A Fortunate Man: The Story of a Country Doctor

I’m a bit of a suggestible reader these days. I learned of this book from one of the comments on the PCHIT blog that I maintain. If you look at the comment and my interests (patient-physician communication, primary care, reducing disparities), it probably makes sense why this work would be of interest to me.

The book was written in 1967 as an essay about a general practice physician in the English countryside. It starts with a few vignettes about Dr. John Sassal’s interaction with patients, continues on into a description of his practice, and into the physician’s life and thoughts on the doctor’s role in society.

He decided to be a doctor when he was 15, when his image of a doctor was “a man who was all knowing but looked haggard,” who could come to your home in the middle of the night, with his pajama trousers hanging out, and still be calm and composed. Into his 20’s and then into his 30’s, his approach changed, to become less about the excitement of the emergency and more about the patient as a “total personality,” who he would work with for life.

The origin of the doctor role is discussed, as starting when medicine men were relived from food procurement duties, in exchange for the awareness of illness in the tribe. A special relationship was created with the physician role - a person (a stranger) who one would submit their body to in the hope that their malady or complaint would not seem so unique. The doctor’s role is to make the patient comparable to himself.

How does he do this?

..he is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity…It is as though when he talks or listens to a patient, he is also touching them with his hands so as to be less likely to misunderstand; and it as though, when he is physically examining a patient, they were also conversing.

He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.

Being a physician takes a greater emotional toll than is shown outwardly.

He is a man of extreme self-control. Nevertheless, when he was unaware of my presence, I saw him weep, walking across a field away from a house where a young patient was dying.

The minor complication that is not recognized by the patient as significant in their disease course is significant to the physician in their role. It causes depression in the professional whose attitude to their work becomes “obsessional.”

In all of this, there is a discussion of the value of this work. Unlike a scientific discovery, how do we measure the “easing” or even saving of thousands of lives by the country doctor? We are reluctant to do so because it would mean measuring the value of human life itself, and this is something that society is incapable of doing.

The book is interspersed with photographs of Dr. Sassal at work in “the surgery (his office)” and of the community members at work and at play. I think every physician today experiences many of the same feelings of a Dr. Sassal, as well as the same accountabilities to the communities they serve. It is useful to remember this as we engage in discussions of how we measure productivity and give people credit for being “good.”

As the comment in the PCHIT blog stated, many of us are only in the business of creating tools. We are not creating the heart of the relationship that the tools support. I think some of these concepts are ones that are personal and as such difficult for physicians to articulate in these discussions, so a work like this is useful.

And what about computers? That’s covered, too:

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.

Peter Kirk, Ingrid Kirk, and Linda J Kristjanson, “What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study,” BMJ 328, no. 7452 (June 5, 2004): 1343.

Connie Ulrich and Christine Grady, “Beneficent Deception: Whose Best Interests Are We Serving?,” The American Journal of Bioethics 4, no. 4 (2004): 76.

Since I have been writing and discussing the topic of transparency lately (specifically with regard to patient medical records), these two articles came to my attention following a discussion that occurred after my presentation at Johns Hopkins Medicine. We talked about when and how we inform patients about aspects of their care, and what the conditions might be for “beneficient deception.”

The first article, which deals with communication between care teams and patients with terminal diagnoses, talks about the importance of good communication not just at prognosis, but throughout the course of treatment. This quote caught my eye:

Many participants reported dissatisfaction with the communication process, especially at disclosure of the initial diagnosis. Six attributes were identified to be important in communicating information: playing it straight, staying the course, giving time, showing you care, making it clear, and pacing information.

We put a high price on the accuracy and compassion that should come with an initial diagnosis, clearly. In the work I am doing, it becomes more and more likely that this information may come in an asynchronous fashion, i.e. the patient may see the result at the same time, or even before their doctor does. In discussions to date, it has seemed that the focus has been on this custom - “doctor gets the information before the patient.” I think the focus instead should be on the factors cited above and our ability to “enhance decision making and keep control.” It’s not clear that the current custom absolutely supports that.

The second article is about the concept of “beneficient deception.” The context, though, is not exactly what I was thinking of, but I am citing it here anyway. It refers to the idea that a physician may adjust or misrepresent a diagnosis to ensure coverage for treatment. In the patient-physician communication world, my assumption is that it might be used to provide hope and a sense of control. I am tempted to agree with the authors of this article, that I find this hard to justify in the long term. Instead, I think about the physician leadership role in making this activity unnecessary. Our patients can guide us on the best way to be accurate and direct, and I think we will all benefit from these conversations.

Of course, your comments are welcome.

• Providence Health Care - What’s New - Providence Legacy Project, St. Paul’s Hospital, Mount Saint Joseph Hospital, St. Vincent’s Hospitals, Arbutus, Brock Fahrni Pavilion, Heather, Langara, Holy Family Hospital, Youville Residence - The project has yielded great results, with an 87 per cent drop in the time from blood collection to the time of arrival in the lab, and a 45 per cent decrease in turnaround time from blood collection to result reporting.
• Primary Care And Health System Performance: Adults’ Experiences In Five Countries — Schoen et al., 10.1377/hlthaff.w4.487 — Health Affairs - Information about access and secure e-mail use, as well as quality measures across several countries.
• How NOT to lead geeks - This is an interesting post, although I think the title is at odds with the content (this is about leading people who develop great things for society). It adds more information to the LEAN idea that people are not the problem, it’s process.
• Toyota passes Ford as No. 2 in U.S. sales - Toyota’s ability to have humility in this situation is something a healthcare organization would be envious of.
• Running a hospital: Looking back after six years at BIDMC - I liked this. Compliment: It represents Hansei in a good way. Constructive Criticism: Thinking about applying LEAN to be more direct in the communication. Overall: More people should do this.
• Your New Title: Chief Inspiration Officer - I think I want to be this. Actually I think I try to be this. And I love it.

PCHIT links for November 29th through December 4th:

• How to talk to a doctor - USATODAY.com - I wonder how much if the burden being placed on patients is necessary in the era of PCHIT?
• Delivering a new kind of care | IndyStar.com - Patient centered HIT starts with patient-centered care, from Indiana
• Benefits of Electronic Health Records Seen as Outweighing Privacy Risks - WSJ.com - Poll by WSJ/Harris: Consumers want interaction with their care providers online. Less agreement on reimbursement.

PCHIT links for November 9th through November 13th:

• JAMA: Soliciting the Patient’s Agenda: Have We Improved?, January 20, 1999, Marvel et al. 281 (3): 283 - Data often cited and here’s the source: patients redirected an average of 23 seconds while providing their history.
• The Center For Health Design Research - Pebble Project - Center for Health Design supports evidence based design of health environments. Have they done work in PHR/EHR enabled institutions?
• Life as a Healthcare CIO: Personal Health Records - John Halamka, MD, supports the idea that PHR adoption is not a technology issue. Consistent with my findings on our recent trip to Boston.
• A Model for Health Care That Pays for Quality - New York Times - NYT Reports on Patient Centered Primary Care Model promoted by ACP, IBM, and others
• E.H.R. Home - HL7 announces balloting for PHR standards