Modern Medicine: Doctoring Today—An Older Patient’s, Older Doctor’s Perspective

By

Leonard Zwelling

https://www.nejm.org/doi/full/10.1056/NEJMp1806984

https://www.nejm.org/doi/full/10.1056/NEJMp1808736

The contrast could not have been more stark.

The issue of The New England Journal of Medicine of November 22 has two editorials that illuminate the problem for the clinicians of today.

The first of these is about going beyond Evidence-Based Medicine to “interpersonal medicine.” This sounds to me like the doctor as scientist and social worker all at once because now the right thing to do for a patient is determined not only by his or her disease and what the medical literature says about the best therapy for that disease, but also must include consideration of the social situation of the individual patient and how best to interact with that patient to have the desired effect (e.g., making sure the patient takes the pills the doctor has correctly prescribed). The authors want to move back to the success of doctoring being measured by the doctor-patient interaction, not the one between the doctor and the scientific literature that currently defines “quality medicine.”

It’s a great idea, but very hard to implement although the authors do point to concrete examples of training in interpersonal communication and the use of care teams that include those who specialize in understanding the social inequities built into American medicine. These specialists can help the doctor get the therapy to the patient once the patient leaves the doctor’s office. This is, after all, what matters.

The next article is a much more personal account by a young British physician Saurabh Jha. He tells the tale of his father the Pakistani immigrant doctor caring for the needs of his fellow immigrants in Britain. The relationship he describes between his father and one of his patients is everything the first article describes as being good medicine, but is really about the paternalistic relationship some patients need to have with their doctors. It’s fine to use shared decision making when that’s what the patient wants. But that is often not what the patient wants.

Patients, especially sick ones, come to doctors looking for help and for answers. They are not looking for debates or challenges to participate in weighing the risks and benefits of three different regimens for hypertension. Many, and I include myself frequently, want the doctor to make a considered decision based on the available medical evidence and tell them what to do. If I feel compelled to offer an alternative opinion, that’s okay, but I don’t think most patients go to the doctor looking for a test about what course of action ought to be followed to nurse the patient back to health, if possible.

The authors of the first piece, Stacey Chang and Thomas H. Lee, raise important points about how medicine is changing. It is only realistic to admit that every patient with the same diabetic numbers does not need the same treatment or even the same approach to the doctor-patient relationship. But it is also true that people still want doctors to be healers, not just the CEO of their care team. This comes through mightily in the Jha editorial.

Just say for me, I think that Dr. Jha’s father could be my doctor. He is a master of interpersonal medicine and he didn’t learn how to do it in a mandatory human resources training program.

These two articles are worth a read. The first sounds theoretically like the future of medicine. The second sounds like reality.

As a patient, which I seem to be with more frequency every year, I’ll take a doctor who believes in evidence-based medicine, but has the instincts and experience to know when to apply it. My only concern is how to get young doctors to be that kind of doctor quickly and reliably. I don’t think it’s through training programs. It’s through more time with real patients. The only thing that ever made me a better doctor was more patients. But what really helped was becoming a patient myself. That’s when I began to learn what patients really want.

Leonard Zwelling