The Bridge

In 1700, there was a common joke; “There is a big difference between a good doctor and a bad doctor, but there is no difference between a good doctor and no doctor at all.”  Apparently, medicine did not have a lot to offer.  300 years later, we still struggle to define what makes a bad doctor, a good doctor or what we all seek, a “great” physician and healer.

Immense advances in biology and science have completely transformed medicine.  A hundred years ago, care was given in the home, with the patient, family, neighbors and friends intimately involved. The treatments were those of common sense and folk remedy.  You recovered or you did not, and therapy little altered that natural course.  Irrational thought, emotion, superstition, and prayer mixed with the powerful support of those that knew and loved the patient.  Medicine was not science; it was Mother Nature and spiritual healing.

This changed with a crescendo of discoveries; bacteria cause infection, we are built of cells, blood flows instead of humors, anesthesia makes surgery possible and the key to life is in our genes.  Miraculous therapies developed which require extensive training to administer, large institutions to house, complex systems to organize, banks to finance, august schools to teach and myriad manufacturers to produce the magic potions.  Thus was born a radically different health care system.

This means medicine, healthcare, is no longer a thing for the home given by friends to patients rapped in blankets by the fire, it is given in clinics and hospitals surrounded by professors, doctors, nurses, encased in tile, glass, brick and metal; sterile, pure, and measured.  The medical care, which we gave each other for thousands of years, was warm, irrational and emotional; the new system is cold, rational and calculated. We still live in our homes, but we give our bodies to heal in assembly line, structured, institutions.

The major problem with this model is that the patient and family who are affected by illness are still soft, delicate and our personal lives intangible.  In the home we use words like family, love, guilt, longing, sharing, anger and tears.  Industrial health uses words like staffing, data, quality, cost, complications and results.  Each day, we touch, share, mend, and every person is, at least a little, transformed by disease.  In the hospital the core management concepts are objectivity, analysis, and sterility; the sicker someone gets the more isolated, until everyone, including the patient, wears a mask.  In the home, we share the sick room and bed, in the hospital bedrails, sterile gowns and bubble rooms keep us apart.

Therefore, there is an immense chasm, a gap, between who we are as feeling, connected members of society and the industrial, scientific model of medical care. We do not surrender our bodies easily to become grist in the medical machine; therefore, we plummet into the gap with the resulting confusion, depression, terror, error, side effects and very often the loss of opportunity to heal. If we do survive, we may be so damaged by the cogs of the wheel that it becomes hard to be a feeling, living person, again.

While a good doctor must have a solid foundation of knowledge and the proper skills to perform his or her specialized task, I believe that the “great” doctor is one who recognizes, at least intuitively, the gap between the emotional, irrational state in which we live our lives and the rational- objective structure of the healthcare system.  The skilled physician understands that he must bridge the chasm.

This does not mean forcing the patient to become an emotionless robot, but rather helping the patient to be “human,” even as the health machine is running.  The best physicians accept the emotions of the patient as healthy, and do not try to suppress and deny those needs. He helps the patient receive rational care, but not lose who they are and supports them so they may cross back and forth between these two disparate worlds. This requires a love of his fellowman, the skill of a fine teacher and above all the patience to listen and understand what each patient feels.

The modern healthcare system was not designed with the real people in mind.  It is constructed for Homo sapiens, a carbon based biologic machine.  Fortunately, that is not all that we are … we are complex, loving, spiritual, dreaming, hoping, learning creatures.  Until the day when medicine is based on these marvelous ideas, we will need guides to lead us in that bizarre healthcare land.  A good doctor is always better than a bad one, but a great doctor is one that touches the human soul.

14 Comments

  • Mary
    Another amazing post, Doc! By your own definition, you have achieved greatness! Even in this impersonal medium, your ability to connect with people you will never meet about their most intimate challenges has been both illuminating and humbling for me. I have been blessed with great doctors and have been cursed with bad ones. You remind me to extend deep gratitude to the first group!
    • James Salwitz, MD
      Thank you for your generous thoughts, jcs
  • Another phenomenal post, except I would say 'he or she' when referring to doctors! I believe you are a great doctor!
    • James Salwitz, MD
      You are absolutely right re the he/she thought. We really need another pronoun. When one is trying to write sentances which flow, he/she is cumbersome and "they" or "them" is not yet accepted. I have tried alternating he and she in different parts of a piece, but it just looks wierd. This is an especially important issue at this time with the transition of medical practice from male to female dominance. I appreciate your observation. jcs
  • Good blog post! I taught at a medical school for 27 years and was part of the apparatus that turned physicians into knowledge machines. I tried in small ways to foster the idea that each human is a unique being. ("See, your cadaver doesn't have the same vascular organization as in the atlas, and yet he lived for eighty years!") But students were so overwhelmed, and they were so unprepared for unorthodoxy, that it probably didn't make much of an impression. Enjoyed the 1700s "common joke" that led into the article. I have contended for years that the reason homeopathy was so popular at the turn of the (20th) century was because it basically didn't do anything - just gave the body the time to heal itself. So it very often "worked."
    • James Salwitz, MD
      WHen I went to med school we had pharmacy class for a year and the PDR was only 1 inch thick. Now it is 6 inches thick and pharm is only half a year. It is really hard for students trying to become statistically based science applying clinicians to remember that their patients are not only anatomy specimens. Still, we try and show them, a little. Thanks for your comment, jcs
    • IBS
      just gave the body the time to heal itself. So it very often “worked Thus, palliative care......
  • alyce
    This is a great post and you are a great doctor. I have a great doctor today and he listens to me and cares about my opinion. I can say just about anything to this doctor and he doesn't flinch. Of course I took my baby steps with Doctor Salwitz when I started my cancer trek. Thank you Dr. Salwitz
    • James Salwitz, MD
      My pleasure. jcs
  • Thank you for the phrase: "The best physicians accept the emotions of the patient as healthy, and do not try to suppress and deny those needs." I'm disappointed and a little angry when an apparently kind doctor ignores the history that makse me dread a test, and merely says "relax." as she passes by.
  • Paula Kaplan-Reiss
    Amen!! I remember when I was going through infertility treatments many years ago, I became curious about whether patients only thought their doctor was a good one if they became pregnant, despite the level of compassion the doctor showed during a very emotional process. To me, a doctor absolutely needs to see me as a whole person and more than a diagnoses and lab results. I want to see the doctor as a whole person too, That's why this blog is invaluable.
  • IBS
    Paula, It was just your doctor's personality. My eldest daughter went through infertility treatments 3x. She never blamed the doctor just extremely sad that her eggs weren't viable? Too old. She has now adopted a beautiful little boy who is 3 yrs old now. My youngest daughter had preelampsia. I adopted her when she was an infant, but the preelampasia really started after giving birth. The doctors , after a long time, finally did a C section one day short of 37 weeks. Thursday, even though she was running a fever, let her go home even though she was having problems with her BP and an infrection in the lining of her uterous. Friday, her BP was 190/140. One medic came and then one abulance . I looked down my driveway and a second ambulance came. Since I'm the sick one in the family, the kids don't tell me much as to not stress me out. She was put in ICU and was suffering from heart failure, and her lungs were filling up...turning blue. She came home again today. She shouldn't have been kept being released knowing she was having BP problems They first told her she had asthma. Everything went wrong. The paramedics and ambulance people were wonderful and so kind. I pray every day that my own beautiful daughter stays well for her beautiful daughter. The nurses were also absolutely wonderful per my daughter and husband. I want to thank ALL the nurses taking care of patients. They are all wonderful, and the patients never forget them.
  • D Someya Reed
    The great doctor is also one who knows that the patient is not at his/her best either physically or mentally. He encourages and welcomes the advocate the patient has chosen to trust to remember that which she can't or ask that of which he may be afraid. He neither makes the patient feel uncomfortable for bringing such a person nor makes that person feel like an interloper. There are doctors for whom this greatness comes easily, almost naturally. For others it may be a hard fought battle with self and self-discipline. Anyone can learn to be a great doctor. You only have to want it above anything else in competition for your time and energy in your practice. As many have said, when you find such a doctor, you treasure them and mourn the day they, deservedly, retire. And...there's nothing wrong with giving them a little grief when you spot them ahead of you in line, ordering a triple-triple cheeseburger, fries and a chocolate shake at IN-n-OUT Burger!
  • Liz
    Oh I think "Irrational thought, emotion, superstition, and prayer mixed" is alive and well even in the day and age of science based medicine... look at the popularity of snake oil. I do think though that snake oil providers have recognized what some of "mainstream medicine" has forgotten - there is a human in there with needs and sometimes/often meeting those needs is every bit as big/important as the need for the benefits contained in the "modern heathcare system".

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