By James Schultz

Crammed into an overflowing waiting room, the afflicted ache, sniffle, slump and otherwise suffer. When your name is called, you rise, shambling into a tiny examination room. Minutes turn into quarter and then half hours. When a doctor finally does enter, she can barely remember your name, much less the nature of your ailment. Weary, spent, you lie back, prepared for the inevitable prodding and probing.

The exam is professional and competent. But it lasts a mere 10 minutes. You are but one of dozens, perhaps a hundred, who will be seen by this physician today and there’s little time to waste on extraneous conversation. You do leave with the correct diagnosis and a prescription that will get you through this particular crisis. So why on your way home do you have the persistent feeling you’ve just been processed like an ingot in a metal factory?

It’s because you have. Like uncounted numbers of fellow convalescents, you’ve slid wholesale into the impersonal maw of the modern health care system. Brilliantly effective, technologically dazzling but largely indifferent to your feelings, late 20th century medicine is expert at physical cures but uneasy with psychology. What you think and how you feel matter less than the malfunctioning biological machine that is simply the sum of various organic parts.

At least, that has tended to be the attitude of many contemporary physicians. Now, says Stacey Plichta, assistant professor of community health professions at Old Dominion University, culture, economic pressure and burgeoning numbers of computer-literate, information-savvy consumers are conspiring to reunite the care of the body with that of the heart and soul. In response, medical schools are establishing programs to encourage compassion and empathy to augment the traditional focus on anatomy and technology.

“Consumers are much more educated. Consumers want to work as a partner,” she explains. “What physicians are challenged to do is work with patients as an equal, to move from the aloof-scientist mode back to the involved mode: someone who knows you, knows your parents and knows your kids.”

Humane Care From The Beginning

With support from the Arnold P. Gold Foundation, a public, not-for-profit organization established in 1988, Plichta is conducting studies at medical schools nationwide to determine the extent to which “humanistic” attitudes are taking hold. She has surveyed more than 6,000 students and has sent questionnaires to hundreds more. The effort is intended to quantify the willingness of young, would-be doctors to be emotionally open to those whom they will someday treat.

“There is no universal definition of humanism,” Plichta says. “I define humanism as taking into account the patient’s interests, their needs, relating to them as people. It’s viewing the patient as a whole patient, treating them with respect and empathy.”

Plichta says three primary questions are at the heart of her surveys: What are the basic attitudes of the country’s future doctors? What do students think of humanism and how should a humanistic physician behave? And how do medical school administrators view humanism?

“What we’ve found is a major problem: a lack of consensus on what makes a humanistic M.D.,” Plichta says. “While most agree that empathy is important, fewer agree that a holistic approach is important. There’s a lot of debate about emotional openness and about always being honest with a patient. Should you, for example, tell someone how long they have to live?”

Plichta’s work, and that of others in the field, could well lead to substantial changes in medical school curricula. If so, potential docs would need more than high scores on medical aptitude tests. They may need proof of humanity, in the form of interviews with members of admission panels and scores on personality tests. No longer would the best and brightest automatically make the cut.

“Patients come in sick and vulnerable,” Plichta points out. “It’s very important to keep doctors humanistic because they have so much power. Humanism keeps doctors from abusing that power.”

More Science Than Art

Medicine’s very success in treating illness and curing disease appears directly responsible for eroding empathy. Particularly in the years during and after World War II, physicians made enormous strides in treatment and care. With the widespread introduction of antibiotics, what once could have killed millions became a tolerable inconvenience. With increased understanding of physical maladies and their causes, medical practitioners were expected to be objective scientists, not emotionally engaged caregivers. Explosive technological innovation accelerated the healer-as-scientist movement.

Unlike their house-calling predecessors, doctors today are rarely rewarded financially or otherwise for lingering with those in their care. There are simply too many procedures to grasp, too much state-of-the-art equipment to master and too much information to process — not to mention the desire of patients, every one of whom expects his or her personal physician to be infallible.

“Advances in technology have been explosive. Treatment has become so much more effective,” Plichta points out. “There was and is just so much more to learn in terms of techniques and technology. So the system tends to produce a very competent but less caring physician.”

The rise of fee-for-service medicine, made possible by the government’s 1960s-era creation of and involvement in Medicare and Medicaid, provided monetary incentives to individuals to practice medicine. Not all who entered the field, Plichta says, were interested only in helping to heal the sick. A very good living was to be had; and until the spread of managed care in the 1980s, a trained physician was at the top of the self-employed earnings heap.

A Pendulum Swing?

But the pendulum may have swung too far the other way. Critics cite managed care organizations, particularly HMOs, for overreliance on cost savings and a lack of regard for human frailty. Physicians are also expressing their dismay, citing the triumph of accounting over compassionate and competent medicine. Users of the system — the patients — have also weighed in with widely publicized stories of neglect and indifference.

In an encouraging and a symbolic nod to a physician’s responsibility as a person-centered caregiver, some medical schools are beginning to conduct “white coat” ceremonies for all entering students. The ceremony is conducted as students arrive and includes lectures and first-person accounts of the need for emotionally engaged patient care. Plichta says that the intent is to impress upon students a doctor’s historical responsibility as a responsive, engaged healer.

Whether reality trumps symbolism remains to be seen. As always, economics will play a major role in the extent to which empathetic care stages a comeback. One limiting factor may be medical school debt. Physician-graduates usually end up owing money counted just south of six figures, and sometimes higher. Young doctors, even those employed for a salary, may have no choice but to increase waiting-room volumes — thereby decreasing quality and extent of time spent with patients.

Plichta believes the movement toward humanistic medicine will succeed only if both the will and the money are present to support it. Strong feeling alone will not suffice.

“We’ll see a lot more compassionate care than we have in the past,” Plichta predicts. “There’s a social movement in that direction now. But the payment mechanism will set some upper limits on the extent to which doctors spend time with patients. As a society we will get what we pay for.”