By Dr. Greg Fricchione, Professor of Psychiatry, Harvard Medical School and Director, Division of Psychiatry and Medicine, Massachusetts General Hospital
Dr. Tom Hutchinson’s new book, Whole Person Care, is timely especially for us in the United States. It diagnoses with precision the quagmire we face in the American medical profession as a result of years of thoughtless genuflection at the feet of our business model of caregiving. Our mess has been created by an unholy alliance between the crusading business experts charged with “bending the cost curve” and reducing the percentage of GDP we pay for health care with the most reductionistic aspects of modern medical science. Guess which essential part of human caregiving has been given short shrift? Yes, you guessed right…it is the human part. In this book, Dr. Hutchinson masterfully gives voice in a very personal and yet very authoritatively professional way, to the absolute necessity of our profession to call a halt to the demise of our vocation. Our vocation is not to become assembly line workers but to fully care for our fellow human sufferers by employing the best of modern science in an effort to cure AND the best of our interrelatedness in order to heal.
Take the saga of the vaunted role of the electronic health record (EHR) in solving the problems of medical care as an example. The EHR represents an advancement in our cognitive capacity that has been oversold as an answer to modern medicine’s problems perhaps because what it does best is perform as a world class billing tool. Back in 2001 the Institute of Medicine’s (IOM) “Better Care at Lower Cost” Report listed the “digital infrastructure” as their number 1 recommendation. But of course, we now realize how ludicrous this was and in 2017 even IOM’s successor organization, the National Academy of Medicine, acknowledged that the EHR is not our No. 1 need. But still certain health care organizations will spend more than a billion dollars to install the EPIC EHR system in their hospitals.
In 2015 Dr. Lisa Rosenbaum wrote a New England Journal of Medicine article on the EHR and the disruption of medicine. She mentions the disruptive transitions of moving from volume-based to so-called “value-based care”, the overreach of “meaningful use” metrics, the fact that healthcare industry customers are administrators now and not doctors, and the fact that you can accumulate a lot of data and yet have very little clinical meaning at the end of the day. She also quotes Dr. Robert Wachter, author of The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age, (McGraw-Hill 2015):
Dr. Hutchinson’s book focuses on the very real power of the “gentle hand holding” tradition in medicine to heal human suffering even when we have no curative answers. This is what he means by integrating the very best medical science with what he calls “mindful clinical congruence” in addressing the vocational vow we have taken as physicians to provide care of the whole person who comes to us with hope and trust.
He also refers to Dr. Wachter in his chapter on “The Digital Doctor”. There is growing recognition that while the EHR has a lot to offer in terms of data sharing amongst physicians, it also comes at the cost of intimate connectedness between patients and their doctors. Dr. Hutchinson achingly laments the gulf that has opened up between doctors–chained to their necessity to meet RVU requirements by writing their billing notes with sufficient CBT coding elements– and their patients. As a result, many doctors today face the choice of neglecting their patients by looking at the computer screen and feverishly typing their templated notes during the patient visit or spending an extra week per month on average catching up on their notes at home. Is this what is meant by “value-based care?” Perhaps the answer is not “the ruthless efficiency of the modern manufacturing plant” after all, especially when the system now being put into place cuts the hand off the parish priest!
Dr. Hutchinson addresses the double hit such a system delivers to the face of medicine—patients feeling uncared for, abandoned and denied true caring and doctors becoming burned out. This is an unsustainable condition with a very poor prognosis for the healthcare system. Dr. Hutchinson has a prescription—whole person care.
In eighteen superbly written and succinct chapters that read like meditations, we are reminded about our heritage as curers and as healers and we are taken on a journey that illuminates how we have come to this pivotal point in our profession’s history. We are bequeathed the scientific tradition of Hippocrates as well as the equally important tradition of Aesklepios, the Greek god of healing. And we learn of the very real dangers for both patients and doctors of relinquishing the latter. Doctors are unique in their requirement to simultaneously use the conceptual network of scientific terms along with the conceptual network of mental and spiritual terms in an integrated and pragmatic effort to relieve human suffering. As a brain doctor, I pretty much know where this occurs in the doctor’s brain. An area of our paralimbic cortex called the anterior cingulate helps us make our decisions when faced with complex and sometimes conflicting information. And this area integrates cognitive data with emotional cues—there is no way to avoid this necessary intermingling to come to our best medical decisions that result in our ability to both cure and to heal. And curiously this is the science that maps onto the ancient wisdom that has made our profession indispensable to society. This is what clinical science is all about after all. Medical school is more than basic science for a reason.
One of this book’s great strengths is that Dr. Hutchinson pours his own soul into his personal narrative. So, we learn of his maturation as a doctor. He links us up with his parental and social caring and his special Irish poetic sensibility about life and with his experience as a nephrologist caring for very sick end-stage renal disease patients. He also reveals how his decision to pursue training in palliative care led to his insights about how the crucial role of healing in patients with terminal illness has the potential to inform a renaissance of caregiving in all of clinical medicine. In palliative care, the doctor strives to bring his or her full self to the clinical context. This is in recognition of the suffering patients experience when an illness represents a potential separation threat to themselves. So, physicians can provide whole person care with 4 steps. Clarify the diagnosis. Clarify the prognosis from the patient’s perspective. Treat the disease. And importantly, create a healing relationship. One might appropriately ask whether such intimacy in the patient-doctor relationship adds to the epidemic of physician burnout. This is where Dr. Hutchinson’s sage advice regarding mindful practice comes in. Mindful practice requires focus on the patient as a whole person through attention to the connections that make the person unique and separate from his disease. This will lead to radiance—an awareness of the patient as a whole person. In this way physicians through the ages have been honored for their ability to provide the solace of attachment solutions for their patient’s separation challenges. This “mindful clinical congruence” means bringing our full selves as doctors to the clinical context. This is enabled through the learning and practice of mindfulness meditation and the enhancement of resilience in all its dimensions as buffers against burnout. And Dr. Hutchinson, with the inspiration of the wise founder of palliative medicine in North America, Dr. Balfour Mount, has created a remarkable 4-year medical school curriculum at McGill in mindful medical practice. Let’s hope it catches on in other medical schools.
Dr. Hutchinson appropriately reminds us of the wisdom of the great Dr. Osler who was a legendary healer at his McGill hospital. When I walk into my hospital, I see these 1927 words of Francis Peabody carved into the marble:
“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” But the full quote speaks more completely to Dr. Hutchinson’s point: “The good physician knows his patients through andthrough and his knowledge is bought dearly. Time, sympathy and understanding must belavishly dispensed but the reward is to be found in the personal bond, which forms the greatest satisfaction of the practice of medicine.”
I have a feeling somewhere among the heavenly hosts of secular saints, Drs. Osler and Peabody are very pleased with Dr. Hutchinson and this fine book.
January 18, 2018