Kathy Merrell

iwellville.com

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What if medical schools cultivated the art of healing along with knowledge acquisition.

By the time a person actually becomes a doctor they've been stunted by spending years on the backbreaking labor of knowledge acquisition. Not only does this activity break the connection to one's "small little voice in the head" that might save the patients life, but it makes a person a slave to knowledge that is quickly outdated. Doctors can be myopic and closed to new information precisely because medical education is overwhelming biased toward studying; it leaves new doctors wildly unprepared to listen and heal.

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    Feb 2 2012: Interesting to read these comments. Many patients seem to feel quite abandoned by their doctors.
    I have quite a different experience. During and after the Medical School we were constantly reminded that we were treating patients, not diseases, and that the patient care is the goal. I participated in groups to discuss medico-patient interaction during years. We knew that a clear communication between the MD and the patient is vital for the treatment. Otherwise you prescribe medication and the patient does not take it, for instance.
    I was never warned against my inner voice during my training, just that intuition should be backed by study, sound medical evidence, and experience. When I was worried with a patient that looked fine but made me feel somehow uneasy, I kept on paying attention, examining and caring very closely, and discussing with other colleagues the case. I learned that anxious, demanding patients can have concomitantly a serious clinical condition in parallel with the psychological condition, and both must be well cared for. Treat the cancer without dealing with the anxiety is bad, as is the other way round.
    I would say that most doctors are open to new information, and are not intellectually myopic - even if a great number of us are physically myopic and use glasses ;-)!
    It is not easy, and it is tiring to be a good doctor: long working hours, always studying, always putting patients first. Maybe the American system does not contribute to a culture of trust between the treating physician and the patient.
    • Feb 2 2012: America has no cohesive system of medicine. We have a patchwork quilt of middlemen sucking the lifeblood out of the profession and the country.
  • Feb 3 2012: What if medical educations were based upon maintaining good health. Suppose the medical system was designed based upon positive assumptions about health.......Oh, what a different system we would have. Now the medical system works within the negative realm of bringing people out of a negative state towards a positive health state. Suppose it operated within the positive realm of bringing people from neutral or positve health states to better, more robust states of health. The work activities of doctors and other medical professionals would be quite different and they might enjoy their work more and have a more powerfully positive impact on the well-being of patients.
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    Feb 1 2012: I have also known physicians - including surgeons - to take weekend long courses in new procedures and technologies and start practicing on patients right away. Isn't medical school predicated on see one, do one. teach one? But that's not to say I disagree with you. I would think certification requirements are a key to widespread adaptation of all integrative and preventive therapies, including acupuncture, yoga instruction, massage therapy, etc. I will point out that this is happening in some places. New York State, for example, requires 200 hours of instruction to receive medical acupuncture certification. which includes 100 hours of instruction and clinical demonstration and 100 hours of sequential specialized instruction in specific uses and techniques. I also want to say I am very thankful for physicians like you who hold the line on quality of care. You are the reason that much of the current healthcare in this country represents the gold standard on the planet. Bests Regards!
    • Feb 1 2012: Thank you for your response, Kathy (and the unlooked for elevation in status) :)))

      I am not a clinician.

      My background is that of a clinical nurse specialist and I have 35 years experience working for the NHS in the fields of trauma and orthopaedics. Having retired 10 years ago from the NHS, I now work for myself as an orthopaedic technician. I specialise in working with very young children with spinal deformities, hip diseases such as Perthes, CTEV (congenital talipes equino-varus) and Ilizarov frames; post leg-lengthening surgery.

      My work is primarily the bread and butter work of fractures secondary to trauma. My specialist work includes NICU, PICU, ICU, (all intensive care units) Theatre (OR) and A&E (ER). The quality of my delivered care is extremely important to me and I do what I can to ensure that the needs of the patient are the only consideration with which I legitimately concern myself.
    • Feb 2 2012: Wow. 200 hours and they get to work as an acupuncturist? Zoinks. That is very little. We have an associate clinician on our staff who has over 2000 hours of oriental medicine coursework and practicums before she even worked a day at that job. Add to that 20 years experience and you have someone who can contribute significantly to pt outcomes. I'm not sure someone with only 200 hours could cut it.
  • Jan 31 2012: Hi Kathy,

    What a wonderful idea/conversation. I have been dealing with alot of doctors lately. Sometimes when I walk out of the office I am so downhearted and feel like I wasn't really heard. I was just a number and not a human being. What is sadder is that my parents are the ones that are the patients.

    Sadly, it is an epidemic.....BUT, I will give you a little hope. We have one exception in our city. The ophtomologist that sees my dad, also is an avid TED viewer. He is so kind and gentle with his ways. He is young, and very much on top of all the latest information. I know, because I started sharing with him some of the TED MED talks I've viewed, and he ellaborated on the technical information that the speakers did not mention.

    It did my heart good knowing that such doctors still exist.

    Your know Kathy, I once ran across a quote about teaching, that can easily be applied to doctors. Just substitute the words teaching, for medicine/doctor care.

    "Good teaching cannot be reduced to a technique. Good teaching comes from the identity and integrity of the teacher"

    Training is good, but what it all comes down to is the integrity of the doctor. It involves his core values, why he became a doctor, and how he views life, any life, not just his paying patients.

    Anyways, a while back I ran across this wonderful talk by the US Surgeon general. One minute into the video, she explains how she stood up for something she thought needed changing in medical school. You sound sort of like her. Maybe watching this wonderful video will inspire to do something great for your colleagues in the medical field.
    Why, you may even wish to notify her and get her backing for your idea.....Why not? Go for it Kathy!!!!!!

    http://youtu.be/MyN0GjRwYyw

    Be Well :)
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    Jan 31 2012: I think we focus too much on treatment of symptoms and not enough on prevention of disease. Eating healthy isn't emphasized enough and people are relying on medicine too much. Doctors could do a better job if they treated patients as people rather than subjects/experiments.
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      Jan 31 2012: I don't think it is a realistic expectation. Doctors are trained to treat diseases many thorough a process called problem based learning. That means, that as a patient, you are a problem to be solved.

      http://www.pbli.org/pbl/medical_pbl.htm
      • Feb 2 2012: Not all doctors are trained like that. Neither patients nor doctors are widgets to be fit into the corporate machine. People are messy. We don't fit molds.

        And any doctors who don't realize this should stop inflicting their dysfunction on humanity.

        on edit: Not all doctors stay stuck in that kind of training. They outgrown and out evolve it. It is a starting point, not an end point.
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          Feb 2 2012: Um. In the United States they are. Check any medical school you like.

          I had the chance to tour Mayo's simulation lab. They have entire rooms set up and dedicated to this type of learning. Most medical schools even advertise this method of instruction.
      • Feb 10 2012: linda - whoops. Mea Culpa.

        I didn't check the link and transposed in my grey cells with another concept. Sorry about that. Age can be a mofo.

        Having said that I would say that yes, PBL is taught in all medical schools, but an alarming number of doctors don't seem to be using it much post graduation. We see WAY too many patients who come to us after seeing another doc who is practicing recipe card medicine: they take the symptoms, mix them together and follow the recipe to find an answer and if it doesn't work, well, it must be because the patients wasn't compliant (or some other excuse).

        I don't blame docs however. It is difficult, if one is mired in insurance based practices to move beyond the box the insurance company is willing to pay for without causing the doc to spend hours arguing with an uneducated no-think-em about necessary. After a while it just becomes easier to do what you know will be reimbursed, cash the check and walk away. Anything else is punished.
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          Feb 10 2012: I completely agree. That is why I am saying why do we think that the docs should do everything? They have a job to do. They are trained and do it well. They got 10 minutes to see you and your issue. Be respectful. I would rather have the science of medicine that the art of healing anyday.

          Besides, the only person I have ever seen heal anything was the patient.
      • Feb 10 2012: Linda,

        The problem as I see it in focusing that diagnostic process to disease management rather than patient management, that you tend to get systems analysis.

        Pt:"Gee doc, I have symptom X, Y, and Z. What should I do?"

        Doc: "I don't deal with X and Z, but here is a prescription for Y and a referral to Dr. A for symptom X and Dr. D for symptom Z.

        The problem here is that too many physicians are not given the time nor tools to make those connections, and if we aren't going to have the doctors do that work, who do you suggest when you say that we shouldn't have the docs doing everything.

        BTW - at our clinic our docs spend an average of 20 to 30 minutes with every pt follow-up appt. and sometimes over an hour with each new pt. intake. They get a thorough history and work up of subjective and objective data. By giving that time to the pt, they are able to miss fewer things and work up a functional understanding of that pts. case. There is a reason that we are where pts come when no one else is helping.

        Again, I don't blame the docs who are mired in the insurance paradigm. FYI - we do not bill insurance (national average of insurance billing specialists to doctors, 3:1 - in Canada that ratio is 1:7 - yikes!!!) and as a result of lowering that significant amount of overhead and wasted medical specialist time, we are able to lower our costs to pts while still maintain a healthy profit margin to attract good docs.

        The insurance (broken) system time is done. Let's stick a fork in it.

        Could you explain your second last sentence more? I'm not sure what you are talking about.
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          Feb 11 2012: Actually I think the docs should do the work you describe. What I don't think is that they should do everything. They don't have the time or the tools so what next? Insurance companies over the years have increasing dictated how health care is delivered and many docs have to refer to doc A and doc D exactly for the reasons you list. (I predate HMOs and remember major medical. I also would like to go to your clinic. 30 min for F/U is a real treat).

          I agree 100% the insurance system is broken. It is troublesome that third party payors are more interested in stockholders than healthcare. I really think Obamacare is gonna tank the entire system. I have been posting against that for a long time. It is not about healthcare, its about insurance.

          That said, many people are going around saying they are healers. Spiritual healers, alternative healers. The art of healing. The word is over used and over applied. The only person I have ever seen heal anything is the patient themselves. Wounds, illness, infection. I think we need to work with patients to help them heal with medicine, treatments, and surgery. But the person that heals is the patient.
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      Jan 31 2012: Yes I totally agree! Doctors are human too, we shouldn't expect miracles...or at least meet them halfway with self-care!
      • Feb 11 2012: I agree with you in most ways in your OP. I do think that too many docs run the recipe card for a particular set of symptoms, matching them to the prescription they know. They do this because of the seriously flawed time constraints forced upon them by the insurance reimbursement system. Many doctors who have never practiced outside the USA don't even realize that there is another way.

        A friend of mine is a doc in Canada and he spends about 20 to 30 minutes with each patient. His nurse handles his entire days insurance billing in less than a half hour at the end of each day online. He works 35 hours per week and never deals with insurance dorks overriding him or not paying him. He knows a year ahead of time what his reimbursement rate is, and if that isn't good he and his professional organization is able to negotiate changes. Best of all he has plenty of time for CE and keeping up with journals.

        Compare that to the USA where docs also see pts for about 35 hours per week and spend the rest of the time in paperwork, plus the also support some of the 3 insurance billing specialists employed for every doctor in the USA.

        I do agree with Linda that the only people who heal are patients. At best docs help them on that journey.
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    Feb 2 2012: that's 200 hours training for physicians. presumably they can figure out what they are treating.
  • Feb 1 2012: Thank you for your response Kathy. While peer-review and randomised control studies are supposed to be the gold standard, I am aware that research is often funded by parties with a vested interest in the outcome and this will introduce a substantial bias into some published research.

    in my experience of acupuncture, I have seen many clinicians who have attended a weekend course in acupuncture and at the end of it they were presented with a certificate and a set of needles. These people are not acupuncture practitioners and what is more, they never could be with such a short induction to a healing art that requires many years of study.

    I have worked with British anaesthetists who had studied acupuncture for 5 years in China. On their return to the UK they were comfortable with allowing major surgery to take place under an acupuncture neural block. The patients remained conscious throughout the surgical procedure and as a result the procedures were considerably safer because all anaesthesia is a calculated risk.

    Back on point: It is the lack of appropriate documentation from practitioners of a particular therapy that cause it to be largely ignored by conventional medicine. The notion of accepting the word of a non-medically trained person as a valid rationale for initiating a particular treatment, is very unlikely to fly, especially where the treatment has little effect or even unintended consequences.

    No clinician, in their right mind, will initiate an untested treatment for a patient because it is a gross dereliction of the duty of care inherent in the patient/doctor relationship. In a litigious society such as that which is found in the USA, a medical doctor would not be practising for long if they were easily encouraged to ignore the work of their prudent colleagues, in favour of snake oil.

    I don't mean that all therapies which are alternative or non-mainstream are merely snake oil but it is clearly undesirable medical practice until proven to be useful.
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    Jan 31 2012: Your question made we wonder, as I am not a doctor or a medical student, whether modern medical schools do, in fact, typically ignore the art of healing as you describe it. I just happened to be reading a book yesterday by Rachel Naomi Remens, a professor at the medical school of the University of California, San Francisco, whose practice and teaching for over fifteen years has been about what I think you would call healing. That remains one of the very strongest and most highly regarded medical schools in the United States.I notice also in the online health information for the HMO to which I belong, a giant one, when one looks up an illness or symptoms, one is directed to mainstream as well as alternative medical approaches to the symptoms or problem at hand.
    From my experience, I would have hypothesized that the integration of alternative ways and styles of looking at healing/medicine is becoming more rather than less common even within established health settings. I don't know this to be true, but it would be consistent with my limited experience.
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      Jan 31 2012: Your comment is really important. Rachel Naomi Remen is one of the pioneers in changing medical education, so you are right in the wheelhouse of transformation. I agree with you that healing and humanity are becoming a bigger part of the medical conversation. But from my observation of medical students and doctors the crushing imperative to acquire knowledge as a student and then for doctors the imperative to be right, still reign supreme. Mention an integrative or alternative treatment to most conventional doctors and they will almost always dismiss it as "unproven" even though standard conventional therapies often have very little research behind them, especially when it comes to long-term efficacy. The openness to alternatives you noticed at your HMO is part of a grass roots movement coming from patients who want more...more answers, more solutions and more tools for becoming well and staying well. I guess that's how the change will come.
      • Feb 1 2012: Your thought provoking question reminds us that some things are amiss with the practice of medicine. When you say: "standard conventional therapies often have very little research behind them", it is an oversimplification of an arduous system of knowledge acceptance and medical advances. My knowledge of orthopaedic treatments is tempered by scientific research into treatment approaches. The work is simple: a broken bone is a broken bone and functionality can only be restored when it is repaired. I also need to have a full knowledge of biomechanics, functionality and the optimum positioning for limbs to function well.

        A search for a simple fracture of the scaphoid bone (essential to wrist function and grip) and internal fixation treatments discovers 561 research articles on PubMed alone. Reading these articles may not point to a counsel of perfection but it provides a starting point for anyone who needs to find out something about the injury and the potential sequelae of internal fixation.

        Medical practice advances by this generally agreed means. Integrative and alternative therapies may work but their application is frequently a 'seat of the pants' usage that is not reproducible easily by other people; who may wish to know more about the skills and techniques required to use a novel method of treatment.

        Medical research is peer-reviewed and others can reproduce and refine the findings of any particular treatment. Where the observer detects a mistake in method application, all previous papers are used as a guide to refine the treatment. Careful documentation of any method is open to deep scrutiny (globally) and alternative and integrative therapies are not yet documented by people in any coherent way. Neither are the people who use a particular alternative therapeutic measure subject to a minimum standard of knowledge requirement.

        Knowing when I don't know is the most important tool which I carry with me when treating acutely injured people with fractured bones.
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          Feb 1 2012: Thank you Jeff, you make a very important point--scientific method and the system of peer review must be respected and preserved. Too often, though peer review articles do not compare relevant therapies, but rather they look at one single therapy against the control and/or placebo. Even so, I think you are able to find particular clarity within orthopedics as opposed to internal medicine with its many gray areas. But I will insist that the conventional bias exists irregardless of evidence. A quick search of acupuncture in the Pubmed database reveals 17,378 articles in peer reviewed journals; this from a therapy many doctors consider to be "alternative" or "integrative." Often the evidence is there but docs remain biased to what they've learned in med school or what their department is currently using.
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    Jan 31 2012: That's why you need a nurse.
    Doctor's treat disease and nurses treat people.
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      Jan 31 2012: We can never forget the incredible world of nursing. But doctors should be treating people, not diseases. And nurses can practice their healing arts in tandem - so the double the effect!
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        Jan 31 2012: Sometimes we have to let go of the 'should be' and deal with the 'what is.' Not all docs, but the vast majority just do not have this skill set. We can all list example after example.