So my elderly mother back in Wisconsin has been gravely ill for several weeks, and her three children have been going through the now-typical and typically frustrating experience of trying to pry information from doctors and to get them to pay real attention to her. During the past year I have also had an unusually high number of encounters with different physicians attached to my health maintenance organization in Los Angeles. These combined experiences prompt me to consider what ails the practice of medicine these days. And if I may be allowed to state my diagnosis right up front: the problem is time.
Doctors aren’t spending nearly enough time listening to and getting to know their patients. I recently told a disbelieving younger friend about the late Dr. Michael Halberstam, my doctor in Washington DC during the late 1970s. Dr. Halberstam would spend the better part of an hour in the course of my annual checkup to ask lots of questions and take detailed notes for my file. Only after the interview was completed would he begin to examine my body. First, he wanted to know about my life.
I dare say there aren’t many Michael Halberstams practicing medicine any longer, except possibly here and there for rich patients who are willing to pay for that kind of caring individual attention. The last really good primary care doctor I had (a member of a small group practice serving mainly gay men in New York’s Chelsea neighborhood) ended up quitting the profession in disgust over how little time he was permitted to spend with individual patients. Brilliant and idealistic, he found himself pushing paper (insurance forms) and pushing lots of pills but not actually practicing the healing arts very much.
In a piece for The New York Review of Books last November, Dr. Jerome Groopman writes movingly about the breakdown of careful medical discernment and individual attention to the sick.
Groopman notes how so many of the things that matter to good medical practice, all of which involve time and attention, are today unlikely to be compensated under the system of “Relative Value Units” by which almost all physicians are now paid:
There is a compassionate, altruistic core of medical practice—sitting with a grieving family after a loved one is lost; lending your experience to a younger colleague struggling to manage a complex case; telephoning a patient and listening to how she is faring after surgery and chemotherapy for her breast cancer; extending yourself beyond the usual working day to help others because that is much of what it means to be a doctor. But not one minute of such time may be accountable for reimbursement on a bean counter’s balance sheet.
Groopman also marks the way that the finance-driven “efficiencies” in medical practice are a relatively new phenomenon. Although there have always been doctors more interested in examining a patient’s pocketbook than his pancreas, Groopman observes that:
only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.
“Wrongly relinquishes the soul”: this clearly isn’t normal physician-speak, but then Jerome Groopman is no ordinary physician. He is an old-fashioned humanist who is willing to acknowledge the deep mystery at the heart of the human being in which body and spirit are intertwined. This is not quite the same as the celebrated “mind-body problem,” although that interface is another great mystery. The spirit-body connection is one that almost everyone acknowledges to be real but that almost no one can pin down.
Attending family members and friends and nurses can often pinpoint, for example, the moment at which the dying person lets go and releases her spirit. Even before then, among those who are at some risk of dying, family members and medical personnel commonly acknowledge the importance of a spiritual will to live in determining whether a given episode of illness will lead to death or to a rebound into active living.
So strong is the spiritual dimension in healing that significant religious movements—Christian Science and (to some extent) Religious Science and Dianetics/Scientology—have grown up around it. Because these movements (along with faith-healing proponents within traditional Christianity) so often take the extreme position of denying the power of bodily illness altogether, sober realists and an overwhelming preponderance of scientifically-trained people, including doctors, have been inclined to move to the other extreme and to insist that pneuma (spirit) and psyche have nothing at all to do with soma (the body).
Hospital-based chaplains and pastoral counselors come up against a fairly brutal form of scientism all the time. In many health care institutions, these people are barely tolerated. They are pointedly not invited to participate in rounds or in patient evaluation sessions. I recall how, as a first-year seminary student doing what is called “supervised ministry” at a New Haven mental health hospital, I was somewhat shocked to see how patients’ behavior was interpreted purely in terms of reactions to their medications, whereas I could see plainly that many of these same patients were responding to the presence or absence of human connection—visits and phone calls from loved ones either made or not made, friendships with other patients either formed or broken.
It is not at all my intention to represent contemporary physicians as soulless robots. I think a great many of them recognize that the quality of their practice would rise appreciably if they were allowed to spend even a tiny bit more time with each patient. But as they and we all know, the economics of health care today militate in the other direction: towards even less time per patient “visit,” and towards even more aggressive mechanization of what Groopman calls the medical assembly line.
If there is any hope for positive change, however, it may just come from this same intense economic pressure to cut costs. I say this because of assembly-line medicine’s dirty little secret: misdiagnosis. Someday someone is going to figure out that the aggregate cost of widespread misdiagnosis is greater than the aggregate cost of allowing a bit more of that precious private time between doctor and patient. Until that day comes, religious people who grasp the spiritual dimension of healing should be as vocal as possible about the urgency of doctors spending real time with those who are ill. And let the healing begin!