Copyright RAY DOWNING, M.D.
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Medical education is focused on the technology of modern medicine, and
rightly so. The techniques of curative medicine can be taught, the results
proven. But healing is more difficult to teach, and approaches to it are more
value-laden. Can it be taught? In this lecture I want to talk about healing and
how it differs from treating because I think this distinction will draw us into
the core of why medical education exists.
Healing means being made whole -
"wholeness" and "health" share the same Greek root word. Treating is doing
something to arrest a disease. Healing has a broad focus and looks for a
certain result - "wholeness". Treating has a narrower focus - a particular
disease, and looks for a narrower result - getting rid of the disease. I will use
my experience as a framework for this lecture, especially in light of my own
recent retreat from the activities of healing to the those of treating. I hope my
own story brings to light some values implicit in graduate medical education.
One of the reasons I chose to study Family Practice was because I wanted to
learn about healing. Family Practice, as I understood it, was a way to
coordinate the advances of American medicine after World War II. But even
more, it was a response to - and a reaction against - the depersonalizing and
compartmentalizing effects of those advances. By the end of the 1960s
technology and specialized medicine had increased so much that not only was
primary care at risk, healing itself was as well. Family Practice was more than
just a way to upgrade the old GPs and give them respectability in an
environment where Board certification was more and more important. It was
a return to seeing a patient not just as a bag of organs, but as a "whole
person" living in a family which could contribute to a disease and also
influence its outcome. I felt Family Practice would give me the opportunity to
study, in Paul Tournier's phrase, "the healing of persons"1.
Implicit in my
thinking was this: specialized technical medicine was becoming very good at
fine-tuning the diagnosis of disease, as well as treating those micro
diagnoses. I had respect for those treatments, but sensed that treatment was
not always accompanied by healing2. I knew people could be "cured" yet not
"made whole". I even knew people who were "whole" - ie content,
well-integrated, and healthy - even though they had a condition or disease
that hadn't been cured. In other words, I knew that though there was an
important overlap between treatment and healing, they
weren't the same
thing. My hope was that Family Practice training could give me an overview
of treatment skills, while at the same time showing me how to use them for
healing.
At least now, looking back, that's what I would want from a Family
Practice program. At the time I think I assumed that simply by mastering the
primary treatment skills of all the specialties, including psychiatry, and by
offering them to everyone in the family, I'd have a better shot at healing. I
think twenty years ago my program assumed the same thing, and they gave
me that overview.
We did not talk much about "healing", though. Family
Practice was only seven years old then, and it was important in that first
generation to define the curriculum and gain academic credibility, all in terms
the medical establishment understood. But we weren't outsiders trying to get
in, we were the medical establishment. So naturally we built Family Practice
in terms we understood: technical diagnosis and treatment terms, not
"healing" terms. To us, then, adequate diagnosis and treatment was healing.
Let me add here, parenthetically, that medicine does not have, nor should it
have, a monopoly on healing. There are many "healing arts", many
professionals involved with helping people become whole. We in Family
Practice understand especially the approach of other scientists, ie, social
scientists such as psychologists and social workers. But we dare not delegate
to them the entire task of making people whole. Their sphere of influence is
almost as narrow as ours. Pastors and spiritual directors can have a very deep
influence in helping some people become whole - but only some people. Wise
friends and relatives can be remarkable healers - but only some friends and
relatives. Actors, singers, and writers can profoundly affect a journey toward
wholeness - sometimes. Even an entire culture can be one that encourages
either health and wholeness, or dis-ease and fragmentation.
But if medicine is
one of the healing arts, how intentional are we in helping our patients become
whole? Are we satisfied with diagnosing and treating the bio-medical parts of
their disease, and letting counsellors and pastors help them live with, or fight
off, the dis-ease? And do all of our treatments aid in healing, or could some of
them actually be counter-productive in bringing wholeness? I shall return to
this shortly.
When I completed my Family Practice training I began practicing in
Maynardville, the county seat of Union County. There my wife and I worked
in what might be called an ideal place for Family Practice. We saw entire
families and provided them with the whole range of out-patient services,
admitting them to St. Mary's Hospital for in-patient care. We lived in the
community and occasionally made home visits, so we saw our patients'
dis-ease in its context. As Medical Examiner and jail doctor, I even had an
inside look at the seamier side of life in Union County. We worked closely with
the Cherokee Mental Health system, and so had immediate access to
professional counsellors. Our first employer was the Public Health
Department, giving us an official link there. We were not just "organ doctors"
or "body doctors"; we weren't even restricted to being "Family Doctors". We
were, in some senses, "community doctors".
In all of this activity, were we
involved in healing? It's not a question I asked at the time. Mostly we treated
our patients and were happy when they "got better". I was taken then by the
ideas of "community health" more than "the healing of persons" - but I think
we did do more than just treat; I think we did try to heal. Beyond the
three-ring circus of services we provided or arranged for, we entered some
people's lives. We struggled with them as they tried to get rid of an affliction,
or more often to live sanely with it. Here and there and now and then,
sometimes because of all the "ancillary" services, and sometimes relying on
techniques we'd been taught, but often using only the personality and common
sense God gave us, we worked to help people become whole.
Then after seven
years, we left to work in Africa. There were many reasons, most unrelated to
our work as healers because "the healing of persons" was not in the center of
what we did. But our leaving did give us a chance to take a fresh look at
Family Practice, and indirectly at healing.
Family Practice intended to provide
cradle to grave, minor to serious, medical and surgical health care for
everyone in the family - or at least to "orchestrate" that care. The idea was
that such a broad view would reduce fragmentation of services by having
them better coordinated, with a single manager, or "tour guide" through these
services. Underneath, I think, was the hope that that single manager would be
in a better position to help the patient heal3.
Our experience, though, was
different. Instead of "coordinating" care, we found ourselves squeezed
between the minor and serious. The increasing standard of care required that,
for most of our hospitalized patients, we consult specialists, and they tended
to take control of the patient care. We didn't orchestrate, we listened. And
with the other "end" of care, the common minor conditions, we found that
nurse practitioners and physician's assistants did an excellent job in caring for
these patients. Sometimes they did even better than we did, because, frankly,
we eventually found some of that work boring. We were still the tour guides
through our caring circus of services, but healing and wholeness became more
elusive.
I mentioned above that I was "taken" by the ideas of community health -
suggesting that I was in a "phase" that I would eventually "get over". That
doesn't quite get it. It's true that my first job in Africa was mostly in
community health, and that I do not have the same involvement in community
health as I used to. But the healing of communities is not a phase; I think it is
an integral part in the healing of persons.
What I found difficult was to do
both at the same time - and so for a while I did only community health. My
experience was like that of a nephrologist being asked to care for someone
with renal failure - who also had heart disease and significant emotional and
family problems resulting from the diseases. To accurately diagnose and
prescribe for the kidney disease requires one set of skills; to care for the
patient's emotional and social problems requires a different attitude and
different set of skills. Likewise the healing of persons requires a different
attitude and set of skills from the healing of communities.
I see that now. But
first in Union County, and then in Africa, my question was less "which set of
skills do I have?" than "which task is more important?" - or rather "which task
is more important to me now?" I knew that prevention, or maintaining health,
was preferable to trying to repair it once it had been disturbed. I felt too that
the restoring of health had a better chance of being effective when people in
the community were involved in the process. Any healing, I thought, should be
the offering of a remedy and the active reception of that remedy. Passive
recipients - whether individuals or communities - may be cured, but only
active recipients could be healed. That belief led me not just to the discipline of
public health, but to the approach called community health.
Community
health, however, proved far more difficult than I first envisioned. Perhaps
that is only a reflection of the difficulty of any healing. There are plenty of
public health remedies - vaccinations, public pipes or private latrines,
homemade rehydration solutions for diarrhea, mosquito nets, and so on - but
more often than not we impose these remedies on communities. More often
than not people are passive rather than active recipients. More often than not
communities are "cured" of their health hazards without being made whole.
Gradually we let go of community health; more and more in Africa we were
asked to practice "individual" medicine. And as we did we discovered that two
things were happening to us:
2) we were no longer attempting to heal.
Each requires some
explanation.
Western scientific medicine in Africa is, in some ways, the
medicine of Osler: the careful use of history and physical examination to
diagnose illness. It is in other ways the medicine of the American 1950s and
1960s: basic X-ray and laboratory to aid diagnosis, and basic medicine and
surgery to treat most conditions. It is, of course, also the medicine of the 1990s:
there are CT scanners and fiber-optic scopes and sub-specialty surgery
available in big cities, and even small rural mission hospitals have ultrasound
machines and - sometimes - samples of the latest drugs.
But in much of the
Third World there are no automated chemistries, no culture and sensitivities,
no respirators, no renal dialysis, no intensive care units, no medical or
surgical sub-specialists. Family doctors and general surgeons - but often just
"GPs" - are the end of the line, and mostly see only referrals from PA- or
nurse-level primary providers. Far from being "squeezed" for work by
boredom on the one side and specialists of the other, family doctors are the
specialists - but without the technology of American specialists. And without
the expectations America lays on them.
The result is that we must rely more
on our hands and ears and eyes for diagnosis, and that we must treat with
ingenuity. Cost-consciousness is not a style of practice that can be rewarded
by an HMO; it is the only way to practice. African medicine and surgery rely
far less on technology simply because it's not there. Yet the amazing thing is
how often we can diagnose accurately and treat adequately without high
technology. We become better clinicians - even by Western standards -
precisely because we lack the technology characteristic of Western medicine.
After some time of practicing this medicine in both Tanzania and Kenya, I
began to think about what had been obvious all along: that I was not building
long-term relationships with my patients. I was like an American surgeon or
ICU nurse: I got to know the sickest patients very well while they were ill - but
then they would either die or go home, and often I would not see them again.
Most of the poor health in Africa is from acute infections or trauma; little is
chronic and degenerative as in America. I was not building long-term
relationships with people because of the nature of their disease and my role as
the one being referred to. I was doing more extensive diagnosis and treatment
than in America, but was no longer thinking about long-term therapy and
change... or healing.
And, in a way, I didn't have to. I may have been the "end
of the line" for Western medicine, but no one saw Western medicine as the end
of the line. People came to our hospitals for "treatment" without, I think, ever
expecting "healing". Healing was still a matter for traditional healers and
culture and family. Even the bulk of Africans who had joined a religion from
"outside" - Islam or Christianity - saw in that religion the ultimate provider of
healing. Doctors are viewed as craftsmen, not artists; as technicians, not
healers.
To say it another way: more is expected of each doctor because there
are fewer doctors, but less is expected from the profession as a whole. We are
expected to be good technicians, as in America, but we are not expected to be
able to prevent every death. A bad outcome in America means a lawsuit
because there is nothing beyond medicine when medicine fails. A bad outcome
in Africa is a tragedy with spiritual, not legal, implications. There is always
something beyond medicine - and for that reason, we are not expected to heal,
but only to treat.
Now we must return to American Family Practice and ask whether or not my
original expectation - to learn about healing in a Family practice training
program - was reasonable.
To summarize the problem: American
sub-specialty technological medicine is very good at diagnosing and treating,
but has been accused of neglecting the "whole person". More than this: the
more a health care system uses technology, the less it depends on human or
"natural" resources for healing. It can even suppress "natural" healing in the
same way that continued high doses of corticosteroids can suppress the
"natural" production of endogenous corticosteroids4. But the biggest effect of
high technology medicine is that by focusing on biomedical treatment, it
ignores the question of healing altogether.
Scientific medicine in Africa, on the
other hand, employs less powerful technology and has not yet eliminated the
healing forces of the culture. Therefore, when scientific medicine in Africa
ignores the question of healing, as does its American counterpart, the
consequences are very different. The treatment paradigm is the same, but it is
at work in an entirely different culture.
American Family Practice intended to
address the problem of fragmentation by asking one cadre of doctors to
oversee health care for the entire family: to recommend preventive activities,
diagnose and treat the majority of their illnesses, and efficiently connect them
with the correct technology and specialists for more complicated disease. The
assumption was that proper training in common illnesses, together with a
broad understanding of what "high tech" medicine can offer, would provide a
doctor with the tools necessary for complete treatment, which was assumed
to be the same as healing.
But this third decade of Family Practice has taken a
twist that we didn't expect, though perhaps we should have. The "high tech"
medicine that we coordinate is very expensive, and we long ago chose to not
let that be a factor in deciding whether and when to use that technology. It
was a matter of ethics: life and health were at stake, and we could not endorse
a lesser level of health, or at least treatment, based merely on money. We
would offer - or "prescribe" - the best to everyone, and it was up to the
patient, or the insurance company, or the government, to find the money to
pay for it.
They did - for a while. And in the process "they" gained control of
our medical system. Now they have told us there is simply not enough money
to pay for all the latest technology for everyone, so they - the ones who pay -
have changed the way we practice. And since their concern is economic, their
changes are based on economics. The healing versus treating debate
disappears from the agenda.
For Family Practice, the change is this: We first
became a specialty, in part, to reduce fragmentation and treat the whole
person. Now we are being told that we are "gatekeepers", suggesting that
real treatment occurs only beyond the gate. We originally were given extra
training so that we could do more than "general practitioners" and treat
patients without referring them. Now we are given extra training in
diagnostic procedures so we can treat patients by referring them. The focus is
shifting from treating the whole patient to navigating that patient through
the whole medical system.
This does not mean that we no longer treat
patients. But it does mean that our center of gravity is changing, and what is
distinctive about us as a specialty is different than it used to be. Twenty years
ago we were developing the expertise to manage clinical problems in the huge
"overlap" area of body, mind, and family. Now we are more able to select out
those few patients in this overlap needing "definitive" organic treatment, but
less able, it seems, to manage the whole problem. The fallout for healing is
obvious.
But then again, is it fair to ask Family Practice to attempt what neither African
nor American scientific medicine does? Can any scientific curative system be
expected to help make people whole - especially when the culture they come
from is fractured? Is health care really the sphere for healing?
It's a difficult
question. If healing is the business of Family Practice, we need to make major
changes in our curriculum, recruit a different kind of new doctor, and try to
reclaim what Western medicine lost centuries ago. On the other hand, if
healing is beyond the scope of Family Practice, then Family Practice is off the
hook - and all of American medicine is on the rack, tortured by a people in
need of healing and seeking it from a system set up only to cure.
I read the last
half of this lecture to my wife, who squirmed until I came to the last few
paragraphs. I had been asking the wrong question all along, she said, hoping
for Family Medicine to teach me how to heal. Of course medicine can't heal,
she said. She, a board-certified Pediatrician, who also passed the boards for
Family Practice, a "generalist" who can do major surgery on a patient with a
twisted bowel and have him well and home in less than ten days - she said
without hesitation, "Only God can heal."
Now, how can we convince the
American public?
Notes
1The 1965 English title of his first book, published originally in
Switzerland in 1940. In the epilogue
he refers to World War II, and indeed his first-hand experience of it, as the
background
for taking a new and more complete look at healing.
2Arthur Barsky calls this "the paradox of health", that in our
society "substantial improvements in health status have not been accompanied
by improvements in the subjective feeling of healthiness and physical well-being."
("The Paradox of Health", NEJM, vol. 318, no. 7, Feb. 18, 1988.)
3Keeping costs down was another benefit, but I do not remember it
being strongly emphasized in the first decade of Family Practice.
4This negative feedback of our medical system is the main subject
of Ivan Illich's 1975 book, Medical Nemesis.
1) we were getting better at the craft of
medicine, and
Copyright RAY DOWNING, M.D.Special Note: Dr. Downing may be reached via this page's e-mail links until July 1, 1997. After that time he may be reached:
c/o Friends Lugulu Hospital
PO Box 43
Webuye, Kenya.
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