Curing distrust in rheumatologic care
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This month’s roundtable, “Paradigms of distrust,” by a stellar cast of clinicians — Priya Fielding-Singh, PhD; Kenneth G. Saag, MD; Jen Sebring, BA(H), MSc; and Shilpa Venkatachalam, PhD, MPH — is a painful examination of moments in practice that are far from what we would envision as caring, and far from what we would want for ourselves or our loved ones if we were in need.
This forthright discussion does not assert that the practice of rheumatology is rife with such moments described as “medical gaslighting,” but I believe it should serve as a warning beacon for all of us that it can and does occur. When it does occur, we are all diminished.
If we try to reflect on circumstances that could arise when patients are marginalized in clinical practice, we reflexively think “this cannot happen to me and my patient,” but in reality it can and does happen to all of us, at least to some degree. The reasons why we may lapse in our humanity to our patients are clearly pointed out, as some of our biases and attitudes are not willful but subliminal — the product of many implicit ideas, beliefs and attitudes with which we are ingrained.
I know this is hurtful to consider but I believe it’s true. Furthermore, even if we do not believe that we have the mental background to lapse in our medical humanity, I will tell you that on a day-to-day basis we are not always the same person. I like to say during orientation of new faculty at Cleveland Clinic that, on a normal day, I am pretty good and can cope with most patient-related stressors. And on a great day, when I “taste my toothpaste” and see the clouds on my way to work, I feel one with the universe and can handle anything.
Unfortunately, on some other days, when I am stressed from the vicissitudes of life, I am not as well equipped to deal with a lot more things than I would like. This is called life.
To buffer from these moments, I remind myself that the same tools I discuss in my Art and Practice of Medicine course, which focuses on the uncertainties surrounding medical humanism for our third-year medical students, apply to us equally well as practitioners. We strengthen our souls through reflection, and we need to work at it.
These practices may include thoughtful discussions with peers, reading fiction, listening to music, watching theater, viewing art or whatever fills your soul. Burnout is the antithesis of a reflective life and thus we must work constantly to buffer ourselves from it. This is more than momentary medical advice and I would ask you to consider it as a lifelong challenge.
Finally, there has been so much excellent work done in the field of advanced medical communications over the past few decades — we should aspire to continue to learn from it and work on our own communication skillset in practice. There are now studies supporting the idea that when we build relationships with our patients as people, we are far less likely to dehumanize and marginalize them, and much more likely to actually care for them.
There have also been research advances in medical communications that, when applied, can facilitate such relationship building. Unfortunately, most practitioners have limited access to such educational resources, and national meetings such as ACR and EULAR rarely emphasize these areas of knowledge and skill. Most of us erroneously believe that this was all taught to us in medical school and that these are skills we have mastered. I assert that efforts to learn and grow in these areas should be viewed on par with our commitment to lifelong learning of clinical science.
By engaging in efforts to improve our medical humanism quotient, we commit to building better versions of ourselves every day. The search for humanism in medicine is ancient and many of the greatest figures in our craft have written brilliantly about it. None have summed up the calling better or more crisply than Francis Peabody, who over a century ago reminded us that, “The secret of the care of the patient is in caring for the patient.” Enough said. That’s my take, what’s yours? Please share your thoughts with me at calabrl@ccf.org or at rheumatology@healio.com.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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