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2.9 The clinician as healer2.9.1 Curing and healing are not synonyms.The term 'cure' is relatively specific, as in 'the operation cured the disease'. However the curing of disease is only one part of clinical practice. The process of 'healing' has two broader meanings - intransitive and transitive:
Healing is particularly relevant to incurable diseases. A disease that is curable by outside intervention is, by definition, finite. However, even where effective treatments are available for chronic diseases and health problems, patients often cannot return to the same level of health they enjoyed before, for example, developing arthritis or multiple sclerosis, or suffering a stroke. The progress of diseases such as these may be halted or slowed, but tissue is irreparably damaged, producing permanent physical effects, sometimes with psychological consequences. 2.9.2 Curing disease and healing sufferingThe progress and effects of chronic disease can sometimes be mitigated, but the patient needs help to come to terms not only with persistent symptoms and disability but also with their emotional reaction to these problems. Many patients feel a sense of injustice, best summarised by the rhetorical question, 'Why me?'. This question encapsulates the feelings of anger some individuals may experience when they develop a serious health problem, and it is related to the religious preoccupation with the meaning of suffering, a branch of religious study known as theodicy. 2.9.3 Doctors are more than drugsIn coining the phrase 'the drug (called) doctor', Michael Balint made an important point, but the word 'drug' is so powerfully associated with the concept of cure or symptom control that the phrase 'the drug doctor' does not adequately express the fact that doctors can also be healers by relating properly to patients. For some clinicians, the emphasis on uncertainty and the promotion of evidence-based medicine pose great challenges in their professional life, as a cry from the heart in The British Medical Journal described clearly, because the pre-occupation with the search for evidence may, in the author's view, have reduced the clinician's commitment to the human side of healthcare. Yet, I fear that our search for certain proof has eroded valuable components of care. Taking time with patients, handholding, explaining, comforting, listening, providing hope, and taking interest in our patients' lives are becoming passé in the evidence based revolution of medicine. These lost arts were the mainstay of practice 100 years ago. Our colleagues of past centuries often used foolhardy, unproved, and, occasionally, outright dangerous measures to combat disease before the availability of antibiotics, antidepressants, and antihypertensives. However, our predecessors often realised the limitations of their medicine and spent time in activities that we no longer esteem because they are not supported by evidence in a peer reviewed publication or the Cochrane Collaboration. We presume that we are better doctors with all of the new tools of science. But I am not so certain. In some aspects we seem to be deficient. With new yardsticks of evidence based medicine we have quickly abandoned vital aspects of medicine that are the most difficult to teach, to measure, and to explain. (16) 2.9.4 All clinicians can be healersIt is not only doctors who are healers. The nurse is often regarded as a healer within the clinical team, complementing the curative work of the doctor by caring and healing. In adopting this approach, nurses, and members of other professions allied to medicine, sometimes see themselves as offering a holistic approach to the patient's problem. They seek to see the disease in the context of the whole person and to promote healing, whereas doctors, in the opinion of the other clinicians, focus on the disease and not the person. This can cause conflict within the team. 2.9.5 Non-clinicians can be healersThe concept of healing is, of course, long established and in Christian societies Jesus Christ is often portrayed as the first healer. Today many people other than clinicians claim healing powers, from individual 'faith healers' through to members of groups, and practitioners of Christian Science. 2.9.6 Spontaneous healingThe term 'spontaneous healing' is increasingly used to describe the curing of an incurable disease, either without obvious external cause or because of an intervention, for example dietary change. Jerome Groopman describes a case of spontaneous healing in his book Second Opinions when a person with incurable and apparently terminal cancer becomes completely free of the disease. Andrew Weil, author and creator of integrative medicine in his book Spontaneous Healing, describes a number of cases of people whose incurable diseases vanished. 2.9.7 The elements of healingHealing may be spontaneous and many people do come to terms well with chronic disease without outside help, but when an outsider, a clinician or non-clinician, tries to promote healing this may be done using one or more of the following methods:
These techniques can be learned, but the skill of the successful healer may be acquired long before he enters professional training because the interventions may be as much a reflection of the healer's personality as the result of training. The healer's influence appears to be mediated by the relationship that develops with the patient, and the need for a new style of practice has been clearly described by one of the people who has studied the work of the physician in most detail, Howard Brady, who wrote In medicine, especially a male-dominated world of medicine, close relationships seem scary and potentially overwhelming, whereas isolation seems safe. Our own sense of safety in emotional distance has probably led us to be overeager to hear the message of detached concern, with the emphasis on the detached rather than the concern. It might be time to explode the myth of getting too close to the patient as a serious danger of attending carefully to the patient's story and affect. (17) 2.9.8 Narrative medicineNarrative medicine is a term being used with increasing frequency. As commonly occurs when a technical term becomes part of everyday language, it is used in different ways by different writers. Writing in the Annals of Internal Medicine, one of the world's most important medical journals, Rita Charon defines narrative medicine as medicine 'practiced with the narrative competence to recognize, interpret, and be moved to action by the predicament of others'. She defines five different types of narrative writing in medicine (Table 7). (3)
The term Narrative Medicine is now given to a style of clinical practice which concentrates on taking the patient's experience as an essential foundation for clinical decision-making. Interestingly, one of the best books on the interpretation of the term is the book entitled Narrative Medicine by Trish Greenhalgh, one of the leading exponents of Evidence-based Medicine, which is sometimes portrayed as the antithesis to narrative medicine. Both research-based evidence and the patient's narrative are important, but for the healer, the latter may be more important than the former. 2.9.9 The patient as healerThe patient has to be centrally involved in healing and needs to be given the resources to do so. References1. Kay, H.E.M. (1974) Letter in The Lancet ii: 586. |
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