Cell Biology: Accomplice Fingered in Cholera Toxicity Anesthesia: Pain Promoter Plays Unexpected Role in Central Nervous System Health Policy: Better Cost–Benefit Ratio Found for AIDS Treatments than for Some Heart Attack, Breast Cancer Therapies Women's Health: Conference Points Up Need for More Minority Women in Clinical Trials Smoke-free Dorms Dampen College Smoking Habit Cholesterol Buster May Also Cut Protein Tied to Heart Attack Economic Status May Affect Care for Colorectal Cancer Patients No Data Found Tying Breast Implants to Multiple Myeloma The Art of Healing Fabric 2001 Dresses Up TMEC with Song, Dance The Fourth-years' Rite of Spring HMS Promotes Berti to Registrar In Memoriam: Donna Rowland William Sweet Countway Offers Weekly Meditation Honors and Advances Setting the Clinician's Temperature: Cool Head, Warm Hand Front Page

FORUM Setting the Clinician's Temperature: Cool Head, Warm Hand Erica Seiguer Photo by Graham Ramsay "You don't lose your humanity—you just have to be active in keeping it." What an admission of the dehumanizing effect of medical training. And that coming from the codirector of my Patient–Doctor II course, a class for second-year students at HMS during which we learn to perform the physical exam. It was the end of a lengthy and stimulating discussion about the relationship between a doctor and a patient, the power differential that exists between the two, and how to understand both to achieve the ultimate goal: to be a better physician to your patients. I have to admit that I was somewhat skeptical of the utility of a discussion on power in the patient–doctor relationship. Part of me felt that these issues were somewhat intuitive, but I welcomed the chance to sit back and think about what it means to be a doctor and to deconstruct the experiences of the doctor and patient. It was a little easier to think through that of the latter (having been one), but it was clear that the transformation to physician had begun to take hold, and understanding the disempowerment of the patient and the empowerment of the physician revealed how critical this explicit exploration of power issues was to the development of a competent and caring physician. A Clinical Imbalance On the list of empowering forces for the physician were possession of medical knowledge, attainment of social standing, status as gate-keeper to prescription drugs, the ability to command the patient, and the prerogative to invade the patient's personal space, both in terms of intimate questioning and physical examination. This was in sharp contrast to the disempowerment of the patient, who comes to the physician in a vulnerable state, many times ill and seeking alleviation of suffering. From the start, the patient is at a significant disadvantage—less knowledgeable (in most cases) than the physician, emotionally and physically vulnerable, perhaps disrobed, potentially perceived as a disease or a number and not an individual, and, at a very basic level, caught in an unfamiliar environment. Thus, from the outset, the doctor–patient dynamic is one of unequal power distribution. This was not very surprising, but the articulation of the factors related to the power differential then led us into a discussion of what we could do, as physicians, to level the field, creating a more trusting, professional relationship. How could we empower the patient? Based on our discussion, it came down to respect. Now, one would hope that whether we are doctors or patients, we respect one another, but the critical point in emphasizing respect was its reinforcement through conscious actions by the physician: addressing the patient as an equal, explaining the exam (not just at the outset, but while palpating, percussing, auscultating) as well as the findings, and walking the patient through the rationale behind the treatment regimen. In other words, throughout the interaction, sharing knowledge. Giving Respect But, really, who has the time? That's what we keep hearing in less and less subtle tones as we learn to better organize our physical exam with the dual mission of getting a better clinical picture of the patient and shaving precious minutes from the encounter. We also keep hearing that what we are learning is an ideal patient–doctor interaction that rarely occurs. Rather, the world of managed care brings us dehumanizing residency programs with sleep-deprived physicians trying to keep patient histories recorded on scraps of paper and note cards stuffed in overflowing white-coat pockets. The kind of time needed to develop a human relationship that for many of us, I believe, made us want to enter the profession, may not exist. Despite the intense time pressures, however, some physicians do succeed in achieving the skill and tenacity to become admired and trusted by their patients. What are they doing right? I think about those physicians who have treated me as a patient, and of my professors in school and their patient interactions. From what I can tell, it is a mixture of superb clinical skills that instill confidence in their patients and an ability to protect the relationship from the insults of a system that in many ways seems built to erode this fragile bond. So where does that leave me, the budding physician, concerned with learning the technical skills of being a doctor and somehow becoming infused with that mystical "art" that will make me the physician my patients need me to be? The directors of the Patient–Doctor course, and those other professors I have encountered throughout my early medical training, are showing the way. They are emphasizing attainment of clinical skill and the importance of stepping back to assess our development as complete physicians. As they do, they are enabling us to realize our humanity in the relationship between patient and doctor. —Erica Seiguer, a second-year MD–PhD student at HMS