Saturday, August 5, 2017
“There is nothing else we can do for you!”
In a plenary presented to the American Balint Society’s first National meeting (Estes Park, CO - 2014), Andrew Elder quoted from a presentation made by Ian McWhinney years earlier in 1998 at the 11th International Balint Congress in London to describe Balint’s radically different approach to improve medical communication:
“The implications of Balint’s ideas for medical education have not yet been addressed. We speak of adding skills and competencies, but not of teaching a new way of being a physician. The difference between these two ideas is fundamental: one is additive, the other transformative; one assumes that the status quo is adequate but incomplete, the other that the status quo is fundamentally flawed; one sees the solution in terms of additional tasks, the other in terms of a transformation that will affect everything the physician does.”
This state of medical education remains true today, almost 20 years later. The bulk (maybe the whole) of medical education today is about amassing information about how the human body functions and all the ways that it malfunctions, along with all the remedies we have to correct those malfunctions, from pharmaceuticals to surgeries to alternative interventions. However, every doctor knows medicine’s dirty little secret: that for some patients, doctors will come to the end of their knowledge to understand what is happening and will be at a loss to suggest remedies that will be effective. Some doctors will continue doing what they know, despite the futility of these efforts. It may be too painful to acknowledge their and medicine’s limits. Some other doctors may say “There is nothing wrong with you physically” or “There is nothing we can do for you.”
This model of medical education is “additive” in McWhinney’s words. All that is needed is more knowledge about how the body works. Think of a vertical axis, and the task for physicians is learning all that they can. Medical culture does not acknowledge that there is a limit to what is known and what is knowable. It also does not help doctors know what they can do for a patient when they get to that limit or even along the way to getting there.
McWhinney’s (and Elder’s and Balint’s) message is that there is another part of medical education that teaches doctors (and other medical professionals) what else they can do for their patients when they run out of answers or remedies. Consider, for a moment, that there may be a horizontal axis - an axis that is measured not in any quantitative way, but rather in an emotional way. This is not an axis of knowledge - it is an axis of our humanity. It is an axis of our ability to emotionally connect with the emotional experience of our patients - to their vulnerability, and of course, this axis touches our own vulnerability.
Maya Angelou captured the power of emotional connection: “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” When we listen to and acknowledge our patients’ stories, we help them feel validated, less alone, understood and we even help them to better understand themselves. This is different than trying to solve a medical puzzle with a set of differential diagnoses or the dilemma of which blood test to order or which technological advancement will unlock the mystery of my patient’s ailment. It’s not multiple choice; there is no right answer. This answer does not come from knowing - it comes from being, from feeling.
It so happens that the road to becoming a physician does not have many stops at the stations named Humanity or Feelings or Emotions. Most physicians know and acknowledge they exist; however, stopping there is often seen as a delay at getting to their destination - a station named Differential Diagnosis and the eventual destination - Treatment. Too many doctors function as if they are on an express train and have learned to not make every stop.
Being in a Balint group helps to unlock some of the keys to helping a patient heal - a distinctly human experience. Too often the image of the patient in bed 2, room 615 does not connect with an image of that same person, as a functioning human being in their own world wearing civilian clothes rather than a hospital gown. We only see that person in their bed!
What does Balint teach? Getting to the doctor’s goal is not the whole picture. Doctors have feelings too, and they may be part of the challenge in making a connection with this patient. We all have blind spots, and sometimes colleagues can help us see them, if we are open enough. And much more ...
There are other ways this horizontal axis can be taught. There are a wide range of reflective practices that can be helpful. Ron Epstein has researched and written about the impact of the ‘simple’ practice of mindfulness. Narrative medicine helps doctors write out their own stories, and reading what they have written to colleagues releases emotions they were not aware they held. Taking time to step away from the office and the hospital to reflect on ones experiences can add perspective to ones work and begin to help make a series of many discrete events have more meaning.
The ultimate goal - the way health care can be the most effective for both the healers and the patients - is to learn to integrate both these vertical and the horizontal axes. Not all patients are looking for deep connections - many just want to be fixed. What’s the diagnosis and what’s the remedy! However, it is the ones with chronic ailments or undifferentiated symptoms - often the most challenging patients to sit with - that most need the empathetic connection with their physician. Healing is better accomplished when all the medical knowledge that is available is integrated with the caring, gentle hand of the healer who is comfortable addressing the emotional component of the illness experience. Medical education needs Balint groups! These aspects of healthcare are best taught in the protected environment of groups of colleagues where the humanity of the healers is also valued and given the opportunity to emerge. There IS something else we can do for you! We can listen, and, in a variation of Osler’s words, “…get to know the patient who has the symptoms.”