Developing Clinicians' Career Pathways in Narrative and Relationship-Centered Care

Footprints of Clinician Pioneers

John D Engel, Lura L Pethtel, Joseph Zarconi

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315346120
• Edition: 1
• Topic: Medicina
• Subtopic: Sanità, amministrazione e assistenza pubblica

'Today, there exists a robust body of work connecting narrative theory and practice with medical theory, practice, teaching, and research. Taken together, what is particularly interesting about these works is that they portray narrative healthcare as both a philosophy of care and a set of skills - ' John D Engel, Lura L Pethtel and Joseph Zarconi, in the Preface This inspiring collection of narrative portraits details the career paths of physicians and nurses who figure prominently in the realms of narrative and relationship-centered healthcare. Each narrative describes the healthcare practitioner's early decision process for choosing their career and follows with a trajectory of events and work situations that brought each person to their present position. They offer a unique view from both a personal and a professional perspective. The collection of narrative portraits provides students, residents, and practicing health professionals a window into the possibilities for constructing professional lives that are oriented to service in ways that are fulfilling, energizing, and creative. The editors have made an important contribution to advancing the practice of narrative and relationship-centered medicine. They invite you to listen for the truths of your own story as you hear the voices of colleagues speak from the pages in your hand. Reflecting on the ultimate concerns that move you will enable you to more fully inhabit your own life story and become more authentic and vital as you heal others. Mark L Savickas, in the Foreword

Career Stories

Howard Brody

He has about him the constant will of a man trying to recognize.

—J BERGER AND J MOHR¹

For many years, Michigan State University (MSU) had a strong hold on Howard Brody. And only until just a short while before my interview with him did he break that hold. It was there at MSU, over a 9-year period, that he earned his BS in biochemistry, his MD, and a PhD in philosophy. He broke away for 3 years to complete a residency in family practice at the University of Virginia Medical Center, but then returned immediately, where he remained for the next 26 years, working half his time in family practice and half in the medical humanities program. Finally, in 2006, Howard bid farewell to MSU and accepted a post as Director of the Institute for the Medical Humanities at the University of Texas Medical Branch. Putting aside patient care, he now directs his energies and talents toward his research and writing and new academic ventures.

Howard’s career and his professional endeavors and writing have been exemplary and highly respected throughout the national and international medical communities. He has authored and coauthored eight books, 48 book chapters, and 174 articles, and he has received several outstanding honors and awards, including a Teacher-Scholar Award, Excellence Award for Interdisciplinary Scholarship, University Distinguished Professor, Distinguished Faculty, and Distinguished Alumni. Aside from clinical topics, much of Howard’s writing focuses on matters such as medical ethics, the physician-patient relationship, philosophy and medicine, palliative care, the placebo effect, and patient narratives. Howard was an early and significant contributor to the field of bioethics, where he remains active and his work continues to be influential. In 1987, Howard published Stories of Sickness,² which was the first medical textbook with the term “stories” in the title. Here, Howard expresses his concern with a philosophical analysis of several concepts that are central to health care. In his book, he sets forth five interrelated aspects of sickness that set the place for narratives in clinical care:

1. To be sick is to have something wrong with oneself in a way regarded as abnormal when compared with a suitably chosen reference class.
2. To be sick is to experience both an unpleasant sense of disruption of body and self, and a threat to one’s integrated personhood.
3. To be sick is to have the sort of thing that medicine, as an evolving craft, has customarily treated.
4. To be sick is to undergo an alteration of one’s social roles and relationships in ways that will be influenced by cultural belief systems.
5. To be sick is to participate in a disruption of an integrated hierarchy of natural systems, including one’s biological subsystems, oneself as a discrete psychological entity, and the social and cultural systems of which one is a member.

Being a great fan of Howard, I was gratified to spend time with him for this interview. During our time together, he expressed that, for the most part, his career has been underscored by his drive to discover ways to liberate patients’ capacities for self-actualization and self-healing. Here is Howard’s story.

A Career in Medicine

My father was a lawyer who was frustrated that he couldn’t go to medical school. So I think early in life this was what prompted me to think that I might pursue a career in medicine. I liked the sciences when I was in high school, and in college I took a biochemistry major with the idea that this might be an area of interest for me. I assumed, as a student in high school and college, that the part of medicine that would intrigue me would be the scientific research area. I was quite surprised when I entered medical school to find that the humanistic and interpersonal dimensions of medicine were more intriguing to me than the scientific ones. I went to Michigan State University College of Human Medicine, where I had been an undergraduate previously. By the end of my first year, I decided that I also wanted to do a PhD in philosophy so that I could engage in medical ethics in a serious way. This complicated my decision for a specialty because I had to consider what it would mean if I also wanted to work in this new area called medical ethics, which was at that time just getting started. I thought I probably should go into something like internal medicine because if I were also to work in the area of ethics, then I should be in a traditionally respected medical specialty that would counterbalance that. But several things drove me in the direction of family medicine. One was the fact that I had had experience working with some family physicians in my second year of medical school and I was very impressed with them and the work that they did. I thought that family medicine really looked interesting and that I would enjoy doing it. The second thing was the fact that the family physician does have continuity with patients from the birth process to the dying process and, seen from an ethics perspective, that’s an ideal vantage point. Finally, when I got to my third year of medical school, I had expected to dislike pediatrics and dislike obstetrics, which would have reinforced my going into internal medicine. Instead I found I really liked both of those areas, so that again made family medicine seem like a good thing to do.

My early interest in ethics was a multifactorial matter. I became interested in philosophy as an undergraduate and I actually started doing what would have amounted eventually to a philosophy minor, except that I didn’t quite finish it. I connected with a faculty member, James Trosko, who was developing a course that he called Science and Human Values, which today would be called Ethics of Science. He introduced me to the existence of the newly founded Hastings Center, a bioethics think tank in upstate New York. I had an opportunity at the end of my first year in medical school to attend a conference sponsored by Hastings, the first national conference on teaching medical ethics. In this way I was able to get in at the very beginning of the field in a way that a medical student would not ordinarily have a chance to do. So there were several lucky things happening that got me into the field of bioethics.

After medical school I completed a residency in family medicine at the University of Virginia Medical Center. When I started looking for jobs, I soon discovered that few people could figure out what to do with somebody who has an MD and a PhD in philosophy. Among the programs that could offer me a job that made sense were the people at Michigan State who had trained me. They knew what it was I could do. I took a job with them and I remained there for the next 26 years. It was a very attractive position because it essentially was half time working in family medicine doing patient care in the university outpatient group practice clinic and half time working in what was then called the Medical Humanities Program. I taught a course in medical ethics for juniors and seniors in the philosophy department in the undergraduate college. Then I did some lectures and some small-group teaching in the medical school. Periodically I would have a medical student with me in the clinic, although I never had the kind of clinic where the student or the resident saw the patients by themselves. They would talk to the patients and basically follow me around. My research was mostly scholarly work and writing. There was very little involvement in any actual data-gathering trials, so it was mostly literature searches, analytic work, and writing philosophical articles for publications.

Views on Relationship-Centered Care and Narrative Medicine

The goals of medicine range from trying to cure a disease, if the patient has a curable disease, to just reassuring healthy people that they’re well, as well as trying to keep people healthy, trying to educate people about their health, trying to manage diseases that can’t be cured. It’s quite a wide spectrum. Different patients require different things, but I believe that the core thing that we do in family medicine is form relationships with patients. I assume that if you took away the surgeon’s scalpel, he would say, “You’ve incapacitated me, I can’t do my work.” For family physicians, if you took away their relationships with patients, they would say, “We can’t do our work.” So most of what we do in family medicine, whether it’s trying to educate a patient, trying to get them to manage their own illness, or whatever it is we do, we do it via the relationship.

I see a primary care visit as having two components that are interwoven. One component, obviously, is to try to handle whatever the problem is that day. If the patient has a sore throat, you do something about it. But every visit is also a relationship-building visit because you’re going to see that person again. If you’re seeing the patient for one of your partners, your job is to reinforce the relationship that person has with your partner. You don’t try to steal your partner’s patients; you try to reinforce the good relationship they hopefully have with the other doctor. So every visit has a relationship-building piece as well as a deal-with-the-problem piece. That’s difficult because the time available for the typical outpatient visit is limited in family medicine.

Some physicians argue that it takes too much time to get so involved in relationships and reflections with patients. Admittedly, I often had more time in my usual visit with a patient than would have been the case had I been in a typical private practice environment. A patient visit consists of the amount of time that you spend dealing with the problem and then there’s the amount of time that you spend in relationship building. It’s not really much extra time that you spend doing relationship building. You can have good relationships with your patients in 10-minute visits interspersed with longer visits. I do know physicians who are very successful with this kind of practice. I was trying to teach my students that the most efficient way to get a good history from the patient is by asking open-ended questions. In class, we’d look at a tape and I’d say, “Okay, here’s an open-ended question, now look at the clock and see what the patient said. How much information did you get and how much extra time would it have taken you to ask a whole lot of yes and no questions to have gotten that very same information?”

By the time I finished my work at MSU, there was more talk explicitly about productivity and generating income than there had been when I started, I felt under more pressure to move patients through faster, and we were getting data about how short of our targets we were. When I started at MSU, my basic appointment time was 15 minutes with a patient. If I had been in private practice in that same community, it probably would have been 8 minutes. I could get two 15-minute blocks if I knew I had a more complicated patient, and I had made arrangements for that ahead of time. When I finished 26 years later, the template for the visit was still 15 minutes, despite all the productivity stuff and despite all the pressures. They were now giving their doctors twice as much time as many family docs in that same community were getting. They committed themselves to saying, “This is what you need at a bare minimum to do a decent job in a family practice encounter.” So I felt I was among like-minded people in that regard. When we went to an electronic medical record, we had the option of using a lot of checklists where you just “click, click, click” and you can check all of the boxes, but you also could write a narrative note. I continued to write mostly narrative notes for my patients and nobody ever said, “Don’t do that, use the check boxes.” I was able to use the electronic record in a way that was friendly to the practice that I had without undermining my values in my practice. So I felt like I pretty much was among people who reinforced rather than undermined what my values were in my little setting.

One thing that likely influenced me to practice relationship-centered care I attribute to my mother. I think she probably was the model for the piece of me that said, “Maybe that’s a good way to be with your patients.” My parents were in many ways quite different. My late father loved the three of us children a lot, but he was very wary of showing his love. He invented “tough love” I think. He was very clear in his mind that if we ever thought that we had his unconditional love, we would stop trying to earn it. His greatest fear was that we would stop trying hard, and that the only way that you succeeded in life was by constantly trying hard. He felt that he was being a good father if he kept pushing and prodding us to always try harder. So he would withhold demonstrations of love and would always say, “Oh, that’s very nice that you did this, now what are you going to do tomorrow?” That was his response to anything we ever achieved. There would always be something he’d find to criticize us about. My mother is noncritical, very loving, just unconditional love personified. I’m hoping I got the better part of each parent somehow.

Another thing that influenced me to practice in this way was the work I did as part of my philosophy dissertation, which had to do with the placebo effect. That was the first area in which I did serious scholarly research. As a result of my work, I came to believe that the relationship that a physician has with a patient is not merely handholding; it’s not merely bedside manner. Rather, it is part and parcel of the treatment of the patient’s illness and, in some cases, at least just having that kind of relationship may improve the patient’s symptoms and their health outcome. I started with the idea that it is as important to have a certain kind of relationship with another human being as it is to have an accurate medical diagnosis and prescribe a certain drug or a certain surgery or a certain intervention in order for the patient to get better. I spent a good part of my practice life trying to figure out for myself what it was that I had to do in each visit with each patient to try to maximize the chance that I would turn on whatever this thing was that patients seem to have within themselves. In some of my writing, I fancifully call this the inner pharmacy that I believe is stimulated by the placebo effect. What is it that the doctor has to do in the visit to enable the patient to access his or her own inner pharmacy? So what I tried to do in my practice was to figure out how to interact with people in such a way as to maximize or stimulate to the maximal degree the powers that they have within themselves to get better under the stimulus of this kind of relationship. As time went on, I became somewhat more comfortable with this effort and more aware of certain aspects of what I was doing. Clearly, from my point of view the reflective practice aspects increased over the 26 years.

When you have this kind of relationship with your patient, you’re basically trying to make yourself into what I once wrote about in an article, “a healing sort of person.” It sounds terribly arrogant when you say it, but you’re trying as best as you can, with all of your limitations, to enable the patient to experience being in a room with a healing sort of person for whatever length of time they spend with you. You’re trying to figure out how you can, with all of your flaws, with all of your baggage, be a healing sort of person. So if you’re trying to be a healing sort of person and be there and be accessible to your patients, then hopefully your patients will have had a healing experience, as minimal or as short-term as it may be. And you, too, will have had a healing experience. When you reach out to your patients in this way, you become sustained, you become nurtured, you become better, and you become somebody you’re happier with. Everybody who talks about patient-centered care and relationship-centered care comes up with the same list of capabilities – some have four, some have eight, some have six, but it’s the same list. Try as best as you can to develop empathy, to listen, to make connections with people, to be reasonably nonjudgmental, to take big things and break them down into small pieces so that the pieces are not so overwhelming. Whenever you pick up an essay about this, it’s the same information, but listening is always at the center of it. Did you actually hear what the patient was trying to tell you?

I don’t believe this movement toward narrative medicine or relationship-centered care is a fad, but the forces arrayed against it are very impressive and very deeply rooted. When you reread the famous essay “The Care of the Patient,” written by Francis Peabody³ in 1927, it’s hard to find a single word that isn’t saying what we’re saying right now. My colleague Harold Vanderpool has been working on a history of palliative care, and he says that he’s been able to find manuscripts going back 400 years in which doctors have been saying pretty much the same thing that we say today about palliative care. The physician states, first, that the comfort care of the dying patient is truly a critical part of medicine, but then he immediately adds that, for some reason, his medical colleagues don’t seem to think that it’s very important. The 400-year history would suggest it’s not enough to blame a particular medical system or a particular set of insurance companies, or a bunch of malp...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• About the Authors
• Acknowledgments
• Preface
• Career Stories
• Index