That Medicine is first and foremost about people, about relationships, is something which may be forgotten in the overwhelm of evidence-based practice and protocols, but the strength of these relationships between doctors and patients is that they are an integral part of treatment and may be healing in themselves.
“To care for patients you first need to care about them”
The nature of patient/doctor relationships
I look back some years and find myself driving down to our local hospital to visit Mr B, a good natured, salt of the earth man who always brightened my day. For reasons now forgotten, I was taking down a bottle of medication which my young daughter was holding very carefully for me. At one point she piped up, “Why is this medicine poisonous for me but good for Mr B?”. The B’s were a lovely couple whom I met early on in my first year in general practice on the beautiful North Coast. Newly emigrated, we had a baby in Cairns and travelled down by caravan, breaking down in Broken Head. We bought a 90 acre block of land and here we have stayed, with no regrets. Mr B furnished our new home from his furniture auction house and the already ageing fridge survived as long as our relationship which was long and mutually rewarding, ending only when he passed away. Like many GPs, I found relationships of this nature a privilege and endlessly rewarding. In all honesty this is what sustained me in medical practice.
These doctor/patient relationships are quite special, unique perhaps in their nature. We are told to set boundaries and to remain detached, but in truth the relationship asks for something else.
There is an understanding, a trust, and intimacy which is quite different from a friendship, but has many of the same qualities. It asks for both to give of themselves, establishing a bond based on honesty and trust, built over perhaps months, or years. A bond unique to that patient and that doctor. Indeed, working in rural areas, often your patients are also friends in your world outside of the surgery, but there is a respect for these different relationships.
Painting a life picture
For me this means building a picture. It is very different from the medical history we are taught as students, and builds with increasing trust and intimacy. Who really is this person, and what has brought them to this place in their lives? What are their supports and resources? What is their belief system about disease and its treatment, about life itself? How do I find the “right care” for them? How do I best fit into the picture? How can this relationship work to optimise care?
I think back on Mr. A, already an old friend when he was diagnosed with liver failure. He was born a Cockney and had a wonderful sense of humour. He told me how he his mum had died when he was too young, and he ran away to sea when he was just a lad. The ship became his home and the sailors his family. He talked of climbing up to the crow’s nest to be close to the wind and the albatross. The life-style of a sailor came at a cost physically and emotionally, as he was torn between his love for the sea and his love for his land bound family. He used to drop in when he was on shore leave, and tell me of the places he had visited, no doubt with some censorship for the “lady doctor.” Then he fell and had a minor stroke, which made going to sea an impossibility. His dying was difficult, his body rapidly failing while all the time he was retaining the hope of organ transplant. It meant that preparation for death, that closing comfort a GP can bring a well-loved patient, never really took place.
Love and compassion flow both ways
Medicine is never smooth sailing. When a relationship is built on a deep trust and friendship, and then a misjudgement is made it is all the more painful, because you would never have chosen to hurt or harm the patient in any way, but through your decisions you have.
Mrs V married relatively late to a man she met through the church. She was elated when we confirmed the pregnancy she never thought she would have. Despite a pregnancy complicated by cardiac arrhythmias, her beautiful son was safely delivered.
Although she was elderly to be a new mother, it took me a long time to diagnose that what looked for all the world like a mastitis which would not heal, was in fact an aggressive inflammatory breast cancer, such as I had not seen before. I found this quite shocking, not only that I had delayed the diagnosis but that this vibrant red-haired new mother should have cancer at all. When in tears I discussed this with her husband, in his amazing forgiveness and generosity he asked if I would mind that he prayed for me.
In Medicine we are forever students, not only of the complex and ever-expanding science that is medicine, but of the beauty of human nature. In the relationship between patient and doctor, love and compassion flow both ways.
Not all relationships flow so readily. In our work, we are often asked to care for people whose behaviour is difficult for us to understand. They too are deserving of the best of medical care and when a bond of trust is established, these relationships may be really special. Working with people recovering from substance abuse taught me more about human nature than I was ever able to offer in return. Watching those recovering from their substance use, finding their true selves in a way they may not have known since childhood was to see a flower blooming, a butterfly emerging from a chrysalis.
I came to see people as wearing overcoats, overcoats which hide their true nature, their deepest fears and vulnerabilities. Sometimes these overcoats are fairly transparent, readily allowing a connection to be established. For others they may be very prickly, shielding perhaps a fragile inner world. For some the overcoat is elegant, imposing, a shield against the outside.
I met Miss G in the outpatient eating disorders unit we ran. At that stage she had been sick for some years. The inpatient units she had been admitted to refused to have her back and when trying to admit her to the medical ward with gross oedema, I was told it would be a complete waste of bedspace. She was very thin and fragile and wore a very prickly overcoat. I believe it was the very feistiness and opposition that drove the nurses and doctors mad that carried her through. When eventually she started to recover, the very gentle being she truly is emerged and it was a joy to work with her.
There is something endlessly special about the relationships we establish with patients. When we peel the layers away, peel away this outer being we present to the world, we find we are all in fact equal at heart. It is from this place of equality that a real connection can be made, and in that connection healing can take place, for not only the patient, but the doctor too; for we are all people, and true medicine is about relationships, first and foremost.