The healing potential of the relationship between doctor and patient has long been recognized in the medical field. Much has been written on how the healing that can occur goes way beyond the technical or pharmaceutical interventions that physicians employ as part of their work in helping a patient recover or improve from physical and mental diseases. And while it is sometimes very clear that some physicians have personalities more suited than others to establishing effective, meaningful, and healing relationships with their patients, the actual specific interactions, techniques, and skills that can make a physician a healer have not been studied intensively.
That is why Larry R. Churchill, M.D. and David Schenck, Ph.D. undertook a study in 2008 to try to find out what interactive skills made a difference in establishing a healing doctor-patient relationship. Many of the relational skills they found to be important have already been alluded to in previous columns I’ve posted on this website, but what I find illuminating about this investigation are the common themes that run through the interviews with the physicians and other healthcare practitioners who were chosen to participate in the study.The article is entitled “Healing Skills for Medical Practice” (Ann. Int. Med., 2008; Vol 149:720-24; free abstract available online, article available for purchase. Drs. Churchill and Schenck interviewed 50 practitioners from the Tennessee-North Carolina area who were regarded by their peers as “especially good at establishing and sustaining excellent patient relationships.”
There were 40 physicians from academic institutions and community settings. They covered a wide range of specialties. There were also 10 non-M.D. practitioners in complementary and alternative medicine. The age range of the practitioners was mid-30s to late 70s. 50% were women.
The subjects were interviewed in person, and the interviews were recorded and analyzed for their content and the themes behind the practitioners approach to their work with patients. The basic questions asked were, “How do you go about establishing and maintaining healing relationships with your patients? What concrete things do you do to bring this about?” The authors found that 8 themes recurred throughout the interviews of the selected practitioners:
1. Do the Little Things: These included “smiling, shaking hands, acknowledging others in the room, and making eye contact.” These actions are important parts of establishing connection with a patient through human contact. They recognize the patient as important and welcome the patient into what may be foreign and unfamiliar territory. One practitioner commented, “If someone feels connected, then you’re miles ahead in terms of being able to affect some sort of positive results or impact on the patient. Touch is extremely important, so shaking hands and a hand on the shoulder…are very, very important.” Small behaviors conveying a sense of humanity can have major effects on establishing a relationship.
2. Take Time and Listen: This is such an important part of interacting with a patient. Listening well takes effort and time, but it is part of being present to and for the patient. As mentioned in a previous column here, “Why Listening is So Important,” it means the professional must put his/her own agenda aside in order to fully hear what the patient is saying. Some of the clinicians in Drs. Churchill and Schenck’s study made insightful comments that summarize the concept beautifully. One mentioned, “I may have a thousand things going, but I need to sit down and try to look relaxed…and try to give them body language that says, ‘I have time for you.’ ’’ Another practitioner said, “…I spend a lot of time listening to the answers to the questions that I ask, and then I try to let some silence take place…so that they can tell me what they’re concerned about.” Some of these professionals talked about the importance of letting the patient tell his/her story, especially as a source of connection to and understanding of the patient. One said, “Asking about them, not just about their disease. Letting them tell their own story without too many interruptions.” Being listened to validates who the patient is and can encourage self-reflection that can lead to self-acceptance and healing.
Of course, many physicians today do not have the time they would like to engage in the “listening” process, but even limited time that is well focused and well used to center the attention on what the patient is saying can still be effective.
3. Be Open: This can be very difficult to do. As the authors of the study point out, all patients have wounds and bring them to the clinical encounter. They go on to say that “It takes courage on the part of the practitioner to be willing to be open to this vulnerability.” One of the clinicians interviewed said, “You listen for the wound and you let them know that you have wounds. You are not perfect.” This is the concept of physician as wounded healer. The physician who is self-aware of his/her own wounds is better able to understand and accept the experiences and suffering of the patient, allowing the patient the freedom to express vulnerability also. The frequent end result of this is an empowerment of the patient that can lead to healing. One of the most compelling and admirable statements in this study comes from a clinician who says, “You know, I might get tearful, or I might get upset, and so I think a lot of physicians, at this point, pull back, become more clinical, and move through it, but if you stretch a little bit, and you allow yourself to feel these emotions, it helps the patient tremendously. It actually is very rewarding, as much as it is difficult.” The physician who is open, accepting, and embracing of his/her own vulnerability is more open to the vulnerability of patients and better able to communicate with, understand, and support the patient in the patient’s search for inner strength and healing.
4. Find Something to Like, to Love: The practitioners found it very important to like their patients, finding something about them, whether an accomplishment, a personality trait, a certain quality, that made them care about and have compassion toward their patients. Compassion is very healing in itself and conveys to the patient that the clinician is interested in them. Some caregivers even expressed having love for their patients, love that would be appropriate with caring about their patients and not beyond the boundaries of a professional doctor-patient relationship. One clinician said, “I have a heart and soul which I can offer them, which is the way of bringing them some love…I think to get to the point of healing you have to love.” Another study participant said, “We’re in it for the moment where there’s that double heart open connection of love and truth. It makes my practice doable.” There is no doubt that to take care of patients well you have to like them, even if some may be difficult personalities. Finding something to admire in another is part of the healing connection.
5. Remove Barriers: The practitioner-healers stressed the importance of removing barriers that prevent any personal interaction, be they physical or emotional barriers.
“I never have anything between me and the patient. I’ve always had my desk up against the wall,” said one of the study subjects. Another barrier is the distancing effect of superior attitude or power instead of the equalizing potential of humility. One clinician commented, “I’m not too good to open a door and roll a patient back into the room.” Another said, “I like to have them understand that I am a human being, that I am not a god. I am a physician.” I think that one of the most instructive, humbling, and affecting things I ever did as a practicing physician was to feed a hospitalized patient with severe destructive rheumatoid arthritis, when noone on the hospital floor was available to help the patient, who couldn’t feed herself, eat. Those fleeting moments of connection, that were not even filled with words, were something I’ll never forget because they touched my heart so deeply.
6. Let the Patient Explain: The respondents talked about how the patients themselves can provide so much helpful information on their own condition, and how important it was to let patients convey their understanding of their own illness. Healing can occur from being heard and acknowledged, and this approach also gives the caregiver a chance to offer insight into what the patient is experiencing related to the illness. One of the caregivers said, “A good way to get the patient started is just asking them what they understand about what’s going on so far. It allows them to be either very scientific and talk about the tests that they’ve had or it’s an opening if the emotional piece is important to them at that time. It gives them an opportunity to frame it for what they need the most…” The authors of the paper also point out that hearing the patients speak about their perception of their illness allows the practitioner to communicate more effectively with the patients, using language and terms that are “understandable and meaningful.”
7. Share Authority: Many caregivers expressed the importance of patients sharing responsibility in their care and, by extension, sharing responsibility for their healing. One of the practitioners, in talking about an initial visit with a patient, said that he/she conveys the following information: “I’ll make some recommendations to you. But you will always dictate what you want to do.”
Another said, “What’s often not recognized is the patient brings a particular level of expertise too. Who knows more about them than them?” Even if the patient participates fully in his/her care, that patient must still have confidence that the clinician will offer good guidance along the way, so that the best options are chosen. And the practitioner must have confidence in the patient’s judgment and ability to make good choices.
8. Be Committed and Trustworthy: The respondents all emphasized the importance of commitment to maintaining the relationship with the patient, so that a sense of trust develops. Many again mentioned how vital it was to listen to and hear the patient’s story as a part of establishing a relationship and engendering that trust. One clinician said, “Healing is about connections, and connections are about listening to people’s stories. Listening to people’s stories is what makes us trustworthy. And as we are found trustworthy, we are able to be more effective.” The commitment is also strengthened by acknowledging and accepting the patient for who he/she is, and agreeing to be there for that patient because the patient is so valued. These professional relationships, built on trust and acceptance and the value the patient and clinician see in each other’s lives, are what make clinical practice so meaningful for many caregivers. The commitment that can naturally result is a mutual one – clinician committed to staying with the patient to foster improvement and healing and patient committed to working with the clinician to promote a return to as healthy a state as possible.
For all the reasons mentioned above and because of all the enriching experiences that can happen for those on both sides of the doctor-patient relationship, the practice of medicine is more than making diagnoses, giving drugs, and doing procedures. There are lessons to be learned about living that the patient and the doctor can teach each other. There is the potential for the relationship to give meaning to the lives of both the patient and the physician. The information from the caregivers in the above study also offers a clear vision of what constitutes a good nurturing relationship not only between a professional and someone who needs help, but also between two people in any kind of beneficial and significant supportive relationship where there is mutual acceptance, an openness to each other, and a willingness to bring their full and honest being to the table. The authors of the paper, Drs. Churchill and Schenck, point out that one must take into consideration that their work did not include both comparisons with practitioners who weren’t recognized by their colleagues as having healing abilities as well as interviews with the patients of the recognized healers. Still, hearing from the effective practitioners themselves is a major contribution toward illuminating how healing can happen on a very practical level and why the human element is still a vital part of effective medicine.