Like many physicians, my career was initially driven by my quest to become a healer, although I must admit, I really did not know what that meant.
It began as an effort to achieve satisfaction and, yes, the joy of helping people treat their illnesses, much of it with the prescription pad. However, in the early days of my military medical service, I got to know more about what healing meant. I saw patients and their families as well, and had time to counsel, comfort and follow-up on their progress -- to go beyond simply treating their diseases. I had time to hear about their suffering; to talk with them about their goals for health care; and to address prevention, health promotion and well-being.
Gradually, however, I noticed the health care system around me was changing. I started to see most patients only once or twice a year and some even less. And I saw patients for less time as my panel grew and the duration of visits shrank. I got to know my patients less and began ordering more tests and referring them to specialists more often. Through this time, I've sadly witnessed the epidemic of physician burnout, and I believe it is primarily caused by the relentless churning of an industrial-transactional medical system that undermines the intimacy and trust that is crucial to creating a healing doctor-patient relationship. Treatment remained; healing faded.
Many people blame the problem on the inability of physicians to get enough time with patients, and that is partly true. It's true that assembly-line medicine, with a harried doctor looking at the electronic health record instead of the eyes of the patient, is a horrible way to "see" someone.
But healing is more than time, and the idea that more time will solve the problem is an illusion; it's rather a question of how that time is structured. If structured with intent, design and skills to create a safe and trusting space, it can help unlock the secret of how that patient can heal. Healing can arise in an instant if we connect deeply with a patient and come to a common insight. If we have a moment of "being with" a patient and not just "doing to" them.
To do this, we must continuously attend to how we are talking with our patients. We know that medical treatment per se is only a small part of the healing process; we don't heal by prescribing pills and procedures. We truly become healers when we relate to each patient as a whole person, considering their full life with all its behavioral, social, emotional and spiritual components.
I'm often reminded of a deeply troubled military veteran in his 40s whom I treated 5 years ago at the chronic pain clinic where I work in Fort Belvoir, Virginia. He was a combat engineer who'd been deployed in both the Iraq and Afghanistan wars where he suffered traumatic brain injuries during missile attacks and roadside explosions.
He suffered from a serious case of PTSD, along with hypertension, heart issues and severe chronic back pain. He had been suicidal for several years, despite psychiatric counseling, physical therapy and other treatments. When I met him, I asked whether he still thought of suicide, and he replied, "every day."
My clinic now uses an integrative model that begins with having patients fill out a short Personal Health Inventory (PHI). The PHI intentionally focuses on the whole person. Instead of just asking: "What's the matter with you?" the PHI asks the patient to tell me: "What matters to you?" This subtle but vital distinction leads me to get a fuller sense of who each patient really is, and what might be driving them beyond their immediate medical complaint toward deeper healing.
That day at the clinic, this veteran's primary complaint was back pain. The clinic's integrative care model incorporates both conventional medicine and evidence-based complementary modalities, including nutritional counseling, acupuncture, meditation, therapeutic massage and yoga. But this patient had never tried any of those services.
After we talked about his physical and psychological pain and isolation, I suggested that his back pain might be alleviated by yoga therapy, with the proviso that he should attend a group yoga class with other military veterans, including a "peer partner."
Our visit did not last very long, maybe 20 minutes, but I was able to maximize its value because he had already filled out the PHI and because I paid close attention to his deeper needs, not just a refill. Even in that short span, we were able to establish a relationship based on his respect for me as a senior military doctor and my respect for his service and the suffering he was experiencing.
He said he'd consider yoga; I stressed the importance of engaging with the peer partner and told him I would ask him about it on our next visit. I pointed him to group yoga programs and peer support available to him through the Veterans Health program called "Whole Health." I didn't see him again for several months. It turned out that he tried yoga for the first time and was encouraged by his peer partner to come back. He ended up attending the group classes on a weekly basis.
When we reconnected a few months later, he told me he was really enjoying the yoga classes with his fellow vets.
"That's great!" I said, "Is it helping your back pain?"
He replied, "Uh, I don't really know... but I'm not suicidal anymore."
I shared his excitement, and I also had to laugh. If he had come to me to treat his depression and suicidal ideation, I would never have prescribed yoga. There's no scientific evidence for yoga preventing suicide. And the yoga didn't even solve his back pain -- but it ended up creating relationships for him, relationships with the peer partner and with a room full of fellow vets seeing each other every week.
For me, there is a kind of spiritual dimension, a sanctity of the encounter that occurs when you explore together what the meaning of suffering is for a particular patient, and therefore, what healing might feel like, if that suffering were relieved or transcended.
What healed him were those relationships. In part, it was his relationship with me, but it was mostly about him becoming motivated by new relationships that moved him toward self-care. I've seen this pattern repeatedly in my years as a family physician, scientist and researcher with the NIH, WHO and the Department of Defense: healing is most likely to emerge when it starts with a trusting relationship. Often, how, and when it happens cannot be predicted or prescribed.
Transactional health care is fundamentally at odds with the relational nature of our work. Various studies suggest that care built around deepened doctor-patient relationships is better medicine. It results in improved outcomes in terms of population health, patient satisfaction, the care team's experience, and even cost-savings.
The literature -- and my personal experience -- is very clear: when there is trust between two people where they feel like they can rely on each other to be honest and seek deeper truths, then that relationship is more likely to be healing. Out of that can emerge something that is relevant and is meaningful both for the patient and for the clinician.