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The Distance Between Us

By Michael Sharp, MD

As some of you know, I spent many years teaching medical students at the UNC School of Medicine in Chapel Hill. There was an interesting phenomenon I observed over and over again. When the students entered school in their first year they had what I’d call patient-centered values by and large. They were sympathetic and sensitive to the feelings and needs of patients and these values didn’t need much encouragement. They were good patient advocates. Somewhere along the way there was a switch. As they became more focused on their roles and the heavy responsibilities of becoming a doctor their sympathies often migrated too. As stories would go around of patient encounters that involved some level of conflict or disagreement, they were much more likely to want to defend or justify the needs of the physician.

Michael Sharp, MD

Growing into the role of the physician is difficult. It involves learning many skills, and an almost impossibly large amount of knowledge. The risks in making mistakes are as high as they come. As a student takes on these responsibilities it is not surprising that their sympathies for the patient might wane. Sympathies lose out in favor of the importance of knowledge.

Access to Knowledge

In this landscape of the doctor-patient relationship, one upending consequence of the digital revolution is the patient’s access to knowledge. No longer is the doctor the sole owner of this domain. And I observe that this shift is not necessarily bringing balance to the interaction. On the contrary, the new access to a plethora of information on the web increases the complexity of our interactions and can raise the defensiveness of both roles. Of course, not all information is reliable and that makes things complicated. Some of my patients believe things I do not. I think I see in some of my patient relationships a tendency to hold the cards close to the chest—a “I’m not going to show you my cards (what I know) until you show me yours (what you know)” kind of dynamic. Or worse, the initial relationship negotiating may seem to center on who knows the most: “If I know more than you do, I win and call the shots.” Not so good I think. I guess this is not unexpected since, so often in the past, the physician and patient have both assumed that how much you know is the most important thing.

If the need to know more than the other can be dismissed, perhaps this new level of knowledge by each patient might introduce an element of mutuality into the equation. An equation might be created where facts are recognized as important and relevant but one where other factors take on more value; factors such as the experience of the physician, the values of the patient and a kind of mutual regard. I value your facts, values, and want to help. You value my facts, values and want to help. We are in this together—colleagues! Too much to hope for?

The Importance of Kindness

As I work on my patient relationship skills I am increasingly appreciating the importance of another aspect of what lies between us: Kindness.
I have written much in these columns over the past few years of the importance of adverse childhood experiences (ACES). We now know these are the single most important determinant of adult health. Many of my patients have had many ACEs and this can’t help but lead to issues of trust.

Having observed the difficulty of the medical student to maintain the patient’s perspective I am sensitive to this issue in my own practice and as I write this column today I am reminded about the complexity of the doctor-patient relationship. As I think back over the years of my practice I realize again how the distance between us can interfere with not only communication and understanding but also the quality of the care and the effectiveness of the outcomes. I’ve known of and observed the importance of mutual respect as an important factor in this relationship and now, as I think about the effects of trauma on my patients, I begin to realize the importance of kindness. Perhaps it is the most important element of all. It has an enormous influence on the nature of the interaction and might well, also be the most important factor in the outcome of the work that goes on between the doctor and the patient. So, here’s to kindness. Let us all embrace it as a key to our well-being.

To your health.