physicians must always respect the faith traditions and beliefs of their patients.
Rituals Then and Now
In the past, the “patient” (from the Latin “to suffer”) made a pilgrimage to a temple of healing or a shrine to ask for guidance and relief from illness. Today, patients go to a medical center or hospital looking for help. The modern MRI has atavistic rituals. Patients enter the inner sanctum of the shrine - the MRI room. They wear special garments while hearing the incantations of the whirling sounds of the MRI. When the ceremony (procedure) is ended, the priest in the white robes doesn’t look at the entrails of an animal to divine the future, but a doctor holds up an image of the patient’s inner self to guide the path to healing.
Conclusion
The highest level of the practice of medicine includes rendering the most up to date scientific therapeutics using the timeless artistry of compassionate human to human interaction.
Figure 1.
In artful medicine the powers of touch and listening cannot be over-emphasized. What patient could doubt their physician’s humanity and concern after hearing, “I will see you through this, I will not abandon you, I am sorry this happened to you.”
Biography
George Bohigian, MD, MSMA member since 1977, is a Professor of Clinical Ophthalmology in the Department of Ophthalmology and Visual Sciences at Washington University in St. Louis.
Contact: bohigian@att.net
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