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DoctoringThe Nature of Primary Care Medicine$

Eric J. Cassell

Print publication date: 1997

Print ISBN-13: 9780195113235

Published to Oxford Scholarship Online: November 2011

DOI: 10.1093/acprof:oso/9780195113235.001.0001

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The Clinical Method and the Patient

The Clinical Method and the Patient

Chapter:
(p.105) 5 The Clinical Method and the Patient
Source:
Doctoring
Author(s):

ERIC J. CASSELL

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780195113235.003.0006

Abstract and Keywords

This chapter asks: how can the clinical method and its techniques of observation that have served medicine so well be extended to the person of the patient? There are four distinct kinds of information, apart from brute facts, that doctors acquire from their patients — information that tells them about the patient as this individual patient — meanings, emotions, aesthetics, and intuitions. The final step in the process of knowing the patient, and an essential feature of the clinical method, is description. In relation to findings on the physical examination, describing what has been observed is essential to the observation.

Keywords:   emotions, individual patients, aesthetics, intuitions, description, physician training

THE QUESTION to be answered is this: how can the clinical method and its techniques of observation that have served medicine so well be extended to the person of the patient? The beginning of the answer is another question. What do clinicians need to know about their patients? The answer involves more questions. What is it about this patient—socioeconomic status, education, occupational factors, home environment, behavioral patterns, and so on—that influences the disease and the illness? What is the pattern of this patient's life with which medical interventions should best fit? What must the doctor know about this patient in order to make a therapeutic alliance? What do clinicians need to know about themselves? Generally clinicians are not being asked to make an assessment of personality or character, approve or disapprove of behaviors, or like or dislike their patients.

Let me begin with two examples that demonstrate this point.

Vivian Progoff is a seventy-four-year-old woman with sarcoidosis of the lungs (a disease similar to tuberculosis but not infectious) diagnosed two years ago. Her doctor, who has been taking care of her for more than twenty years, believed her to have two overwhelming passions: her daughter and her appearance. Prior to the onset of sarcoidosis, she had never had an important illness. She (p.106) characterizes herself as a worrier and a hypochondriac, but she has visited her physician infrequently; she says that she is afraid of doctors. When she does have an illness, however mild, she is articulate about her impending doom.

The diagnosis of sarcoidosis was made after a persistent cough forced her to see the physician. The X-ray was suggestive, so she had a computed tomography (CT) scan of the chest, saw two consultants, was asked to return frequently, and had a confirmatory biopsy by mediastinoscopy. During her workup she developed Bell's palsy, which cleared very slowly but almost completely. Her disease remained stable and required no treatment. Adult-onset diabetes was diagnosed about the same time as the sarcoid. Throughout this period she made endless telephone calls to the doctor to calm her fears, positive that she would never live through the experience (even her daughter could not reassure her). After about five months, her cough cleared and the calls stopped. On her most recent routine visit, she characterized the last ten months (which had been without symptoms, unlike the previous illness-ridden times) as the worst of her whole life. Why? The very slight residual droop of her right eyebrow occasionally interferes with her vision, and she has required several unpleasant dental procedures.

This is the kind of patient doctors generally do not like. She is demanding and vain. She gets as upset by trivia as by things that really threaten her. She consumes time and requires endless patience. But, despite all the Sturm und Drang, fears of impending doom because of her chest disease, the undoubted blow to her vanity of the Bell's palsy, and the shock of her diabetes, Mrs. Progoff did everything necessary because of her diseases and in a timely manner. Why? For five months she required more telephone calls than most patients, her fears required considerable attention, and she needed the reassurance that the doctor would not abandon her—nothing more. A therapeutic alliance was formed.

Walter Harnick is a fifty-one-year-old executive with a five-year history of diabetes. He runs a large corporation and sits on the boards of many businesses and civic organizations. His opinions about business and politics are valued by many leaders. He does not take care of his diabetes, however, does not follow a diet, exercise, or test his urine or blood, and does not keep doctor's appointments. Pushed into seeing his physician because of a syncopal episode, his glycohemoglobin was 13.8 (very high!). He adamantly refuses to take insulin but says that he now realizes he must be (p.107) more careful. However, he did not follow up on the advice given or keep his next appointment.

Admirable, handsome, likable, and seemingly much easier to deal with than Mrs. Progoff, he is heading for real trouble. His care, if success is possible, will require endless effort, but a real therapeutic alliance of mutual trust is unlikely. Yet, most physicians would rather take care of Walter Harnick. These two cases highlight a common error. Witness how the letters from consultants commonly end—for example, “Thank you for permitting me to take part in the care of this lovely lady.” What has “lovely lady” to do with the consultation or the patient's care?

How different are relationships in everyday life! There we are concerned about personality and character and everyday behaviors. This is how we choose our friends and associates, make work decisions, and steer our associations with others. These features of persons are the essence of the value judgments we make all the time in order to get through life. We can see the difference between physicians' relationships to their patients and to persons in everyday life by using as an example the relationship to the body in everyday life. For most people, the body is their body and they have a personal relationship to it. In the same way, we have a personal relationship with other people, whatever place they have in our lives. Physicians, on the other hand, in the course of medical school and socialization, learn about the body, an impersonal object of professional interest apart from their own personal bodies. In the same manner, primary care physicians (preferably, all physicians) must learn about the person, an impersonal “object” of professional interest apart from persons in everyday life. There are real differences, of course, between persons and bodies that make the task of knowing persons as objects very different from knowing about bodies. The first and most important difference is that if persons are treated as impersonal objects, they cannot be known in the way required to optimize their care. The second difference is that only a person can know another person, and if medical knowledge of persons is to enter medicine differently from the everyday knowledge of persons, the doctor persona—doctor as doctor, Eric Cassell as doctor—must be developed and distinct from the doctor's everyday person—Eric Cassell as husband, friend, or neighbor.

For years, I took exception when people asked me what I, “as a doctor,” thought about something. I took pains to explain that while I might be a physician, there was only one me. Wrong. There is one (p.108) person, perhaps, but more than one persona, one of which is a doctor. Physicianhood is a role—a set of performances, duties, obligations, entitlements, and limitations connected to a function or status. The role has its social counterpart in the expectations of the role that patients and other people have that make the performance of its duties possible and impose its obligations and limitations. It is a special role that makes possible the special, almost magical connection that constitutes the doctor-patient relationship.1 The role has historical and ethical dimensions that have led one author to liken it to a covenant in which doctors embrace the norms, knowledge, and historical expectations of the profession in return for its powers, its status, and the protection of their personal health and happiness that a professional identity provides.2 Early in training, medical students suffer the emotional pains that come from taking the sicknesses and deaths of their patients personally. As their training continues, they develop a professional self-image, as part of which they become increasingly immune to the emotional distress of their patients; unfortunately, they do it in a self-defeating way.3 As with so many other aspects of doctoring that are not explicitly taught, the doctor's identity as a physician—the physician persona thus acquired—frequently has flaws. Probably the most common flaw is the doctor's relationship to the emotions of patients. The world of sickness is filled with emotions—for example, fear, sadness, grief, relief, dread, happiness.*

The variety and intensity of emotions in the medical setting are demanding. They can be upsetting, or even overwhelming for inexperienced students or physicians. The usual reaction to this stress, explicitly reinforced by many teachers at all levels, as well as by the (p.109) medical care setting itself, is to suppress the emotions and distance themselves from the patient. Before long the doctor is able to deal with the worst of human misery, emotionally distanced from the patients and with all negative affect repressed.* In the absence of awareness of patients' emotions or of their own affect, doctors lose an important tool for knowing patients for which no other can substitute. The ability to know patients' emotions is a learned skill. It depends primarily, however, on the doctor's ability to be consciously aware of his or her own affect and emotional state. If this means that doctors will again be subject to all the unhappy consequences of the sea of emotion in which they work, what is to protect them? Here is where the distinction between the doctor as a separate self or persona and the everyday person is crucial and must be emphasized in training. It is sad when one of my patients dies but not more than that. The patient was not a member of my family or even a friend, even if he or she has been a patient for many years. A patient as a patient is not a friend even if the patient is a friend. A friend who is a patient is a patient while a patient and a friend in other settings. (This may be a difficult distinction to maintain on occasion. When I see my friends who are also patients in personal settings, I literally cannot remember intimate medical details about them.) When a patient lies to me, it is not Eric Cassell, the person, being lied to, it is the doctor. Lying has a different meaning in this setting than in everyday life. It tells something about the patient in relation to sickness and medical care. Seductiveness directed at me is also about the reaction of the patient to sickness or to relationships with doctors. Sexual feelings are prevalent in medical settings, but they are much more often related to the intimate connection established in the care of the sick than about sexuality per se. Knowing these things increases a doctor's diagnostic and therapeutic effectiveness: it makes no sense to merely hope that a doctor will (p.110) finally learn them, if at all, after twenty years of practice. At a hospice meeting I attended, a physician in his forties got up to say something extremely important to him that he had never been able to talk about. He felt it necessary to confess that he had once had very strong sexual feelings for a dying young woman in his care. The intensely close connection necessary for effective care of the dying is often interpreted as and feels like sexual arousal. All perceptions, even of feelings, are given meaning, and meaning is expressed in all dimensions of personhood, including physically. Most people have no experience of such closeness except sexually, so that is how they feel it in the clinical situation, often to their embarrassment. All that anguish occurred because no one had ever taught this physician how common sexual feelings were in the care of the sick. In general, the hidden (and sometimes explicit) sexuality present in the medical setting must be mastered by clinicians if they are to be maximally effective and comfortable in their work. Conversations with sexual meanings, handling and examining bodies, breasts, and genitalia, as well as the attractiveness of some patients to doctors and doctors to patients, brings sex into the thoughts of many physicians on frequent occasions. If physicians-in-training are not actively taught to deal with this problem, many end up ducking discussions of their patients' sexual problems and avoiding examinations of sexual organs. Yet I have rarely encountered doctors who were taught about the problem of sex in medical practice. There are some things one should not have to learn about by oneself. It is impossible to teach physicians how to be their own instrument while avoiding the issue of sex.

Training programs can teach physicians to be their own instrument if they understand the task and its importance. Teaching the concept and the specific skills requires a supportive atmosphere because of the undeniable difficulties such a goal poses for most medical students and recent graduates; the previous paragraph about sex provides an example. The problems faced are highlighted by the discussion in Chapter 3 of the effect on physicians of technology. There it was pointed out that technology is overused, in part, because of the certainty that it seems to offer in an otherwise uncertain world; by the what-you-see-is-what-you-get quality of immediacy that attends its use; by the unambiguous values it represents; by how fascinated doctors become by its new, shiny, and exciting features; and by how it confers power on its (p.111) users. Some of these difficulties are best solved by focusing on the patient as the logical center of medicine and by specific training in the use of different modalities. On the other hand, managing uncertainty is a personal challenge to even the best physicians. There are techniques of reasoning that help reduce its impact, but ultimately it is dealt with within oneself. Managing uncertainty, for example, requires a kind of training different from that of teaching technical medicine. Trainees are being supported while they personally change and while they learn to depend on kinds of information arising from within themselves that were often deprecated in medical school. The highly competitive milieu of many programs is not conducive to this type of training, particularly as the physicians are learning to utilize their emotions professionally in a manner that might have been deemed weakness in their previous training.

Knowledge From Patients

There are four distinct kinds of information, apart from brute facts, that doctors acquire from their patients—information that tells them about the patient as this individual patient—meanings, emotions, aesthetics, and intuitions.

Meanings

Meanings are at once the most accessible and most complex type of information. There are at least two senses of the word meaning that are important to physicians. The first sense is significance: numbness in the toes of the diabetic may signify diabetic neuropathy; anterior pressing chest pain with effort may mean angina. The alarm clock ringing means that it is time to get up. The second sense is importance. Diabetic neuropathy means that my diabetes is finally getting me. Angina with so little effort means that I can hardly do anything anymore. The alarm already? I don't want to get up. The importance of something is always personal because it is always important to someone (even though the thing may be important in the same way to many others). Importance is another way of saying value; all meanings have an element of value. When we know what an event means to people, we know both their beliefs about the thing and how they value it on the (p.112) scale of good and bad or right and wrong. If one knows a lot about the beliefs and values of someone, one knows a lot about the person.

When people perceive something about their bodies or functioning which seems wrong—perhaps a strange-looking thing, or an odd sensation or discomfort, or a change in breathing—the first interpretation is that something is different. Usually, an assignment of meaning quickly follows—for example, the strange-looking thing is cancer, the discomfort is from the kidneys, the changed breathing is asthma. People call or visit doctors because they interpret as illness, or as something wrong, alterations in their customary sense of themselves or of their function. How something so perceived becomes a symptom has a complex relation to the person's ideas of normal being or function, what illness is, and what it is proper to present to doctors. Physicians' understandings of symptoms are quite different. Doctors act as though a symptom is the direct effect of the disease on the person, as though a symptom is the voice of the disease through the patient's mouth. These differences are a source of frustration to both patients and doctors. How symptoms are formed, and the differences in their meaning to doctors and patients, is discussed at length in Chapter 7 of The Nature of Suffering. It is common for patients not to tell physicians directly about their observations—for example, the cough or tightness in the chest—but to go directly to the interpretation, “I think I have bronchitis.” Most often the interpretation is familiar, a diagnosis or a disease name, but sometimes it is so strange that the doctor may disregard the original observation. This case is an example.

Joseph Heelon is a thirty-one-year-old single carpenter whose union provided a physical examination. He said that he had been to a lot of doctors with the same problem: in the last two or three years he's noted a connection between ejaculation and phlegm. Phlegm rises into his sinuses and into the scars on his forehead and makes them puffy. It also fills up his nasal passages and his chest. When he doesn't ejaculate, he has much less phlegm. Because of the effect of orgasms he was thinking of giving up his girlfriend, but the problem occurred even when he masturbated. He had become increasingly concerned about the symptom and the effect of sex on his body. The doctors always told him that he was perfectly healthy and that there was no such thing as what he was reporting. Further questioning revealed that he had a perpetually “congested head” (p.113) and a stuffed nose that was worse at work (where wood dust was always in the air), apparently associated with a full feeling in his head when he had an orgasm.

Examination revealed well-healed 6-cm scars above each eyebrow (the result of an auto accident years earlier). The nasal mucous membranes were reddened, glairy and boggy, with a thin, watery mucus discharge. The appearance was that of allergic rhinitis. The remainder of the examination was negative.

The patient was advised to be more scrupulous using dust masks at work and treated with inhaled nasal corticosteroids. The pathophysiology was explained to him. Over the course of several months, the symptoms disappeared and the nasal mucous membranes became normal.

Joseph's previous doctors had made the common error of accepting the patient's strange interpretation as the symptom itself and treating him accordingly. As we all know, when people start assigning meaning to events, they rarely stop at a simple naming of the phenomenon. Instead, one interpretation follows another, usually ending with the most dire one that the imagination can conceive. Whatever meaning is assigned, the original perception is usually available in memory for reexamination, allowing the physician to give it a meaning in medical terms. The meanings related by patients, as with everyone, are not only connected to symptoms, but are presented in relation to every object, event, or relationship that enters a conversation. Meaning, especially the evaluative component, is also conveyed by gestures, body language, and other nonverbal communications. In virtually every doctor-patient interaction, whether full-fledged history taking or the briefest telephone conversation, these two systems of meaning coexist. The interconnected set of the patient's meanings has been called the life world, as opposed to the doctor's world of medical meanings.*

In order to know the patient, the life world cannot be disregarded. In times past, doctors' questions and observations extracted only the kernel of disease, diagnosis, and treatment-related facts and discarded the rich layers of personal meanings in which those facts were wrapped. Primary care physicians cannot continue this (p.114) practice. It is difficult for physicians to make therapeutic alliances with patients whose meanings are disregarded or discarded. The physician listens to the patient and hears the meanings attached to the manifestations of disease and the everyday life events in which they are embedded. The doctor's questions and explanations should be framed with the assumption that the patient's world is the world. You, the doctor, place yourself within the patient's system of beliefs to the extent possible. This does not suggest that you agree with or endorse the patient's beliefs. You are not there at all; the doctor is. In fact, the patient's ideas may be abhorrent from the life-world perspective of the everyday person who is the doctor. What does matter is the doctor who is asking questions and offering explanations. Medical explanations in technical terms or in jargon fail not only because the patient usually does not understand them, but also because they show that the doctor does not understand the patient. Otherwise, why would the doctor remain in a world external to the patient? Why should patients trust the advice of someone who doesn't understand them? Doctors often believe that patients listen to them because they know medicine. Patients take that for granted.

The patient's actions, behaviors, and purposes are another way in which meaning is displayed. There are many levels of meaning within everyone, and only some of them can be brought to awareness. Sometimes people assign two or more conflicting sets of meanings to the same thing. Some determinants of action are unconscious, hidden because of the inner conflicts in which they are ensnared. Others are long forgotten, yet the behaviors based on them continue as part of everyday life. Some actions are taken without a thought, but on reflection the person can tell you why he or she behaved in this fashion. Despite the fact that behaviors may be based on conflicting meanings, all normal actions, behaviors, and purposes are logical in the same sense that all normal speech is logical.4 Logic is used here in its most basic sense—as a system of related premises that lead to a conclusion, or a way of relating ideas so that they lead to another idea. Patient A says: “It is logical that I take my antibiotics because the doctor said it will help my infection.” Patient B says: “It is logical that I don't take my antibiotics even though the doctor said they will help my infection. I want to treat my infection, but antibiotics hurt your immune system. Doctors don't believe that antibiotics hurt the immune system, but they are (p.115) wrong. I am more afraid of injuring my immune system than of not treating my infection.” The behavior, taking or not taking antibiotics, is the logical conclusion. (The example also makes the point that because something is logical does not mean that it is correct.) Inexplicable as some actions or behaviors may seem, when the meanings on which they are based are known, they make sense. From the clinician's point of view, this implies that meanings can be discovered by figuring out what would make the behavior reasonable. Since future behaviors are likely to be similar to current behaviors, the meanings on which actions are based must be relatively stable. Put another way, if one wants to change the patient's behaviors, the meanings on which they are based must be altered. The values component of meaning can also be read from actions. The patient who, in the face of an infection, doesn't take antibiotics must feel strongly about the importance of protecting the immune system to risk the untreated infection or not believe the infection to be serious. The attempt to change the behavior must take into account not only the incorrect meaning, but also the importance to the patient of the values. These behaviors can be changed, but only from within the patient's system of beliefs.

Using meanings as information requires not only careful observation and careful avoidance of premature interpretation, as with all observation, but also the use of conscious reasoning about the logical structure that relates one meaning to another and makes sense of observed behaviors. Both speech and the actions of patients flow by so fast, and their meanings so often seem obvious, that it takes systematically trained effort to reconstruct the belief system of the patient. This is especially important in chronic disease because it is this nexus of beliefs (given the disease and other circumstances) that determines the nature of the illness and the degree of suffering. On the other hand, the physician's knowledge of the patient's structure of belief is limited, even in the best of circumstances. What is necessary is solely the focused knowledge that makes optimal care of the patient possible. This is like knowing that the route of travel through a region does not imply grasping everything about the region. It is the same way that the patient knows the physician—as a physician, not as a person.*

(p.116) Emotions

Walk into the consulting room of a primary care physician and look for the box of facial tissues. If they are present, patients know that tears are acceptable; if not, it may be because the doctor is averse to displays of emotion. The same physicians who are uncomfortable in the presence of tears have learned to tolerate cries of pain; otherwise, they cannot do a necessarily painful procedure. Physicians who do not solve the problem of patients' strong and painful affects cannot acquire the information about the person of the patient necessary for their work. Emotions, affects, passions, and sentiments are spontaneous responses to circumstances occurring before there is time for thought.5 They may be almost instantaneous, as with the rise and disappearance of a flash of anger. They may become the person's state of being—for example, an angry or happy person. They may break into action, as when someone acts angrily. Some people may be unaware of their own emotion even though it is obvious to an observer; in others it dances around the person's surface, evident to all. Despite these variations, emotions are a reflexive commentary on events that are often as true to situations and relationships (or more so) than words. We are often of two (or more) minds about things. Each “mind” has a set of beliefs coherent with the emotions based on them. For example, patients may want the doctor to know how brave they are and how much faith they have in the doctor (to keep the doctor on their side); on the other hand, they may be filled with dread. It is the dread and its underlying beliefs that must be addressed by the physician, as well as acknowledging bravery and reassuring the patient that abandonment is unthinkable. Fear may radiate from someone who seemingly has nothing to fear. If there was nothing to fear, then fear would not exist. The doctor, sensing the fear, must find its source and, if possible, lay it to rest. Even if the fearful event cannot be dismissed, the loneliness of unexpressed fears can be managed by strengthening the relationship. None of this can be done if the emotion is not known.

Patients' emotions may be evident from their facial expression, posture, or gesture or may not be apparent except as they are sensed as the emotion of the doctor. Therein lies the problem of using emotion as information. When psychiatrists tell medical students to “use your feelings,” it is this phenomenon to which they refer. The students are often puzzled on two counts. They do not know how to (p.117) be aware, moment by moment, of their own affect, and they do not know that emotions can be transmitted from one person to another. Primary care physicians may be similarly ignorant. Psychiatrists-in-training soon learn both facts because emotional states are their stock in trade. If they can master these states, so can primary care doctors. How can the doctor be sure that the emotion is what it seems and that it originated in the patient? Certainty is not possible. However, the perception of an emotion must meet the tests of any other piece of information. There are four criteria. First, it must have external logical consistency; it fits the other facts about the patient and the circumstances known to the doctor. Next, it must have internal logical consistency; it doesn't fit the doctor's inner state. (“Why do I feel hopeless? I have no reason to feel hopeless. Maybe I've caught the patient's feeling of hopelessness. I'd better find if, and why, the patient feels hopeless.”) Third, it must conform to experience; it is an affect seen in similar situations. There are ways in which it can be confirmed. Finally, the risks of any action based on it are appropriate to its certainty.

There is a further problem about using information such as the transmitted feelings of the patient that feels so “soft.” The law of facts is that hard facts drive soft facts from sight, and soft facts drive softer facts into hiding. Doctors must gain confidence in their ability to observe accurately and employ personal information. Otherwise, emotions as data will always be defeated in a contest with numerical data. Patients' meanings, values, and emotions, doctors' emotions, and even the sensations under the physician's examining hand can be easily overwhelmed. The following case makes the point:

Abby Corcoran is a sixty-one-year-old secretary who called herself nervous. Three weeks ago, she had the first of three similar episodes that caused her to go to the emergency room of her local hospital. She became acutely short of breath and panicky; and the dyspnea lasted for several hours. It subsided while she was in the emergency room. Except for tachycardia and florid varicosities of her lower extremities, the examination was unrevealing. Laboratory studies, electro cardiogram (EKG), and chest X-ray were negative. Blood gases were not tested. She remained shaken by the experience and frightened but otherwise well until four days later, when it happened again. In the emergency room the same scenario followed, and she was sent home. One week later it happened again and, filled with (p.118) dread, she went to the hospital. On this occasion, the chart also recorded negative findings and the impression that she was having panic attacks. While waiting to be discharged from the emergency room, she became severely dyspneic and cyanotic. She was effectively treated for what was shown to be a massive pulmonary embolus (with evidence of several previous emboli).

This was a preventable near death resulting from failure to give the patient's dread and dyspnea more weight than the negative studies. The difference between the physicians' lifesaving expertise in the face of the emergency and their inept response to her initial symptoms makes a striking statement about their training. Panic attacks in a sixty-two-year-old woman with no previous history and no precipitating episodes are, I believe, less common than pulmonary emboli. Among the other errors was the failure of the physicians who made this judgment to ask themselves the crucial question, “What if I'm wrong?”

Errors such as this are prevented by training doctors how to observe, how to think about the personal information they gather, and how to give it as much weight as hard data. Every event has a history, no fact exists in isolation, nothing is observed outside of a setting, and there is always an observer doing something with the information. When the physician remains focused on the patient, on what the information means to and for the patient, on what must be done for the patient, then it is easier to integrate hard and soft facts, deal with conflicting values, and maintain mastery over both patients' and doctors' feelings. Perhaps the best method of teaching these issues and strengthening the development of a doctor persona is in the discussion of the emotional burdens of patient care in groups such as those described by Michael Balint.6 Balint was less interested in the problem of integrating the information obtained through patients' meanings and emotions, but these concerns may also be taught in groups. The group not only helps the trainee deal with his or her own emotions and those of the patient, but also validates the basic concept that it is necessary to be aware of these emotions as clinical data. Role playing or video or audio critiques may also be used in these groups. The training program must mandate attendance at these groups or they will fail, because the house staff does not think them as important as things emphasized by the specialty boards.

(p.119) Aesthetics

In addition to knowing people through their meanings and emotions, we also know them as aesthetic objects—wholes with parts in specific relationships to each other and to the whole.7 Look at your hand. There is no other way to know that this specific hand belongs on your wrist besides the visual appraisal of a good “fit.” You could make the (almost) absolute determination that it was your hand through DNA analysis, but that wouldn't tell you whether it belonged on the right or the left arm. Much of the knowledge physicians utilize in clinical medicine is of this type. There has been much debate about the nature of aesthetic thought,* but we will not get into trouble if we simply accept that there is an aesthetic intuition.8 In this act of thinking, objects and their relationships in a percept are grasped as a whole, and an idea is formed based on this information. This is why, when looking at persons, we say that they are old, young, strange, or beautiful—making almost instantaneous judgments that we are often hard pressed to spell out in detail. We hear the patient's story of events and it doesn't make sense—aesthetic sense. The patient's distress at the disfigurement resulting from disease is at the aesthetic insult of the disease. Our unhappiness with some surgical procedures can refer to the unaesthetic result. But things that do not fit the life pattern of the person can be similarly unaesthetic, so it becomes necessary to develop an aesthetic sense of how patients with chronic diseases have lived their lives in order to better fit medical interventions into that pattern more effectively, or to treat patients so that they resume an existence more nearly like their normal lives. It is here that telling or writing the story of the patient's illness or treatment (p.120) can be very effective in understanding the aesthetic dimension of persons. (See the discussion of the description below.)

Just as the medical world and the life world differ in their meanings, differences exist as well. Ultimately, aesthetics deals in relationships, and what it teaches is the relationships of parts to wholes, of wholes to groups of wholes, and of groups to communities. It keeps the physician focused not on this patient to the exclusion of everything else, but on this patient as a person who must always exist in relation to others and to a community. It is possible to see acute disease apart from these relationships, but it is not possible to understand chronically ill patients in isolation from others because that isolation would be part of their illness. Patients' lives also have a rhythm that endures over the years. Sometimes it is a languor that impatient physicians characterize as slowness, or the staccato way in which the patient acts, or a dignified, waltzlike motion in which everything is done. Working within the patient's rhythm, where possible, strengthens the therapeutic bond. To fight with it is a waste of energy. This is another aesthetic fact that should be appreciated. These two cases make the point.

Janet Freeman has been my patient for thirty years. In that time she has had idiopathic pleuropericarditis, a hysterectomy, and a fractured humerus, as well as assorted upper respiratory infections, urinary tract infections, and other afflictions and injuries. The salient fact about her care is that she gets better very, very slowly. I think she should be out of bed and back at work; she can't. Her cough should be gone; it isn't. Her pain should be better; not yet. This happens not in one, or two, or even three instances, but in every illness, large or small. It is the rhythm of her life and it cannot be speeded up; it can only be respected—although it took me a while to accept that fact.

Sophie Robertson married a New York artist and bore three children in the first three years of her marriage. Her husband was successful, and they lived in the intellectual artists' world of New York City. Except for her children, Sophie was chronically discontented. She was a weaver and a banjo player, but much more the weaver. She developed carcinoma of the breast in her forties, eight years after her divorce. She tolerated the mastectomy and the chemotherapy, as she had so many other things by just doing what she had to do. Then she discovered Kentucky bluegrass banjo music, and it transformed her life. Years have passed since then, and she has remained the happy, engaged woman she became as soon as she discovered her rhythm, (p.121) Kentucky bluegrass. She moved to Nashville, where she teaches bluegrass banjo and performs. There were no important new relationships or significant others, no change in her children or her health; she simply found the proper rhythm.

INTUITIONS

As discussed in the footnote below, there is another method of acquiring information from the environment, often called a feeling, as in “I have a feeling about …”* Here, in observing or experiencing the patient, ideas come to us; we form impressions or intuitions that we cannot spell out in detail. In fact, the act of spelling out in detail is called discursive thought, separate from the intuition, and it is the kind of thinking to which ordinary logic applies. These intuitions, or feelings, sometimes called nondiscursive representational thought, are not logical in the conventional sense, but theyprovide the raw material on which logic operates. There certainly is no antagonism—as though one is good and the other bad—between nondiscursive intuitions and discursive, logical thought. To the contrary. “Carpenter's knees,” we say, looking at Joseph Heelon's legs, where rough calluses are seen below both patellae. Then we move on to assumptions that logically follow about how carpenters work. Or, seeing how sick the patient looks (the nondiscursive intuition), we brush aside as not making sense (the discursive, logical follow-through) her contention that she has merely had the “flu” for a month. The skill of Sherlock Holmes lay not only in the careful deductions he made, but also in the perceptive intuitions on which the logic was based.

(p.122) Think how wrong intuitions can be. You think a patient looks fine, but it turns out to be clever makeup. A limp is a fake, grimaces of pain are not pain but grimaces, and so on. “You see that thing there?” asked my professor, pointing to a shadow on the chest-ray. “That's cancer. How do I know? I just know, like you know I'm male without looking at my parts.” It was tuberculosis. In the era of objective scientific data, this kind of evidence has been discredited as old-fashioned, flawed, and hopelessly subjective. Guilty on all three counts. However, how often is an aunt mistaken for an uncle, or a hand for a foot, or a basal cell carcinoma for a wart? What else can be counted on to make the crucial determination that “this patient is sick”? Reliable intuitions are distinguished from undependable ones by experience and training. Over the years you have been trained to distinguish instantly your left shoe from your right, just as physicians are trained to distinguish the sound of muscle tension crackles on the chest wall through a stethoscope from rales in the lung. Reliability is increased by learning how to verbalize the information (even if only to oneself) so that it can be evaluated and then organized into an anecdote. Anecdotes are knowledge, and carefully constructed anecdotes—accurate about the events and balanced in the reporting, so that the story speaks for itself—retold at the appropriate time are effective knowledge. Telling an anecdote is a crucial clinical skill.

It is not as if, in this era of scientific and technological medicine, nondiscursive intuitions have been banished from medicine. That is impossible; they are part of normal everyday thought. Instead, their skilled use has atrophied, leaving behind inexpert (and therefore frequently incorrect) intuitions to provide a type of clinical information available nowhere else, even when inadequate in the particular instance. The trained use of intuitions, impressions, or feelings about something is marked not only by an understanding of their importance, but also by the ability to fit them in with and examine them in the light of other facts. Skilled clinicians use the same method to make more subtle assumptions about patients' thoughts, behaviors, and past history, and then quietly test the ideas against other facts before basing any action on them—even the next question.

Adequate training will provide the basis for the development of these skills. Many of the examples I have given are based on visual observation, and that is probably the easiest area in which to train doctors. Teaching physicians how to be attentive observers is designed (p.123) to complement the information from meanings and emotions that they have or will obtain. They need to learn to see who the patient is—to make the patient real as a person—at the same time as the details of the body and disease are observed: to provide an integrating center for all the information (and therapeutic action) that bears on the purposes of the patient. This is why presenting cases on rounds is so important. There are a number of components to attentive observation. First, attentive observers are always observing. Next is the importance of separating the observation from the interpretation previously noted. The third facet is the appreciation of the relationships between the percept, its parts, and the surrounding world. Fourth is attention to change. It is not an isolated event that is observed, but an event in an unfolding process. Fifth, an attentive observer does not leave a perceptual field prematurely. Finally, observations are in the service of goals that anchor them to other observations.

Description

The final step in the process of knowing the patient, and an essential feature of the clinical method, is description. As discussed earlier in relation to findings on the physical examination, describing what has been observed is essential to the observation. The written histories of patients currently admitted to the hospital, which are meant to serve this purpose, generally bear little relationship to an actual person. They are often deficient as narratives of the unfolding process of the illness or chronic disease itself. They do not provide the model for the description of both the patient and the evolution of the illness that should be possible given the information from brute facts, meanings, emotions, aesthetics, and intuitions obtained by an appropriately trained primary care physician. Teaching this kind of descriptive narration is an essentially new field in medicine created only in the last twenty years with the advent of courses on literature in medicine.9 Understanding the interaction between the unfolding life of the patient and the evolution of the disease is best accomplished by narration. A narrative approach to questions raised by human illness finds company in the recent work of scholars in other fields of the humanities and the social sciences. There is now a rich bibliography and many trained faculty in the field. The characterization of a patient and the narration of the story of the (p.124) illness are not only descriptive acts, but experimental as well. For example, the physician can see how changing an element in the description changes his or her idea of the patient, and consequently how subjective knowledge can be easily biased or protected from bias. Such learning further strengthens the separation of the doctor's professional judgments of people from mere opinions easily voiced by nonprofessionals. Similarly, changing certain features of a narrative and then seeing what that does to possible futures or pasts allows physicians to understand how this patient's story can be changed by different actions of the doctor or the patient or the context. The ultimate functions of description and narration are to make the subjective objective and open to examination. This case is an example.

Magda Ofkowski is a very attractive Polish-born, married, fifty-two-year-old woman who has been a violinist with a major orchestra for twenty-seven years. As on one previous occasion, she has had to stop playing because of severe pain in her neck radiating to her right arm. She found a new physical therapist whom she likes, but after the second treatment she developed severe pain in the right buttock radiating to the inner thigh and down to the foot. On examination she was obviously in pain, and straight-leg raising was restricted, but there were no other neurological findings or muscle weakness. The pain prevented her from making the anticipated first visit to a psychotherapist. With adequate pain medication and a benzodiazapine, she was sent for bed rest. The pain in the leg got worse, as did the neck pain. A magnetic resonance imaging scan of the lumbosacral spine showed a significant disc bulge at L3–4 with impingement on the foramina. A few days later, while she was gargling with her head thrown back, she developed very severe pain all the way down her right side into the foot. An MRI scan of the neck showed degenerative disc disease and a few areas of minor disc bulges. Questioning revealed that she has not had sustained bed rest for even a half-day.

She had had a successful mitral commissurotomy for rheumatic mitral stenosis at the age of thirty-one. A left mastectomy was done at age forty-two. She had left home at age twenty-one following one of her mother's routine beatings to make her practice the violin. She got married immediately, but it ended within a few years. Her present marriage of twenty years, childless, has been excellent. This episode of neck pain preceded not only psychotherapy, but also the start of rehearsals by a new chamber music group of which she had (p.125) become a part. The previous occasion of disabling neck pain ended an attempt to create a career as a soloist.

One can see the temptation to turn this case into an example of either psychogenic back pain or intervertebral disc disease requiring intervention. Change the size and extent of the disc intrusion, and an impatient generalist could have her in a surgeon's office. Change the era in which it took place, and she would soon be in an operating room and perhaps on the way to having an overoperated, failed back. Forget the history and the obvious pain (which happens not infrequently), and she would soon be dismissed and wandering from one alternative therapy to another. It would not take much to transform her into one stereotype or another. Disastrous permanent disability waits only for error. The case cries for more information about her and her physical status, all of it available. It also makes clear how little changes in the story of the person or the body would change the case and, therefore, how important are the stories of both the person and the body.

Recently, the new editor of the Annals of Internal Medicine, Frank Davidoff, wrote about his ideas as he took over the journal. He spoke about the importance of science to internal medicine: “Science is cognitive, involving accurate observation and clear description, hypothesis generation, data gathering and interpretation, and the creation of theory. But science is also a state of mind: skeptical, open, balanced, respectful of evidence, thorough, always on the alert for bias.”10 Everything here except perhaps the creation of theory applies to the clinical method. In your mind's eye, consider the past and you will see a tradition that goes back to Eugene Stead and William Osler, to John Locke and Thomas Sydenham, and then to Hippocrates. Why, over the millennia, have they seen the clinician's task in such similar terms? Because they all knew that the fundamental truth of medicine resides in knowing the patient. Over the ages the meaning of the word patient has expanded its dimensions, so that it now includes the whole person. Physicians themselves are the means, the relationship with the patient the vehicle, and the clinical method the tool by which this knowledge is gained. We have only to know how to teach this.

Notes:

(*) The words feelings and emotions are often used as synonyms. I believe it is important to understand their differences in the context of training primary care physicians. Emotion and affect can be considered synonymous. I might say of someone, on the other hand, that “I have a good feeling about him,” but not mean that I feel happy or some other emotion. “I have an uneasy feeling about this case,” but as I say that, I am unaware of any particular emotion. It is the impression someone gets who is observing or experiencing. The word feeling is sometimes employed in aesthetics to represent the idea the viewer gets from a painting. We use feeling, as above, to describe the effect on us of a situation or an event. In medicine, feelings are experienced as qualities of our patients or clinical situations that are not vague or indefinite at all but have a concrete and particular character. They do, however, resist conceptual, systematic, or logical treatment. It is with this category of feeling that we will be dealing; separately but in addition to mood and emotion. (Susanne K. Langer, Feeling and Form, New York: Charles Scribner's Sons, 1953.)

(*) A high personal price is paid for this solution to the problem of emotions. As physicians repress the unpleasant emotions of their patient, they also repress the good affects, including the patients' emotional support of their physicians. They don't get the pleasure of gratitude or enjoy the emotions of successful care of patients. They may also be so effective in repressing their affect arising in the clinical setting that they are unable to enjoy the emotions of family life or be aware of the negative affects in personal life—for example, the deadening of their reaction to their spouses' emotions—that warn of the necessity for psychological repair of oneself or one's intimate relationships.

(*) Many authors have discussed the importance of the life world of the patient and the opportunities for optimal medical care that are lost when this information is disregarded. One of the best such discussions is inKay Toomb's book, The Meaning of Illness (Dordrecht, the Netherlands: Reidel, 1992).

(*) A more complete description of how one comes to know who the patient is, and how their beliefs, values, and aesthetic dimension describe persons, is given in my book The Nature of Suffering, chapter 11.

(*) Aesthetics is a problematic word. Aesthetic knowledge is an often untaught grasp of order versus disorder, pattern versus chaos, that which in a sensory perception fits and is appropriate versus that which is disjunctive and inappropriate. Aesthetics is essential in so many medical phenomena, from the appearance of wounds to the presentation of persons to the world, that it is curious that its importance is virtually unheralded in medicine. Suzanne Langer argues persuasively that intuition is the form of cognition of aesthetic phenomenon (Feeling and Form, New York: Charles Scribner's Sons, 1953, and Mind: An Essay on Human Feeling, Volume I, Baltimore: Johns Hopkins University Press, 1967). In which case, clearly separating aesthetics and intuition is probably incorrect—the latter being how the former is known.

(*) Intuition is a difficult word. On the one hand, it is used to signify a kind of knowing that is akin to instinct: the alleged possession of information without any demonstrable source. As such, it has been (justly) disparaged in medicine as a kind of magical knowing that is the opposite of the logical marshaling of information acquired by observation. Its more important interpretation is the process by which the mind directly grasps forms of things, recognizes the similarity of some percept to a known form, relationships, and meaning. As such, it is a basic form of thinking akin to the meaning of feelings as impressions, described earlier. John Locke said of intuition: “Such kind of truths the mind perceives at the first sight of the ideas together, by bare intuition, without the intervention of any other idea; and this kind of knowledge is the clearest and most certain that human frailty is capable of” (An Essay Concerning Human Understanding, Book IV, chapter ii, Amherst, NY: Prometheus Books, 1995, p. 433).

(1) Eric J. Cassell, The Nature of Suffering. New York: Oxford University Press, 1991, chapter 5.

(1) Frank Davidoff, The future of the Annals.Annals of Internal Medicine 122:37–76, 1995.

(2) David A. Landis, Physician distinguish thyself: Con¡ict and covenant in a physician's moral development. Prospectives in Biology and Medicine 36:628–41, 1993.

(3) Mary Jean Huntington, The development of a professional self-image. In The Student-Physician, ed. by Robert K. Merton, George Reader, and Patricia Kendall. Cambridge, MA: Harvard University Press, 1957, pp. 179–87.

(p.194) (4) Eric J. Cassell, Talking with Patients. Vol. I: The Theory of Doctor-Patient Communication. Cambridge, MA: MIT Press, chapter 3, 1985.

(5) James Hillman, Emotion. Evanston, IL: Northwestern University Press, 1962.

(6) See M. Balint, The Doctor and His Patient and the Illness. London: Pittman, 1957; and M. Balint, E. Balint, R. Yosling, and P. A. Hildebrand, Study of Doctors. London: Tavistock, 1966.

(7) Richard V. Lee, The clinical picture, Journal of Clinical Epidemiology 43:527–31, 1990.

(8) Benedetto Croce, Aesthetic as the Science of Expression and General Linguistic. New York: Noonday Press, 1958.

(9) Rita Charon, Joanne Trautman Banks, Julia E. Connolly, Anne Hunsaker Hawkins, Kathryn Montgomery Hunter, Anne Hudson Jones, Martha Montello, and Suzanne Poirer, Literature and medicine: Contributions to clinical practice. Annals of Internal Medicine 122: 599–606, 1995.