Physicianship
restoring the healer’s art to the profession of medicine.
© 2006
Kenneth Hawley Hamilton MD, CM
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Is
today’s physician a healer? Is today’s physician a professional?
Is s-he neither? or both? The answers to these questions are of
vital importance in today’s society. Tremendous societal
pressures exist today that ask us to change the way we think
about ourselves. They not only affect us as individuals, but as
institutions and professions. Costly technologies have thrust
medicine into the forefront of this change and they threaten to
break the bank of the United States. Over the past half-century,
business, politics, and technology have diverted our attention
from medicine as a practice of “healing” to medicine as a
“profession”. This diversion has led to a split in medicine that
exacts great emotional and physical cost from the population it
has served for thousands of years. Healing the split will create
a profession of healers trained in and practicing
“physicianship”.
Physicianship is a term coined by Doctors Sylvia and Richard
Cruess at the McGill University Faculty of Medicine in the mid
1990's when Dr. Richard Cruess was its Dean. They
were aware that a majority of incoming North
American medical students saw themselves as healers. They also
knew that the pressures of training the medical student to be
able to join the medical profession subjugated the healer.
Healers
have been part of all societies for millennia. To heal is
to make whole. Those two words derive from a Germanic
root that also means holy. The implication that healing
is a sacred function emphasizes the importance of the healer in
medicine. Healing as a wholeness implies integrity, which, when
coupled with the implication of sacredness, creates a richly
psychospiritual appreciation for the whole of medicine.
According to Dean Cruess, the professional is “a means of
organizing the delivery of complex services which (society)
requires, including that of a healer. (PowerPoint presentation,
Physicianship, Professionalism and Medicine's Social Contract
with Society)”
Professions, per se, have been a part of Western society since
the Middle Ages when society created guilds and universities.
“Profession” has come to mean an occupation or calling that
requires specialized knowledge, which comes from extensive
academic preparation and training. Cruess also says, “(The)
members (of the profession) are governed by codes of ethics and
profess a commitment to competence, integrity and morality,
altruism, and to the promotion of the public good within their
domain. (ibid.)” Codes of ethics that describe governance and
commitment comprise the oaths found in all professions,
including the medical profession’s Hippocratic Oath (in all of
its interpretations). Today, a host of societal attitudes and
belief systems that challenge the governance and commitment of
the oath create a need to appreciate the value of this clear
description of a profession and to preserve it, for without it
altruism and care cease to exist.
The
Doctors Richard and Sylvia Cruess persuaded the McGill Faculty
of Medicine to critically examine the concept of physicianship
and create a curriculum thereof, citing the need to sustain the
profession’s ability to care. They succeeded, and the Faculty’s
graduating class of 2009 will have been exposed to the precepts
and concepts of physicianship from the very beginning of their
McGill medical studies. Whereas these young physicians comprise
only 167 new physicians out of a cohort of hundreds of thousands of
practicing physicians, is there any hope for the many already
out in practice?
The
reader can readily identify the many harmful pressures on
medicine and those whom it serves. Of great importance is
physicians’ need to spend quality listening time with their
patients. To do so reduces risk of malpractice suits; it may
also increase the effectiveness of their therapies. Medicine
also needs to improve its abilities to serve those with chronic
illness. The placebo effect seems to do its beneficial work in
people who perceive that their doctors care for them. This all
takes time; the question is how to get it.
Two ways
stand out to provide that time: First: Let computers handle a
database that is larger than any physician can possibly put in
their own memory banks. In a December 8, 2005, article called
The computer will see you now, The Economist pointed
out “Medline, a medical database, indexed 3672 articles about
adult coronary-heart disease studies in 2004…. If a physician
took 15 minutes to read each article, it would take 115
eight-hour days to read up on this one clinical area alone.”
Twelve thousand known diseases comprise the medical database;
the reader can draw her or his own conclusion about any one
human’s ability to have a good working knowledge of that
database and its constant flow of changes. Today’s computers
have storage capacity for a database of such size, but do the
current database-management programs with their fixed algorithms
create the opportunity for anything more than cookbook-style
clinical application of the databases? Probably not.... However,
this deficiency stimulated the mind of
Lawrence L. Weed, MD, who
says, “The best medical information must be available to health
care professionals through software at the time they perform; it
is at the point of integrating knowledge and action that they
need help, not in learning the facts themselves.”
In 1969,
Doctor Weed, then professor of medicine at the University of
Vermont, developed the problem-oriented medical record (POMR).
Simultaneously, he created a specialized computer program called
the Problem-Oriented Medical Information System (PROMIS) that
could bring the information of a POMR up to the information
(data) of the PROMIS in a manner that Weed called “knowledge
coupling”. Knowledge coupling (“Couplers”) brought a list of
possibilities to the physician and the patient that were not
simple cookbook, database-managed conclusions. Rather, they
presented the clinical pair—patient and physician—with
diagnostic and treatment options that, according to a long-time
user of PROMIS, Doctor Charles Burger of Bangor, Maine, were the
“best fit for that patient. (Personal communication)”
Given
that a diagnostic accuracy of 80% is acceptable in medicine—as
with expert management of virtually all living systems—Burger
made a powerful discovery… making that “best fit” with his
patients improved his clinical performance beyond the norm. Of
couplers, he says the following, “Couplers create a positive
environment that is immediately perceivable and (they) give us
time to focus on the people-time. Questions of psychosocial
nature are built into most of the couplers, (and they) enrich
the relationships. (Personal communication)” Burger has a large
primary care medical practice with a long waiting list and he
still has time for himself, his family, his friends, and his
hobbies.
Weed
could not get the University of Vermont to adopt PROMIS, so he
left UVM in 1982 to form the Problem-Knowledge Coupling
Corporation (PKC) to bring a continually updated medical
database to professionals using the POMR to reveal diagnostic
possibilities and therapeutic approaches for any given patient’s
symptoms and lab findings. PKC engages patients at every meeting
in such a way that the health-care provider—physician or
physician assistant— has more time to spend with patients
examining (touching) and listening to them— healer functions,
all.
Second:
Bring patients together in dual-purpose supportive groups
“guided” by trained nurses or physician assistants who focus
interactively on helping their patients understand and
participate in their therapies, and who help their patients put
these same therapies in the context of finding that which brings
meaning, value, and purpose to their lives. Such groups play a
valuable role in the management of chronic disease states. In
these groups, both the professional and the healer have active
functions. Such groups are not conventional, facilitated,
therapeutic support groups; rather, they are guided, intentional
supportive groups. They do not concentrate on the
medical, professional model that something is wrong (diagnosis),
something caused it (pathology), and it can be changed
(therapy). Rather, they focus on the healing that comes from
finding answers to the most important questions of life: “Who
are you?” (…more than what you have, have done, or what others
think of you.) “What would you like to have happen in your
life?” (Core passion) “How are you going to attain it?”
(Success) and “What are you going to do with it when you have
it?” (Service) Such groups promise to give both the patient and
the physician the time each needs in order to participate in the
healing process where the physician can promise the patient that
they will do everything in their power to help the patient
achieve those aims.
The
presence of professionals as group guides enables group
participants to help each other to understand their therapies
and provide feedback to their guides about the effectiveness of
their therapies, their qualitative life style effects, and any
desirable changes thereto. Professional guides are ideally
qualified to convey that information to the appropriate
physicians for the most beneficial adjustments in participating
patients’ treatment plans. This group function comprises a vital
component of each patient’s therapies. In this way, it becomes a
reimbursable service that qualitatively and quantitatively
improves the professional aspect of the practice.
Physicianship needs a physician’s time in order to bring the
professional function and the healer function into balance. This
essay presents two means for physicians to acquire that time.
The one decreases the professional’s database management
workload; the other increases the healer’s availability to her
or his patients. Thus, it is possible for medicine to begin to
implement physicianship today, with other means certainly to
follow.
Indeed,
our society needs physicianship for its own health. Given that
the means for taking quality listening and touching time is not
a dream but a manifest reality, society needs to demand it and
medicine needs to provide it. The result... health care reform.
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