UNCERTAINTY IS THE ONLY CERTAINTY
Posted by bmhegde on 1
Richard Smith, the editor of the British Medical Journal, was lamenting, in one of his recent editorials, about the poor communication skills of the doctors in general and their incapacity to deal with the uncertainties in medicine. Doctors have been predicting the unpredictable outcomes of their interventions to patients all along. Time evolution does not depend on the patchy knowledge of the initial state of the patient. This myth of wrong future predictions is at the root of patients losing confidence in their doctors. If one is well and healthy at any given time it is because of chance: if, on the contrary, one is unwell it is again because of chance. This concept is well appreciated in Islam, InshAllaH and AlHamdullillaH mean exactly the same. In fact, the word chance simply signifies God without His signature being affixed.
The answer to this is to teach medical students in training that doctors, like everyone else, are fallible and could make mistakes, but should try to learn from them to avoid repetition. Being honest about the mishap and sharing one’s joys and sorrows with the patient could ease the situation and enhance communication. The crux of the healing process is the coming together of two human beings-the one who thinks s/he is ill or imagines that s/he is ill and the other in whom the former has confidence. This coming together of two human beings with mutual trust is the summit of medicine from where all other aspects like diagnosis, therapy, future management etcetera follow. It is here that the patient gains confidence in his/her doctor.
Sincerity, honesty and being open about the hollowness of the myth that the medical profession could even bring back people from the jaws of death would create a better rapport between the doctor and the patient. Technology, in the last half a century, has deified the medical profession sending wrong signals to patients to expect the sky from their doctors-one of the reasons for the burgeoning consumer suits in the west against the medical profession. This has transformed the holy doctor-patient relationship into that of a seller and a buyer, resulting in the market forces uprooting medical ethics. “Cure rarely, comfort mostly, but console always” was a good Hippocratic advice. It is not what the doctor tells the patient that counts but what the doctor really does that impresses the patient. When once the patient realizes that his doctor does walk his talk, patient confidence could easily be won.
William Osler had this to say to the young medicos of his time that the doctor needs two great qualities of head and heart-imperturbability and aequanimitas. His speech on the occasion of his retiring finally from Johns Hopkins- Aequanimitas-is a piece worth its weight in gold for all times to come.
If the doctor knows the communication skills well, diagnosis becomes a pleasure on the bedside. “If you listen to your patient long enough, he/she will tell you what is wrong with him/her,” wrote Lord Platt in 1949. Recently, five of his old students, conducted a prospective study using the latest research methods to confirm the truth of Platt’s statement in an article in the BMJ in 1975 on the role of history taking and other methods of diagnosis on the bedside!
Confidence builds on the doctor’s capacity to listen to the patient. Listening is a very difficult art. Every medical student should be trained to master the art of listening. Most of us are good talkers but poor listeners. True listening is to be attentive while the patient pours out his sorrows with appropriate responses as and when needed. Prof. Calnan in his very good book Talking with Patients elaborates on the art of listening. Henry David Thoreau wrote, “To affect the quality of the day-that is the highest of arts.” The art of listening to the patient is the capacity of the doctor to enhance the quality of the patient’s day!
Listening to the patient is not confined to listing the patients’ symptoms, past history, his social and family history. The crux of the art of listening is to understand patient’s fears, his religious, spiritual and social beliefs, his cultural upbringing and, more than all that, even his irrational obsessions in terminal illnesses. Even if the doctor is a rationalist and thinks that medicine is a pure science, he/she will have to try and understand the irrationality of the patient’s thinking to respond to that to the patient’s satisfaction. The medical profession has to understand that the only truth, even in the king of sciences, physics, is the uncertainty principle of Werner Heisenberg and not the Newtonian deterministic predictability laws or Einstein’s relativity.
Watenchap is wot whatenchoppen doen-science is what the scientists do-is the real truth and science is not the truth. “Say not” wrote, Kahlil Gibran in his The Prophet “I have found the truth”, rather say “I have found a truth.” Science is only a search for the truth. When the chips are down even the best of rationalists become irrational. Rock Hudson, once President of American Rationalists’ Society, was quietly going to drink the holy water in Lourdes when he was seriously ill, I am told. People swallow their skepticism when death stars them in the face. If a doctor could understand all this, it is easy to deal with uncertainty on the bedside. Modern medicine also started five thousand years ago as magic, witchcraft and sorcery on the banks of the river Nile, anyway!
The “quiet art of medicine” does stimulate the human immune system that really heals. Healing is universally possible while curing is rarely an attainable goal in medicine. A healer must have a large heart coupled with a strong and well trained head. Combining humility and wisdom together is not impossible, albeit difficult. One should follow the advice given by Jesus to his followers. “Be ye therefore wise like a serpent but harmless like a dove.” One of the good books that I could recommend to doctors is On Doctoring by Richard Reynolds and John Stone (Simon and Schuster, New York)
My personal experience since 1956, when I first started seeing patients as a medical student, has been that if I have a genuine interest in the patient’s welfare, the patient would have full faith in me. This matters a lot in the final outcome of illness, uncertainty notwithstanding. Faith heals.