Friday Reflection 59: Healing Rather than Treating

TP is a 74-year-old man who presents to our Urgent Care clinic. He has just had his third episode of nausea, vomiting, and abdominal pain in the last week. The first episode led to a visit to an urgent care clinic. The second led to an eight-hour stay in an emergency room.

So often, a student, resident, or colleague will clarify my thinking about medicine. Sometimes they do it by sharing their own insights; sometimes they recommend an article, book, or podcast that helps me see something in an entirely different way.

Recently, I participated in a course for the senior medical students. The course is barely even a course. We ask students to choose an article or a book chapter. Each student then leads a discussion. In the session I attended, the articles we read were:

• Resident Report

• Doctors, Revolt!

• On Calling – From Privileged Professionals to Cogs of Capitalism

• Association Between Physician Burnout and Identification With Medicine as a Calling

All these articles deserve a read, but the one that affected me the most was Doctor’s, Revolt! It is a pretty amazing 1000 words. It was written by Rich Joseph about his experience caring for Dr. Bernard Lown. Dr. Joseph was an intern at the time, and Dr. Lown was on his service. Dr. Lown, of course, was a professor of cardiology at Harvard who developed the direct current defibrillator. He also co-founded International Physicians for the Prevention of Nuclear War.

The article is filled with pearls, and we spent a good 45 minutes in class discussing it. What came to me as a revelation (on this, possibly the tenth time I’ve read the piece) was the difference between treating patients and healing patients.

I’ve come to realize how easy it has become to treat patients without really thinking about them. There is so much algorithmic and guideline-based medicine that every specific patient problem — their chief complaint — suggests an evaluation and treatment. In an era in which medical centers advertise personalized care, this sort of medicine is impersonal and generic.

One paragraph in the article references this dichotomy, quoting Dr. Lown:

The hospital, he lamented, is more like a factory — “it tests every ache and treats every laboratory abnormality, but it does little to heal its patients.” Treating and healing are both necessary, but modern health care too often disregards the latter.

Later in the article, Joseph quotes one of Lown’s books to explain what he means by treating, rather than healing.

“Doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” body parts, Dr. Lown wrote in “The Lost Art of Healing.”

TP is a type of patient commonly seen in tertiary care centers. He has an impossibly complex medical history; just reviewing his problem list makes you feel crushed under a cognitive load. He is alive only because of the miracles of 21^st-century medicine, but his care requires an understanding of the consequences of these treatments — immunosuppression, post-surgical anatomy, and polypharmacy.

The week I saw him, TP had been treated, but not healed.

At his first visit to an urgent care, nausea/vomiting/abdominal pain called for treatment with an antiemetic.

At his emergency room visit, nausea/vomiting/abdominal pain called for labs and a CT scan. The labs were normal, and the CT revealed only gallstones. He was discharged with an appointment to see a general surgeon to discuss an elective cholecystectomy.

In our urgent care, TP was asked to describe the episodes that sent him to urgent care, to the emergency room, and now to us. As he took us through the episodes, he mentioned dizziness during the second episode. On careful questioning, it became clear that each episode had been accompanied by vertigo. The nausea and vomiting were so severe that the vertigo had been glossed over during his previous visits. On this third history, it was clear abdominal pain was not a primary symptom but the result of the vomiting — more abdominal wall soreness.

We performed the Dix-Hallpike maneuver and noted rotatory nystagmus. TP also developed severe nausea. We made a diagnosis of benign, paroxysmal, positional vertigo. After we performed the Epley maneuver, his symptoms resolved.

Three days later, TP called to cancel the appointment with the surgeon.

Treating patients sometimes gets people better. In emergencies, algorithms standardize care and allow doctors to run protocols when things are so rushed and chaotic that measured reasoning is difficult, if not impossible. Most of medicine, however, is not emergent. Most presentations do not follow serious trauma, or involve a cardiac arrest, or a visit to The Pitt. Most cases of abdominal pain don’t warrant a CT scan. Most patients need someone to, in Mandrola’s words, stop and think. To listen to the history of their present illness and their past medical history. They need someone to consider the data, determine a plan with them, and care for them. They need someone to practice medicine.

They need a doctor to heal them, not treat them.