Bioethics Discussion Blog: Doctors Maintaining "Clinical Distance": A Patient Value or None

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Sunday, September 16, 2012

Doctors Maintaining "Clinical Distance": A Patient Value or None


The doctor looks at the patient who
Sits restlessly, coughs and is not smiling
The doctor's first thought
"Why is this patient coughing?"
Instead of
"This patient appears uncomfortable,
What can I do or say to relieve the discomfort?"
+++
What I have just described is a simple example of the professional behavior or perhaps misbehavior of maintaining "clinical distance".  It is the mindset of a technician to immediately look at the anatomy and pathology of the patient's symptoms rather than to look at the patient. Shouldn't the doctor's first interest be the observation and consideration of the patient as a whole human person who comes for consultation because of a personal problem and attempt to understand how the patient is feeling? But the fear of being contaminated by the patient's "feeling" may be more in the mind of the doctor than being exposed to whatever bacteria or viruses the patient is bearing and has become the basis for maintaining "clinical distance"; not measured in meters but in pain, in sorrow, in anxiety and fear.

But, shouldn't, at first, the doctor be more than a technician in the diagnosis and treatment of illness?  Shouldn't the doctor at first find and express some signs and acts of partnership with the patient's worries with responses of sympathy ("I care") and/or empathy ("I understand")?

In the current rush of medical practice where time is limited to attend to each patient and the fear by doctors of "becoming too emotionally involved" (contaminated), it is considered a wise practice to maintain that "clinical distance".  But is "clinical distance" really what makes a good medical professional? Does it provide a way to maintain physicians in less emotional distress, fatigue and more time to diagnose and treat and thus is of benefit and value to the patient?

On the other hand, maybe it is the basis of why some patients are dissatisfied with their doctors in many ways. Perhaps, we medical school teachers should more strongly emphasize to the students something more than the creation of a differential diagnosis list as the doctor-patient relationship begins and strive to shorten that "clinical distance". 

What is your opinion about maintaining vs shortening "clinical distance"?  Should the following be the doctor's first thought?
+++
The doctor looks at the patient who
Sits restlessly, coughs and is not smiling
The doctor's first thought
"This patient appears uncomfortable,
What can I do or say to relieve the discomfort?"

..Maurice.


4 Comments:

At Sunday, September 16, 2012 4:26:00 PM, Anonymous Anonymous said...

It takes a huge leap of faith to bare our body and soul to a complete stranger. If the physician (any provider for that matter) does not sincerely convey sympathy and empathy, he/she will not participate in my care. I'm a human being and expect to be treated as such. "Clinical distance" is nothing more than a fancy way to rationalize treating patients as a disease or piece of meat.

Ed

 
At Tuesday, September 18, 2012 7:17:00 PM, Blogger Maurice Bernstein, M.D. said...

The following was written today by Doug Capra to this thread and also to the Patient Modesty #50 thread. ..Maurice.


Maurice:
A review in the Sept. 27 New York Review of Books, by Jerome Groopman, of the book "God's Hotel: A Doctor,A Hospital, and a Pilgrimage to the Heart of Medicine" by Victoria Sweet. Groopman compares the book with The House of Shem by 1978), a roman a clef about a Boston teaching hospital.
Groopman writes: "Shem charted the trajectory of the many interns who arrived idealistic, with a humanistic vision of medicine, and end their first year of training bitter, cynical, depressed, and mercenary. The word used by Shem's young doctors for the elderly demented and debilitated patients is "GOOMERs" (Get Out of My Emergency Room). The doctor's feel that they can't do anything for the GOOMERs. (They should be "turfed," transferred out of y our charge as quickly as possible.)
(As a side note -- just last year an idealistic young medical student who had worked in the emergency room, hit me with another expression now used -- an arriving patient who has no chance of survival is referred to as CTD -- circling the drain.) An example of that dark, cynical humor perhaps needed for survival by human beings doing this kind of emotionally draining work.)
Shem's book advocates that clinical distance to the extreme.
Sweet's book is more balanced, about the human connection between doctor and patient. She writes:
"The essence of hospitality -- hospes -- is that guest and host are identical, if not in the moment, then at some moment. Whatever our current role, it was temporary. With time and the seasons, a host goes traveling and becomes a guest; a guest returns home and becomes a host. That is what the word "hospitality" encodes. And in a hospital, the meaning of that interchangeability is even more profound, because in a hospital, every host will for sure become a guest; every doctor, a patient."
But there is a often a huge difference between a guest and a patient, a difference involving pain and vulnerability and embarrassment and helplessness and yes, death. We know we'll all be guests and accept that. We know we'll all be patients, but we don't accept that as well. We don't want to accept that fact. We avoid it -- especially those who work daily around patients and see clearly what the "role" patient looks like.
Here's the article. I recommend it highly.

http://www.nybooks.com/articles/archives/2012/sep/27/medical-sanctuary/?pagination=false


 
At Wednesday, September 19, 2012 5:49:00 PM, Anonymous k johnson said...

As a nurse, I have often seen that thirty seconds of kindness, pays big dividends in caring for a patient. The patient who already has your attention will not have to work to make themselves the center of your attention later. They are more agreeable and usually easier to communicate to when they feel you understand them as a valued member of society.

 
At Thursday, September 27, 2012 4:04:00 AM, Blogger T said...

CTD is just one of the acronyms, there are many 'worse'. Many websites have them, here's a good example:
http://www.messybeast.com/dragonqueen/medical-acronyms.htm
They are funny, sure. But some do have an underlying bit of disrespect for patients.
I don't mind if the doctor's first thought is 'why is he coughing'. I'd probably have the same though. People with scientific minds probably make good doctors.
As long as a subsequent thought was 'why is he uncomfortable' followed by 'what can I do about ALL of this'.
And yes, if we don't feel like a health care provider cares about us, there can be no trust.
TAM

 

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