| | | |

The clinical relationship is the essential tool of diagnosis and treatment.

The patient is afraid and irrational, must be dependent, at least initially.  The clinician as student  is struggling to overcome his own fear of the disease and death the patient faces.  The clinical task is to give the patient access to processes which will enhance his autonomy, his ability to make choices in his own life.

What is it the accomplished clinician has?  What has he accomplished?  What are the tools he has available to use comfortably, reliably and regularly?

It is through the clinical relationship diagnosis and treatment take place.  It is a relationship between two persons, two real persons, two unique persons.  It is a special relationship, not of equals, not for mutual benefit.  It is the patient who is the subject and the object of the work upon which the relationship is focused, the only party for whom benefit is sought.  Information about the patient from the patient's own experience is central to understanding the problem (“subjective”).

Observations and measurements about the patient (“objective”) are essential to confirm his subjective experience and to orient patient and clinician to the realities of what is happening so that they can make plans which have a chance of succeeding to solve those problems.  Things done to the patient as if an object, no matter how rational, logical, plausible or well-intended cannot be applied reliably without the patient’s consent on several levels (subjective and objective).1

Just as the processes of evaluation and treatment must be real to the patient on subjective and objective levels, they must be real to the clinician on subjective and objective levels as well.  We are fairly well ready to accept standards of the clinician's objective comprehension of the patient's problem.  We share the common notion that the clinician should have easily at hand a "scientific"   understanding of the patient's conditions.  The clinician should recognize the signs of disease, formulate a plausible differential diagnosis, execute exploratory and confirmatory scientific tests and examinations, formulate and be ready to execute logical medical treatments.

Another objective task of the clinician (which has been described in detail in other chapters) is to know the parameters of the clinical relationship and this patient's reaction to it at this time of the encounter, to reflect back those observations to the patient.  This is what I mean when I say that the subject of clinical science is the clinical phenomena themselves, that the clinician is responsible to understand and to communicate not only what is happening within the patient but what is happening within the clinical relationship.

How can a clinician subjectively apprehend the experience of a patient?  I have cautioned clinicians against over-identification with the patient (that is, reacting as if the clinician were himself the sufferer, as if the pain would be his own, for that would be an unrealistic distortion of the simple truth, by my practical definition psychotic).  The accomplished clinician knows how to separate his own memories of pain from the present real pain of his patient, but at the same time he knows how to keep in mind what it means to have such real pain.

The clinician can remember his own experiences in several ways.  He can remember his emotional experiences of dependency as a child, as a student, as a patient.  He can remember his experiences of physical pain in the discrete parts of his own body (and if lucky enough to have survived serious disease, remember the complex ordeal of being pained and dependent).  He can remember the correlations with previous experience he recognized in his studies of the secret inner parts of the human organism.  (“Every student suffers every disease he studies.”).  He can remember the psychological torment of anxiety, depression, fear, anger, confusion in his own real life.

Because the clinician recognizes the separateness of his remembered experiences in his own soul and body from the present experiences of the patient who faces him, he need not be afraid that the patient's pain will hurt him, and he need not confuse his idea of the patient's experience with his memory of his own experience.

His memories, enhanced to brilliant vividness by conscious careful processes of imaging, will shed light on the patient's experience:

“I do not ask the wounded person how he feels; I myself become the wounded person [in my empathic meeting with the other, what Buber calls the between].”
Walt Whitman, hospital volunteer for soldiers of both sides during the Civil War.2

These are not unusual talents to develop.  These are the talents I and my patients use when we watch soap operas on the television, or when we go to the movies.  Even if we feel pain and we cry, we know that we are separate from what we are seeing.  We are able easily, reliably and objectively to advise the characters what their true situations are, and what realistically they must do.  (“Martha, don’t marry George; you’ll regret it.”)  We are not shocked at the manifestations of their blindness to their own tragic situations, but we wish them well, hope they will extricate  themselves from their predicaments.

This is what I sometimes call “The Little Old Lady with a Pink Parasol” principle (LOLWAPP).  If you and I stepped onto a bus and saw a little old lady with a pink parasol sitting in the back seat, we wouldn’t have to interview her to know about her, all we would have to do is to really pay attention for a few seconds (just ask Sherlock Holmes).

The clinician is not merely a voyeur.  He is present with the patient, and knows he participates in the process by which the patient may relieve himself of fear, confusion or pain.  What I have just described is the part of the clinical task which we rarely openly acknowledge.  It leads to the parts which are more often  accepted (also of great importance), those not fully available until the clinician has tuned in subjectively and objectively, in awareness of the patient's experience of suffering and his condition of being a patient.  And the clinician integrates these into being himself in this present real situation (able to sit quietly in the consulting room and at the same time be comfortable in his own skin).

The parts of the clinical task which go beyond careful conscious tuning in and feeling as a clinician, going on to act as a clinician, are best summarized by our teacher Hippocrates:

"The course I recommend is to pay attention to the whole of the medical art.  Indeed, all acts that are good and correct should be in all cases well or correctly performed; if they ought to be done quickly they should be done quickly, if neatly, neatly, if painlessly, they should be managed with the minimum of pain; and all such acts should be performed excellently in a manner better than that of one's own fellows."3

The acts which ensue from the harmonious and well directed clinical relationship do not constitute paternalism or exploitation.  The patient is likely genuinely to accept and actively cooperate with the clinician's recommendations.  But the clinician need not be perfect:  there is built into the relationship the most reliable of safeguards, the continuing working together of patient and clinician, which will keep the clinician from pursuing a course alien from the life of  the patient.

Most processes of clinical action have an approximate end (the discharge from hospital, the end of the active phase of an identified illness), though the relationship between clinician and patient may continue strong.  Discrete goals will be accomplished in the active phases of clinical relationship.

What is the nature and value of a "dormant" phase of the clinical relationship?  First, it is what many persons wish from a clinician, to be able to say, "I am well, but I have a personal importance to my doctor, which will give me access to comfort and help if ever I come to need them."  It is a reassurance to the clinician, who can say, "If anything changes with my patient it is likely I will not miss it, because I know something of how he is and how he has been, and he will let me know if something is amiss."  Clinicians are not trained in this relationship because they rarely have the opportunity during their training to experience any continuity with a patient.

The personalness of the clinical relationship is not "gravy," not superfluous.  When someone suddenly is sick and meets a new clinician he brings his previous experiences and expectations with him.  When a clinician meets a new patient, perhaps in an urgent situation, he can understand some deep aspects of that person's conditions past and present from his own experiences with other patients.

A patient can afford to trust a clinician, and a clinician can afford to be trusted, because the clinician has accomplished the ability to recognize painful and threatening realities with a minimum of denial.  The clinician is not pressed to defend against the painful realities of the patient's life because he knows and feels he is separate from the patient while he is focusing on the patient, caring.  This separateness-but-relatedness is basic to proper clinical behavior and trust.

We all need very much to share basic and similar expectations of the clinical relationship, and of the society's institutions of health care delivery.  We need clinicians to know very well what happens when persons become patients, and we need to know very well as patients and consumers what we need and what we may expect.  We need to become accomplished patients.

A person becomes an accomplished patient by growing more able to understand, decide and act. His is the heroic task.  His is the risk.  No matter what his mother or wife or doctor is willing to expend, it is his life which is at stake.  (Some other time it will be his mother's turn, or his doctor's.)

Somehow he has become the patient, is in need of help, deserves attention not because of his character or wealth, but because of his very being.  If he does not succeed in the heroic task of  growing more able to understand, judge and act, he will diminish or perish, becoming less than he was or would have been to those who attend him, or perhaps become nothing, become dead.  Each of us will die eventually.

The processes of authentically being who we are, in our selves, in relation to others, are always our greatest tasks; but to become a patient means to face necessity more closely than any of us wishes.  To accomplish the goals of having become a patient will take the form not of becoming a "good patient" but of needing less to be a patient.

It is difficult to gauge success of a patient in the clinical setting because the dwindling of the  clinical relationship in intensity and frequency may indicate failure or success (avoiding  processes of diagnosis and treatment because of fear or because of deficient clinical relationship; or “graduating” from being a patient, deemphasizing the clinical relationship because improved health, comfort and functioning have now been accomplished).  It may be easier to discern  improvement from outside the clinical setting, closer to where the patient lives and functions, where changes  in comfort and capacity more easily can be seen.

As long as someone lives he may become a patient.  Processes of clinical care are merely continuations of processes of self-care we pursue each moment.  Being cared for by others has  taken place extensively before one is formally cared for by a clinician.  Examples of the accomplished patient will be open-ended stories, not of those who have achieved immortality but  of those who continue to pursue their human lives.

I have chosen complex examples, not the usual model of glowing success of a healthy person having ailed, having been repaired and having resumed pure health.  (Throughout these essays no case I have cited seems to me without a measure of success, even when the patient has died.)

1.  A healthy, rebellious boy became a healthy responsible man.  Hard-working and productive, he cared for his extended family, making secure their affluence and closely controlling their affairs.  He overindulged in food, alcohol and chocolate, but had quit smoking and playing cards.  A thorough evaluation including exercise electrocardiogram indicated significant risk for heart attack, but he took it lightly.  His heart attack came four days after the birth of his daughter's first child, during a time his remaining son was threatening to sue him over business matters.  His other son had been killed in combat five years earlier.  He recuperated in coronary care without complication, but capsulized his fighting response against disease and his sympathy for the nursing staff's difficulty caring for him by posting a sign above his bed, "Beware of Dog".  He was seen walking the halls eating ice cream on a stick.

Out of the hospital he drastically changed his diet, began walking many miles each day, took vacations between intense bouts of work (sometimes flying to several cities in a day in the plane he bought to avoid the stress of airport lines and hauling luggage).  He spent much thought and energy establishing trusts to care for his grandchildren, engineering them to avoid enhancing self-indulgence or damage or death attendant thereunto.  He separated his business affairs from those of his in-laws and children to a great extent, but began new projects of his own to avoid retirement (including philanthropic work).

He consulted cardiac specialists in many cities, considering coronary bypass surgery, but during several years of good functioning he religiously maintained a regimen of many medicines, occasionally "violating" with alcohol or chocolate.  He refused to complain of angina pain.  When his energy gradually waned and he could not easily remain active, eight and one-half years after his heart attack he had bypass surgery.  He was home in less than a week celebrating Thanksgiving with his extensive family.  Within two months of surgery he cruised around the world with his wife.  A photograph shows him smiling broadly in front of Taj Mahal.

Now nine years after his first illness he and his wife prepare to tour Europe with six of their seven grandchildren.  He will likely overeat sometimes during the trip, but without undue guilt, partly because his most  trusted of many cardiologists (who lost more than eighty pounds himself) has deemphasized guilt imposed through medical authority.

2.  Less than two years from retirement from his government job as dispatcher at a loading dock, and still less than forty, he had been maintained on methadone intermittently for nearly fifteen years and had continued heavy drinking.  His supervisor at work protected his job even when he was clearly unproductive, with the support of regulations which protect the status of a career government employee.

The methadone clinic staff overlooked his drinking for years because he was quiet and employed.  His family were concerned, but tended to come to his rescue, his younger brother keeping an eye on him.  When his  confusion and toxicity became more than obvious and he was vomiting blood he was hospitalized for alcohol detoxification, but was ejected for drinking on the ward.  He was begun on disulfiram (Antabuse) at the methadone clinic, but continued to  drink.  Severely confused, his plight brought communication with his counselor from family and supervisor.  He was again hospitalized for detoxification, and again ejected for drinking and taking pills.

Again an outpatient but paranoid and confused he came to the hospital lobby and chapel daily while his counselor and the program physician negotiated for readmission to the hospital and longer-term placement.  His family's attempts to commit him to the State Hospital were frustrated by applications of regulations meant to protect individual rights.  His confused ambivalence was characterized by his jumping out of the first floor clinic window (when he could have walked out the unlocked door) mere seconds before his counselor was ready to walk him across the parking lot to the hospital.

Arrangements were finally made to admit him voluntarily to the State Hospital.  His younger brother attended to him through the weekend and on Monday drove him across the state for admission.  He stayed for a few weeks, during which he was detoxified from methadone.  He was given haloperidol (a tranquilizer which can cause muscle stiffness and tremor as side-effects).

He called to thank me the other day.  He sounded clear and said his life was different.  He was back at work, feeling well, taking no drugs or medicines.  He said he had left the State Hospital early because they would not give him anything for his "nervousness" (the muscle stiffness and tremor, and akathisia--inability to sit still--caused by the medicine).  He was no longer "nervous” after he left the hospital.  I explained his fidgetiness was due to the tranquilizer, encouraged him he needed no drugs, wished him well, thanked him for making the phone call, for thinking of me.

A rule of thumb for the assessment of success of a person as a patient might be the level of autonomy he achieves compared with what might be expected.  Synonyms of "autonomy" in all clinical practicality are “independence”, "health" or "adjustment".  The irony which tends to puzzle clinicians is that accomplishment as a patient implies becoming less a patient; that is a person's success as a patient is gauged in terms of his  success as himself, not as a patient.

The accomplished clinician must adjust to looking to lose his patient, not knowing how the patient is, no longer having the control he had when the patient was most dependent.  What the accomplished clinician has accomplished through the experiences of the clinical relationship is strength, wisdom and growth in his own personality.

To be a doctor, as Lewis Thomas has implied4, is to be a teacher--literally, etymologically. The roots of the words reflect both teaching and learning.  I treat my patient by teaching him; whatever I know I have learned from my patients.


1 Actually, of course, “subjective” versus “objective” are misleading ideas which might be improved by consideration of the “intersubjective”. Buber, Macmurray, child development psychologists, phenomenologists and other students of human relationship have begun to develop alternatives to the sterile materialistic dichotomies of subjective/objective. The nature of the intersubjective is beyond my scope in this chapter, but I’ll keep working on it for you.

2 Whitman, Walt.  "Song  of  Myself", Leaves of Grass, section 33, page 56; New York:  The Modern Library, Random House, 1950.

3 Regimen in Acute Diseases, IV, translated by W.H.S. Jones.  Hippocrates, Volume II, page 65; Loeb Classical Library: Harvard/Heinemann, 1972.

4 Thomas, Lewis. The Youngest Science, Chapter 6, "Leech Leech, Et Cetera", pages 51-60; New York, Viking, 1983.

| | | |