Content provided in partnership with

Health Care Industry

Cards, cakes, and homegrown tomatoes - loss of the human touch in medical care - Editorial

Journal of Family Practice, Jan, 1993 by Paul M. Fischer

The year 1993 will be a pivotal one for medicine in the United States. Bill Clinton has promised quick action on the problems of health care cost and access. The changes are likely to be swift and imperfect. To date, most of the debate has narrowly focused on how the country can provide more medical technology, to more of the people, at a lower cost. There has been no articulation of the need to provide each American with a personal relationship with a primary care physician. Instead, physician care - usually referred to as "physician services" - has been viewed in this debate as a generic commodity that can be bought, sold, reallocated, or traded to the lowest bidder. In our attempt to provide CT scans for all, will we develop a system that ignores the central role of the human relationship in the fragile balance between health and disease? Will the doctor-patient relationship survive the health-care-crisis solution?

Most Popular Articles in Health: Fuel your workout: exercisers who eat before they work out have more energy ...; Soothe a dry, itchy scalp: 5 easy expert solutions; Cocktails and calories: Beer, wine and liquor calories can really add up. ...; The sour truth about apple cider vinegar - evaluation of therapeutic use; The, six best supplements you've never heard of: these secret weapons can ...; More »

Shirley's Case

I met Shirley 5 years ago. She had been regularly seen at the Rheumatology Clinic during the previous 2 years with complaints of swelling and pain in her joints, especially those in her hands. Each of these visits had been accompanied by detailed history-taking by medical students and drawing of blood for many laboratory tests. These often repeated tests invariably resulted in the same conclusion at the next rheumatology visit: "Findings are suggestive of rheumatoid arthritis, but the patient's rheumatoid factor is negative."

By the time I met her, she had been forced to quit her job as a seamstress. She simply could no longer sew. She was 28, married, had two children, and a very large extended family, all of whom I was later to get to know. She had been referred to me by her friend, who was also my patient.

Her rheumatologic history had been accurately and extensively recorded. Not noted in the chart was the fact that she was a tough woman who had rarely missed a day of work before her hands started to swell and hurt. She could not understand why her problem had remained so perplexing and why no one had been able to help. I reached out and took her hand. Her PIP and MP joints were obviously swollen, hot and tender.

The diagnoses were obvious: (1) seronegative rheumatoid arthritis; (2) reliance an a test result rather than the patient's signs and symptoms; and (3) lack of continuity of care in a subspecialty clinic.

I shared the first of these three diagnoses with Shirley and asked her if she would be willing to try an experiment. We would treat her with prednisone for 7 days. If my hunch was right, we could confirm the diagnosis in a week without drawing a single tube of blood.

I knew the results when I walked into the room that next week. She had a wonderful, little-girl smile. She presented her hands like presents to me - no warmth and no swelling.

My experiment had secured a trust that would endure. Not that it has not been challenged. Shirley has since had gold-induced nephrotic syndrome, azothioprine-induced diarrhea, and NSAID-induced gastritis. But Shirley is doing very well on 10 mg of prednisone every other day. She is sewing again.

Shirley and I share what is euphemistically referred to as a "doctor-patient relationship." She agrees to let me experiment with her care. I agree to be there when she is sick. She agrees to take her medicines, even when she does not like the side effects. I agree to think about her "case" sometimes when I am driving to work in the morning. She agrees not to call me unless it is important. I agree to get right back in touch with her when she calls. She bakes me cakes. I eat them.

Patients as Voters

I worry that the people involved in the political debate cannot answer for themselves the simple question, "Who is your doctor?" They seem all too eager to replace the personal relationship between patients and physicians with micromanaged, bureaucratic, and inflexible - "programs." Efficiency will be gained by "managed competition." Overutilization will be eliminated by "clinical guidelines." Medical care will be organized around "health care systems," not patients and their doctors.

Family physicians have been rare voices in calling for attention to this issue. Dietrich showed that primary care physicians manage 75% of patient care in a fee-for-service setting.[1] Franks, Clancy, and Nutting[2] have identified the doctor-patient relationship as an essential element for avoiding unnecessary treatment. These are undoubtedly the reasons why family physicians have been shown to be more cost-efficient providers of care than other specialists.[3] Mold and Stein[4] have described the "cascade effect" that occurs when patients are cared for by "systems."[4] Brody[5] has eloquently argued that the doctor-patient relationship must be the basis for ethical decisions about a "good death' that avoids prolonged pain and suffering.

Each medical specialty has its own therapeutic technology. Gastroenterologists have their endoscopes. Gynecologists have their laparoscopes. Cardiologists have their balloon catheters. For family physicians, the fundamental therapeutic technology is our relationship with our patients. Further compromise of this relationship will have a profoundly demoralizing effect. We will be like surgeons without scalpels.

Health Care Industry

Cards, cakes, and homegrown tomatoes - loss of the human touch in medical care - Editorial

Journal of Family Practice, Jan, 1993 by Paul M. Fischer

Find Research Guides for:

Find Featured Titles for: Arts

Most Popular Articles in Health

Most Popular Publications in Health