How Should Physicians Approach the Problems of Their Patients?

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COMMENTARIES

How

Should

Physicians

Approach

the

Problems

of Their

Patients?

During a recent seminar with pediatric residents to

discuss the role of empathy in the doctor-patient relationship, the following dialogue occurred.

Resident: It is fine and terrific to talk about how useful

empathy can be, but it does not work when children with

reactive airway disease have parents who continue to

smoke. I feel strongly that people should not smoke. When

these children wheeze, their parents bring them to the

Emergency Department and we have to see them and deal

with the same problem over and over again.

Physician: Have you talked to the parents to try and

understand their feelings about smoking and whether they

believe it influences their child’s wheezing? Resident: No response (shrugs shoulders).

The resident in the above example was frustrated

and angry with parents whose smoking precipitated

the onset of wheezing in their children with reactive airways disease. This resident and others in the

group also were frustrated because they were unsure

about how to manage this problem effectively. This

dialogue illustrates the dilemma that physicians face in the everyday practice of clinical medicine

concern-ing their perceived role and actions in effectively

trying to manage the problems of their patients. I

wish to examine this problem by giving a historical

perspective and then by offering a possible solution.

Although I phrase this discussion in terms of the

physician and patient, in pediatric practice the

par-ent usually is the proxy for the patient, so that an

effective relationship must be formed not only with

the patient but also with the parents.

HISTORICAL PERSPECTIVE

The features of medicine are determined to a large

extent by how society views the ifi person and the

physician. In primitive medicine the explanation for

serious disease was magical or religious. In the fifth

century B.C. in Greece, medicine became a

profes-sion with the appearance of the Hippocratic school.

The Hippocratic Oath and Corpus Hippocraticum

were attributed to Hippocrates, a famous physician

from the isle of Cos. Some historians believe that

these writings were formulated over several

centu-nes by physicians who followed Pythagorean

prin-ciples.1 Regardless of the author or authors, these

Hippocratic works became the guiding principles of

medical ethics for 2500 years.

From the Department of Pediatrics, Children’s Hospital Medical Center,

Cincinnati, OH.

Received for publication Jan 15, 1994; accepted Mar 23, 1994.

Reprint requests to (P.S.B.) Department of Pediatrics, Children’s Hospital

Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039.

Acad-emy of Pediatrics.

Though these writings emphasize concern and

respect for others, kindness, justice, and practical

wisdom, the role of the physician that emerges is

that the physician knows what is best for the

pa-tient and is expected to decide for him.2 In one of

the works of the Corpus Hippocraticum called

De-corum, the physician is advised: “Perform all this

calmly and adroitly, concealing most things from

the patient while you are attending to him” and

. . .sometimes comfort with solitude and attention,

revealing nothing of the patient’s future or present

condition”.3 The moral principle of Hippocratic

medical ethics is beneficence, that is, doing good,

or doing whatever the physician thinks would help

or benefit the patient.4 The choices reflected in

these writings are from the vantage point of the

physician. The patient has no role in the decision

making process, but is someone who needs to be

protected against the anxiety of too much

knowl-edge.2 According to Edelstein in his essay “The

Hippocratic Physician”: “If the physician is to

help, his relationship to the patient must be that of

the person in command to one who obeys.”5

Since the days of Hippocrates, physicians have

been committed to the idea that they must make

decisions for and not with patients.6 However, in

recent years, the Hippocratic Oath and Corpus

Hip-pocraticum have come under criticism as guiding

principles for the relationship between doctor and

patient. In our pluralistic democratic society with the influence of contemporary science, technology, social organization, and changed values, the view of the physician as a paternalistic figure who decides all for

the patient is inconsistent with the desires of most

informed and educated people.7 Most people want to

understand their medical situation and have some

say in decisions affecting themselves. As an example,

in a recent article Harrison8 along with others

pro-posed principles for family centered neonatal care

that include open communication between parents

and professionals on medical and ethical issues and

parents working with professionals in making

informed treatment choices.

A POSSIBLE SOLUTION

How should physicians approach the problems of

their patients? The answer lies in how the physician perceives himseff and his role in the doctor-patient

relationship. Does the physician view himself as a

paternalistic figure assuming that he knows what is

best for the patient and making all the decisions or

does he Iry to understand the patient and his feelings

and involve the patient in the decision making

pro-cess? It is my experience that the latter approach

leads to a better relationship between the doctor

and patient and is a more effective way to solve

problems.

In the doctor-patient relationship, both the doctor

and patient have rights and obligations. The

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COMMENTARIES 929

cian’s role enables him to inquire of the patient,

examine his body, and carry out treatment. He is

obliged to be medically competent and to provide

help and comfort. The patient is entitled to ask for a

physician’s help, to submit to examination without

fears of exploitation, and to share his personal feel-ings and thoughts in confidence. Such a role obliges

him to cooperate with the physician and to accept

restrictions required for adequate study and treat-ment. This general consideration of roles does not

define the nature of the relationship between any one

physician and patient. The relationship is deter-mined more by circumstances of illness, the personal characteristics of the physician and patient, and the

previous experience of each. The determinants may

not all be conscious or rational, but may be based as

much on the personalities, prejudices, and uncon-scious mental attitudes of each person, as upon the reality of the situation.9

The doctor-patient relationship contains the same

elements as any other human relationship such as perceived roles, responsibilities, and expectations

which are influenced by special needs, wants,

feel-ings, and values. When a person becomes ill and seeks help from a doctor, this in itself creates a spe-cial relationship. The physician wants to care for the

patient as best he can without compromising his

integrity or moral values. The patient wants to be

cared for as a person in a dignified way and as one

who has the freedom of choice about whether to

comply with the doctor’s advice. Patients are not fighting for liberty or equality of legal rights, but

rather the desire to be recognized and understood as

unique individuals.’0 They do not want to make

de-cisions alone, but seek guidance and help with these decisions from their doctor. In the decision making process the physician must respect the patient’s

value system, and recognize that for some patients,

there may be more important values than medical values. These may include religious, philosophical, cultural, social, political, ethical, moral, interper-sonal, or personal values. A relationship must evolve

between the doctor and patient which recognizes

that the crucial decision is the choice of what should be done and that this choice cannot be the exclusive privilege of one or the other. The decision must arise

somehow between someone in need, the patient, and

someone, the physician, who professes to alleviate

that need. This can only occur when the

doctor-patient relationship is based on mutual respect and

trust. Freidson says it well: “ . . . I assume that when decisions are at bottom moral or evaluative rather than substantive, laymen have as much if not more to contribute to them than have experts. This assump-tion reflects the substance of equality in a free soci-ety, equality not of ability, knowledge, or means, but

moral ty1

The relationship between doctor and patient will

succeed if each can learn to respect and trust one

another. To be effective, the doctor must be able to

communicate well with the patient and family. He

must learn how to listen and talk to patients, espe-cially those who are anxious and fearful. The only help at times is a therapeutic conversation with a

physician. He is the only person who can do this,

because he is the one person whom the patient looks

to for help. According to Tumulty, the greatest asset

of the physician is his interest in listening and talking to patients.’2

Such a physician has the capacity for caring about

and being concerned about others, particularly those

who are ifi, troubled, or distressed. For the patient,

there is the need to be listened to, to be valued, and

to be understood. The physician has his own need to

listen and to understand in order to be responsible

and effective. This attentive listening often has a

compelling effect on the patient to tell more about himself, by revealing more. The patient’s confiding

in turn has a compelling effect on the listening

phy-sician. The illness can only be understood through

the patient’s words, by listening to what he says.’3

For the patient, to feel understood means more

than feeling that the physician understands intellec-tually. The physician must display an understanding about the patient’s life circumstances and about what

he is experiencing and feeling. “Do my doctors know

who I am, who I have been, who I still want to be? Do

they understand what I am going through, my

suf-fering, my pain, my distress? Do they understand my

hopes and aspirations, my fears, my shames, my

vulnerabiities and strengths, my needs and

obliga-tions and my values? Above all, do they sense my

personhood and my individuality. Do they

acknowl-edge my humanity? Do they care?”4 As Peabody so

eloquently stated: “The treatment of a disease may

be entirely impersonal; the care of a patient must be

completely personal” and “ . . . the secret of the care of the patient is in caring for the patient.”5

This caring and understanding is the essential core

of the relationship between doctor and patient. The

use of empathy can be a guiding principle in this

endeavor. Empathy is the capacity to understand

what another is experiencing, the capacity to place

oneself in another’s shoes. Its essence is the accurate

understanding of another’s person’s feelings. The

physician does not have to experience these intense

feelings or emotions, but he must understand and

relate to them while maintaining a sense of self.

When the patient feels that his doctor understands

his experiences, particularly his feelings, this

en-hances the patient’s trust and confidence in the

doctor.’6

In order to understand the patient, the doctor

also must be aware of his own motives, impulses,

prejudices, and actions which may adversely affect

his relationship with patients. The doctor must

constantly ask himself how he relates to patients

and how they relate to him. He also needs to be

aware of the unconscious feelings patients may

have for him (transference) and his own responses

to those feelings (countertransference).

Transfer-ence is a normal phenomenon which occurs to

some degree in all human relationships, but these

feelings become more intense when patients are

anxious and fearful. Although transference

in-volves unrealistic expectations and attitudes,

positive transference generally has a beneficial

ef-fect on the doctor-patient relationship. It helps the

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patient to open up with his doctor and does much

to reduce fear and anxiety by providing a feeling of

security. Occasionally, these feelings may exceed

medical usefulness, especially if the patient has

existing psychic problems and conflicts. Negative

transference feelings may include irritation,

dis-trust, contempt, envy, and anger, but the doctor

must understand that these emotional attitudes of

patients are irrational and unconscious and that

the transferences are not directed against himself

personally. By understanding the patient’s

trans-ference and his own countertransference feelings,

the doctor can develop more realistic perceptions

not only of his patients, but also of himself, and

use this knowledge both diagnostically and

therapeutically.’7

In any relationship, conflicts will occur, but most

of them in medicine are due to fear, anxiety,

igno-rance, and lack of information, as well as

misun-derstandings and misconceptions of roles and

re-sponsibilities. These issues can and should be

addressed by the physician. Resolving problems

by discussion is a critical part of helping

relation-ships and together the doctor and patient can solve

most of their problems. The goal is that the patient feels that he has received what is in his best

inter-est and the doctor has done what he believes is

professionally appropriate. Compromise can occur

so long as professional standards are not breached

and both people are satisfied. The most effective

physicians sense their patient’s worries,

hesita-tions about treatment, and misconceptions about

illness. By means of dialogue, they create an

atmo-sphere where patients can present their

perspec-tive, so that mutual understanding can occur.’8

In the above example the physician could act in a

paternalistic way and tell the parents that smoking

contributed to the child’s wheezing and should be

stopped. That would be the end of the encounter.

A more effective approach is for the physician to

understand the parents’ feelings, communicate this

understanding through the use of empathy, and

involve the parents in making appropriate decisions

for their child’s health. This opportunity for dialogue

and understanding strengthens the doctor-patient

re-lationship and offers a better chance for developing

realistic ways to solve problems. People are more

willing to listen and cooperate with physicians if

they feel that the physician cares, takes the time to

listen and understand, and involves them in the

de-cision making process. The failure of communication between doctor and patient is one of the reasons why

so many people are dissatisfied with the care they

receive.’9 Communication skills including the use of

empathy can be taught successfully to medical

stu-dents and residents.20’’ With regard to smoking

ces-sation, videotape analysis showed that residents

im-proved their counseling skills significantly after a

3-hour training program? Further research

demon-strated that patient centered counseling by

physi-cians which explored the motivation to change

smoking behavior, past experiences with stopping, current concerns, resources available for change, and

interest in developing a plan for cessation was well

received by patients and significantly increased the

likelihood of cessation at 6 months when compared

with physician-delivered brief advice.z The

knowl-edge and skills that a physician needs to sustain the

doctor-patient relationship are not merely a matter of

intuition, common sense, and experience; they rest

on a body of knowledge and a set of principles about

human behavior and relationships arrived at

through systematic inquiry, that is, scientifically.’4 To

teach medical students and residents the necessary

knowledge and skills remains a challenge for the

leaders of medical schools and residency training

programs in this country.

PAUL S. BELLET, MD

Children’s Hospital Medical Center Cincinnati, OH 45229-3039

REFERENCES

I. Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation.

Supplements to the Bulletin of the History of Medicine, no. 1. Baltimore: Johns Hopkins Press; 1943:1-64

2. Pelligrino ED, Thomasma DC. A Philosophical Basis of Medical Practice.

New York: Oxford University Press; 1981

3. Jones WHS. Hippocrates With an English Translation. Volume II. London:

William Heinemann; 1923:297-298

4. Veatch RM. The Patient-Physician Relation. Bloomington: Indiana

Urn-versity Press; 1991

5. Edelstein L The Hippocratic Physician. In: Temkin 0, Temkin, CL, eds.

Ancient Medicine. Selected Papers of Ludwig Edelstein. Baltimore: Johns Hopkins Press; 1967:98

6. Katz J. The Silent World of Doctor and Patient. New York: The Free Press; 1984

7. Pelligrino ED. Toward an Expanded Medical Ethics: The Hippocratic Ethic Revisited. In: Bulger, RJ, ad. Hippocrates Revisited. New York:

Medcom Press; 1973:133-147

8. Harrison H. The principles of family-centered neonatal care. Pediatrics.

199392:643-650

9. Morgan WL, Engel GL The Clinical Approach to the Patient. Philadelphia:

WB Saunders; 1969

10. Berlin I. Two Concepts of Liberty. In: Berlin I, ed. Four Essays on Liberty.

New York: Oxford University Press; 1970:118-172

I I. Freidson E. Profession of Medicine. New York: Dodd Mead; 1970:336

12. Tumulty PA. What is a clinician and what does he do? NEJM. 1970;283:

20-24

13. Jackson SW. The listening healer in the history of psychological healing.

Am IPsychiatry. 1992;149:1623-1631

14. Engel GL. How much longer must medicine’s science be bound by a

seventeenth century world view? In: White KL The Task of Medicine, Dialogue at Wickenburg. Menlo Park, CA: Henry J. Kaiser Family Foundation; 1988:125-126

15. Peabody FW. The care of the patient. JAMA. 1927;88:877-882 16. Ballet PS, Maloney MJ. The importance of empathy as an interviewing

skill in medicine. JAMA 1991a66:1831-1832

17. Tahka V. The Patient-Doctor Relationship. Sydney: ADIS Health Science

Press; 1984

18. Lazare A, Eisenthal S, Frank A, Stoeckle JD. Studies on a negotiated

approach to patienthood. In: Gallagher, EB. The Doctor-Patient

Relation-ship in the Changing Health Scene. Washington, DC: US Department of Health, Education and Welfare; 1976:119-139

19. Cousins N. How patients appraise physicians. NEJM. 1985;313:

1422-1424

20. Poole AD, Sanson-Fisher RW. Understanding the patient: a neglected

aspect of medical education. Soc Sci Med. 1979;13A:37-43

21. Fine VK, Therrien ME. Empathy in the doctor-patient relationship: skill training for medical students. JMed Educ. 197752:752-757

22. OckeneJK, Quirk ME, Goldberg RJ, KristellerJL, Donnelly G, Kalan KL,

Gould B, Greene HL, Harrison-Atlas R, Pease J, Pickers 5, Williams JW. A residents’ training program for the development of smoking inter-vention skills. Arch Intern Med. 1988;148:1039-1045

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COMMENTARIES 931

23. Ockene JK, Kristeller J, Goldberg R, Amick U, Pekow PS, Hosmer D,

Quirk M, Kalan K. Increasing the efficacy of physician-delivered smoking interventions: arandomized dinical trial. JGot Intern Med. 199l6:1-8

Mortality

and

Growth

of Low

Birth

Weight

Infants

on

the

Kangaroo

Mother

Program

in Bogota,

Colombia

The kangaroo mother program was started by Drs

Rey and Martinez at the Instituto Materno Infantile

in Bogota, Colombia in 1978. Mortality was high

among low birth weight infants when hospital care

was attempted. Neonatal intensive care was virtually nonexistent, and nosocomial infection was common.

The essentials of the kangaroo mother program

were: (a) educating and motivating the mother as the

baby’s main resource; b) discharge home regardless

of weight as early as possible to minimize

nosoco-mial infection; c) exclusive breast-feeding; d)

encour-aging bonding and keeping the baby warm by

skin-to-skin contact inside the mother’s clothes; and e)

vertical position between the mother’s breasts to

minimize reflux and aspiration. UNICEF provided extra funding and an ambulatory clinic was built to supervise the mothers and infants after discharge.

Mortality was claimed to be as low for babies below

1500 g birth weight as with conventional neonatal

intensive care.’ There has been great interest from

around the world in this imaginative approach, but

with calls for better documentation before the same

approach is applied widely.2’

Skin-to-skin contact without early discharge has

been studied in developed countries and shown to help

with the maintenance of lactation,4 body temperature and oxygenation,5 and the mother’s confidence.6

However, the really important questions for

devel-oping countries have not previously been

con-fronted. Does the full kangaroo mother program

with very early discharge result in better or worse

survival than conventional care? Does relying on the

baby’s ability to suck from the breast give adequate nutrition and growth? Does the early close contact

between mother and baby give measureably better

development later in life?

In this issue of Pediatrics Charpak et al approach these questions. After >10 years of belief in the advan-tages of the kangaroo mother approach, it was consid-ered unacceptable to conduct a randomized controlled trial of the kangaroo program at the Instituto Materno Infantile. The authors therefore compared infants with birth weights under 2000 g in the kangaroo mother

program with infants who would have been eligible for

kangaroo care at a large maternity department in the

same city with conventional neonatal care. The data

were collected prospectively and simultaneously with

Received for publication Jun 14, 1994; accepted Jun 14, 1994.

Acad-emy of Pediatrics.

complete follow-up on 290 infants. The mothers in the

two hospital populations were similar in weight,

height, and previous obstetric history but differed sig-nificantly in socioeconomic status, antenatal care, and mode of delivery.

The two populations of infants were nearly identical

in gestational age and had a slightly lower birth weight

in the kangaroo group. However, 12 kangaroo infants

had a 1-minute Apgar score of three or less as against

only one in the control group and the infants in the

kangaroo group had more mechanical ventilation and

oxygen therapy. Thus, there is consistent evidence that

the infants in the kangaroo mother program had more

serious perinatal medical complications and were

be-mg discharged early to homes with significantly worse

social conditions than the control group. One would be

surprised if any of the outcomes turned out in favor of

the kangaroo group.

Crude mortality was higher in the kangaroo infant

group but after adjustment for differences in weight

and gestational age, the investigators found a lower

mortality risk in the kangaroo care group. Neither of

these differences were statistically significant.

A marked difference in weight, length, and head

circumference developed during the first month and

this difference persisted until 12 months. The most

likely reason is the immature infant’s inabifity to

suck adequate volumes of milk from the breast

de-spite the constant availability of the breast to the

“kangaroo baby.” However, breast-feeding was

con-sistently better maintained in the kangaroo mother

group up to 12 months. This, in itself, represents a

considerable advantage to the infants in a

develop-ing country. One surprising finding was that the

mean difference between the two groups in

hospital-ization time in the first year was only 2 days. Thus

the study did not support the idea that kangaroo care

saved substantial amounts of money.

Charpak et al’s study will doubtless be criticized

on the grounds that no useful comparisons could be

made between two groups who differed so much in

socioeconomic and medical status at the start. The adjustments done afterwards stretch one’s faith in

multiple regression to its limits and cannot make up

for the lack of randomization. Unfortunately,

ran-domized studies of survival will face major

prob-lems. To reliably detect clinically significant differ-ences in mortality, eg, risk ratios of 0.7 or 1.3, the

study has to be about 10 times larger than that of

Charpak et a!. This is because death is a binary

outcome with low probability. Moreover, because

survival depends strongly on local home and

hospi-tal facilities, extrapolating conclusions from one

lo-cation to another may be questionable.

A period of moderate undernutrition when being

fed only mother’s milk may not have long-term

ad-verse effects but it is important to prevent more

severe nutritional deficiencies. A practical next step may be to address the problem of growth retardation

among “kangaroo babies.” This approach would

lend itself more to randomized trials with

manage-able numbers of infants. We would also advocate

coordinated observational studies aimed at

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1994;94;928

Pediatrics

Paul S. Bellet