Maimonides
The Problem
Healthcare is broken and doctors are
burning out.
That is the current mantra. Healthcare has
gotten too expensive and impersonal, and there is inconsistent access to that
care. Doctors are increasingly stressed and do not seem as engaged. Patients
complain that their doctors are too busy and no longer listen. They ask, “Who
will take care of me as a person and not just as a bunch of x-rays and lab test
results?” I trust my doctor, but why does she seem so distracted and
disengaged.” With all the technological advances of the last several decades,
with genomics and PET scans, MRIs and super-subspecialists for every conceivable
body part, what in the world is happening to the very doctors who care for us? We have all this “High Tech,”
but, where is the “High Touch?” Is
being a physician no longer a calling? Has
it become just another job? Have
patients become commodities? Why has doctoring gone astray?
Gaps
The American system of medicine has become
organized largely as a disease-management system, and not as a health-care
system, with diagnoses and treatments now reduced to an impersonal set of
numerical codes. The concept of “caring” is no longer central to a discussion
of “health care.” Patients are being viewed by their health care providers
more as the sum of their diagnostic testing, or as the
"I-patient," to use the term coined by Abraham Verghese M.D. of
Stanford University, which is to say, the "virtual" patient, seen by
the physician more through the lens of that physician’s pda, laptop or computer
screen, and not as the real, live, hurting individual in front of them.
Of course, this is an oversimplification.
There are legions of dedicated doctors who are serving an ever larger and aging
population, and who do so with empathy. But we as a society have indeed reached a
watershed moment, a saturation point on many fronts. We now live ever more
hectic and hurried lives, with hardly a moment to stop and reflect. With
increasing demands on our time and resources, we have become more anxious, are
getting less sleep, and are making poorer dietary choices. The cumulative
effect of this leads to illness. However, when we get sick, we still want help,
and we have come to expect that help to be prompt and caring. Yet, even when we
do find that help, it seems to have become curiously robotic and disengaged.
It is crucial for the health care profession
– now a health care system,
comprised of collaborative teams of physicians, nurses, PAs, social workers,
ethicists, and even economists – to remain focused, engaged, vibrant, and
committed to caring. We cannot have it any other way. We cannot be a healthy
society, with healthy citizens contributing to the success and happiness of
that society, without an engaged health care team. We need to (re)-train
physicians for a lifetime of caring, so that they continually demonstrate
empathy in their work, and so that they themselves remain energized and happy
in their careers, as this will improve patient outcomes over time.
Physicians cannot heal without caring, and
they cannot care without first being informed by a core set of ideals that will
carry through their training and into their professional careers. Medical schools are set up to
train physicians, and at many of them, there is already an awareness of these
problems which I have outlined, and some initiatives are in place. But the
system, engrained and with its own cultures and rituals and focused on disease
management, has lost sight of its ideals, the ideals embodied in the
Hippocratic Oath.
Solutions: Frameworks in Medical
Humanities
We must re-embed a pathway of caring in
our health care providers and transfer a lifelong set of skills that will
inform them throughout their careers, certainly in the physicians who still
lead the health care team. What is needed is an overarching and cohesive
rubric, which I have entitled The
Course in Compassion: A Curriculum of Caring (The Course). These skills can be identified,
quantified and measured, and will populate The
Course. The Course will be divided into modules, and
taught using an accepted paradigm in most medical schools, the Problem-Based Learning
(PBL) format. Six core modules, which are termed “Frameworks in Medical Humanities,” would be taught over the four years of medical
school in weekly two-hour sessions:
Sensory experience Motor task
Dance and Movement Motion
Research
Music Appreciation
Rhythm/Melody-Making
Narrative & Reflective
writing Diary-Keeping
Mindfulness and
Spirituality Yoga/Meditation
Art & Aesthetic Appreciation
Drawing/Sketching
Empathy Training & Acting Care-Giving
Stakeholders
Patients, physicians and
physicians-in-training (medical students and house officers), medical school
administrators, curriculum designers, The Association of American Medical
Colleges, state licensing boards, and insurance companies – each of these
entities is a stakeholder with a say in physician education. Adopting The Course will require hours of time to
teach its principles, hours that will have to be taken in part from existing
core disciplines as anatomy, biochemistry, pathology, physiology and
microbiology, as well as from time already assigned to the medical students for
hospital wards and outpatient clinics. Conversations will
need to occur at many levels to allow stakeholders to “buy-in” to The Course as a foundational aspect of medical
education.
However, The
Course does not have to be
built “from scratch.” There
exist a number of programs which have pilot projects aligned with my vision and
ideas. A number of medical schools, (Harvard, Yale, Weill Cornell, Johns
Hopkins, Stanford, UCSF, and Columbia, inter
alia), offer courses which champion aspects of The Course. These existing initiatives are already
testing the “proof of principle” of The
Course. They are virtually all elective (that is, they are not required to
graduate), but they exist. Therefore, it is not necessary to “reinvent the
wheel” to populate the syllabus of The
Course. Rather, The Course would be populated with “best
practices” from existing efforts in addition to new initiatives I would add
that have not yet been created or tested.
As Harvard Business School Professor Rosabeth Moss Kanter has written, change is often a result of “Big Vision and Small Steps.” The Big Vision is creating and curating The Course in Compassion: A Curriculum of Caring (The Course). The small, essential and crucial steps are to pilot a series of medical humanities courses in all six modules, and, utilizing longitudinal data analysis, create metrics to measure patient outcomes and satisfaction over time, and physician satisfaction through their careers.
Impact
“It is far more important to know what person the disease has than what disease the person has.”
Hippocrates
Medical humanism is a core set of ideals
that should be taught from college through medical school, internship and
residency, and that should continue to inform a physician through their career.
Medical humanism serves as a beacon and lodestone for how physicians listen,
respond and care for their patients, as well as providing a road map for the
well-being of a physician’s own mind and body over the course of their professional
lives. The Course in Compassion will
be a foundational paradigm around which physicians can be better engaged, and
more motivated and passionate about providing care.
Patients will achieve better outcomes, and physicians and their healthcare
teams will enjoy longer and more fulfilling careers. This is an initiative
which can no longer be fragmented, ad
hoc and elective. The Course must become the epicenter of medical
education and professional practice.
© Vincent P. de Luise MD
FACS
