Not a loss of professionalism

Not a loss of professionalism, but an expression of unselfish love, that is the mark of a healer.

Stange’s definition of friendship in medicine¹

Recently I came across a series of articles authored by Dr Stange and his colleagues that were published in the Annals of Family Medicine.^1–7 They immediately captivated me. It was Dr Stange’s article on the science of connectedness that particularly, well, connected with me.²

While many of the concepts and theories of Dr Stange were unknown to me, I was struck by how strongly they resonated with what I had observed more than a decade earlier as a family medicine resident and student. Perhaps more surprising was how much they ran counter to what I was taught during medical school. As a medical student I found that much time and effort was spent on distancing one’s self emotionally from the patient. In fact, so much effort was spent in the preclinical years on reinforcing this professional divide that once we began to move into the clinical setting, the benefits that came from connecting with patients seemed to contradict what we had been taught.

Admittedly, with the clock reading 2:00 am as I completed the second of 3 admissions during one overnight call in internal medicine, this emotionally distant definition of professionalism was easy to accept. It had been made clear to me during the course of the admission that this second patient had inoperable cancer and that her ascites were a result of the intra-abdominal metastasis. Nothing good would come from tapping the abdomen, so I shouldn’t even consider it. But, as the days went by and the patient dealt with nausea, constipation, and generalized weakness, she expressed her concerns that the end was near and that she might never go home. As I got to know the patient and her family, I found myself growing unhappy with the plan. I had connected with her and no longer saw it as simply my professional duty to medically usher in her final days. Instead, I began feeling that it was my duty to re-explore all the possibilities for providing treatment to a fellow human being—a mother, a grandmother, a friend—who was relying on me to help her with my knowledge.

After I hounded my chief resident, he decided to take advantage of the situation to teach me how to do a paracentesis. When I failed, my senior stepped in, and when he failed, we decided to refer the patient for an ultrasound-guided paracentesis. Nearly 4 L of drained fluid later, my friend was a new person—sitting up in her bed during my morning rounds, with enough “vim and vigour” to actually be considered for discharge. She felt great—or as good as someone with a diagnosis of ovarian cancer could feel—and thanked me for taking an interest in her case.

Now a practising family physician in a small town, I often think of the many patients I met during medical school. In particular I think about those whose care I could not limit to their disease, and whose experience of illness I felt obligated to consider as well. At the time, I questioned why I even bothered. Was it not a sign of a poor clinician, to be so dedicated to the psychosocial elements of health? But then I found small-town family medicine: a place where the doctor was just Doc, or even just plain old Steve. The powerful relationship between patient and doctor that develops over years of visits for colds, routine annual examinations, poison ivy, questions about medications, and chest pain, ultimately to become a trusted bond—a friendship—is healthy, but its full effects are still not completely understood.

Should we not ensure that we have a better understanding of the nature of this relationship before delegating it away to other primary health care providers? It is at the heart of what we do, and yet, we, the everyday practitioners, know so little about it.

My residents will read Stange’s articles, and I encourage you all to read and share these pieces. Thank you, Dr Stange, for reminding us that there is still much to learn about the science of connectedness.

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