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THE SEASONS OF THE PATIENT-PHYSICIAN RELATIONSHIP
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THE SEASONS OF THE PATIENTPHYSICIAN RELATIONSHIP Rita Charon, MD, PhD
All patient-physician relationships-their climates, methods, and goals-change over time. The patient grows up: the neonate becomes a toddler; the first-grader becomes an adolescent; the middle-aged adult becomes an elder. Medical attention, as a matter of course, accommodates to such biologic and social changes in individual patients’ lives. Immunizations give way to attention to home safety; school readiness gives way to preparation for fertility; prevention of heart disease gives way to the prevention of falls. The older patient’s relationship with his or her doctor proceeds through stages as well. The young-old patient presents medical and social issues that differ from those of the old-old or the oldest-old. For example, gynecologic screening strategies or advance directive guidelines differ for the 60-year-old woman and the 90-yearold woman. That which makes sense in terms of biology, epidemiology, cost-effectiveness, and ethics changes as the older patient ages. The doctor, too, grows up: the exhilaration and terror of internship give way to the confidence and heroism of the full stride of one’s profession, which in turn may give way to the resignation and modesty that can mark the older physician’s practice. Older doctors have been found to know more than do younger physicians about their patients’ relational difficulties7and to be less ageist with older patients,l and are hypothesized to be more understanding of their older patients because of their shared life experience.8The young internist just out of residency training, newly challenged by each clinical combination, may relate to a patient and his or her illness with a manner and set of goals different ~
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From the Department of Medicine and the Program in Humanities and Medicine, College of Physicians and Surgeons of Columbia University, New York, New York
CLINICS IN GERIATRIC MEDICINE
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VOLUME 16 * NUMBER 1 FEBRUARY 2000
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from those of the aging internist who gazes, in the middle distance just beyond the patient, at retirement. The young doctor might feel obliged to display his or her new powers (if only the powers to memorize the lists and master the drills), either for the sake of the science itself or to demonstrate that technical competence has been achieved. The older doctor, conversely, might have become accustomed to improvisation or to watchful waiting. In part as a result of life experience and in part as a result of having witnessed countless illnesses and countless deaths, the aging doctor might have scaled back his or her expectations of medicine’s power and might have developed a corresponding respect for the power of sickness and the power of time.
RESEARCH IN THE DEVELOPING CLINICAL RELATIONSHIP
The companion variables to the age of the physician are the longevity and the evolution of the doctor-patient relationship. Considerable literature supports the common-sense notion that long attendance with a physician is valuable3,lo*11, 14; however, longevity is not always a predictor for depth of physicians’ knowledge of their patients’ predicamentsZ1More important, perhaps, than the duration of the therapeutic alliance is its evolution and quality: How has the relationship grown? Has it stalled or deepened? Do its participants continue to surprise one another? Does it accrue worth for doctor and patient as time goes by? Here, too, little research has been accomplished, in part because of the methodologic challenge of studying doctor-patient relationships over the years and decades in which they evolve. Most research on the doctor-patient relationship is performed crosssectionally, capturing interactive dimensions of a doctor-patient relationship at one point in time without reference to that which preceded it.2,l5 Such methods have illuminated in considerable detail the ways in which doctors and patients talk to one another, establish agendas for their visits, handle disagreements, convey emotion, and perform their clinical work. Questions about the evolution of the effective or ineffective relationship, however, cannot be addressed through snapshot methods. Recent conceptual and qualitative work suggests some of the characteristics of the sustained partnership between doctor and patient and the possible stages through which such relationships move.6,l3 This developing area of research posits the importance not only of length of attendance but also of such elements as a focus on the whole person, physician’s knowledge of the patient’s personal history, empathy, trust, and shared decision-making. Two reported studies have collected longitudinal data on doctor-patient relationships over time, audiotaping doctor and patient at every interview over a period of l or 1.5 years (Michele Greene, DrPH, and Ronald Adelman, MD, unpublished manuscript, 1998).18 Both these studies fail to show smooth or incremental development of
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such dimensions as patient-centeredness or supportiveness, suggesting instead a rather chaotic and highly unpredictable path on which these doctor-patient pairs travel. Rather than dismissing hypotheses about the evolution of trust, empathy, or patient-centeredness (or their opposites-suspicion, hostility, or boredom), these preliminary studies suggest that whatever occurs between a doctor and a patient over a period of years or decades is not a graphable gradual process but, instead, is a series of wide swings from sudden intimacy to dull detachment, each relationship as particular and singular as the lives of its participants. Such preliminary research suggests two principles in studying the development of the doctor-patient relationship: that each relationship must be studied on its own rather than as typical of or generalizable to other relationships, and that the temporal frame within which to inspect these developmental events is probably marked in decades and not months or years. If chronologic or developmental models for the evolution of the patient-physician relationship have failed to guide productive research, perhaps investigators need to adopt nonlinear narrative frameworks for examining these living processes. Because so little is known about the development of the doctorpatient relationship, I have started to ask other internists to reflect with me about patients they have cared for over long periods of time and about ways in which they find themselves changing as physicians as they age. A physician in his 35th postgraduate year (PGY) writes, "I think I'm much more understanding and have a better perspective on what is possible and makes sense. I've had more life experience. I'm much more interested in [my patients] as people." A PGY 30, in describing a man who for the second time in his life has all but risen from the dead, says that he has grown to know what his patients want and to tailor care based on this intimate knowledge of what they have chosen through the years. In describing an older patient with multiple medical problems who has been under her care for 10 years, a PGY 11 writes, "I am now able to focus more on her emotional needs and worry less about her lab tests. At some point, I realized she did not expect me to cure her of her pain (or diabetes mellitus [DM] or hypertension [HTN]). I think I have changed as a person and this has changed me as a doctor." A PGY 20 writes, "[I have become] more patient, hopefully a better listener. I have a better idea of what death and dying are. I can see/understand what patients mean when they refer to themselves as parents, now that I myself am a parent." A PGY 8 writes, "I have come to see medicine more through the eyes of the patient than the eyes of the profession." These few comments from a pilot study support the realization that the therapeutic relationship is, at heart, an intersubjective undertaking; that is, a relation between two human beings, two selves. Doctors and patients undergo a great deal at one another's hands: patients go through acute crises, recoveries, or chronic disabilities while doctors go through diagnostic uncertainties, clinical mistakes, occasional victories, and therapeutic defeats. In it for the long haul, doctors (at least the
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generalists among us) and their patients routinely have relationships that last 30 or 40 years, outlasting many other nonfamilial relationships in their lives. They live through one anothers’ joys and losses, the doctor accompanying the patient through diseases and recoveries and the patient accompanying the doctor through the large stages-marriage, parenthood, and the like-in his or her life. (I remember a woman internist in her late 30s saying, ”When my father died, it was my patients who saw me through it.”) They age together, doctor and patient, slowly weaving between them at times a tapestry of complex narrative richness.
THE NEWS ONE GETS FROM POEMS
Framing the doctor-patient interaction within a context of intimate human relationships rather than within a context of technical interchange provides a deep and rich tradition of knowledge and experience as background and inspiration. While dwelling on the seasons of my relationships with patients over almost 20 years, I have found my sources of clarity and insight in ordinary human understanding of personal relations rather than in scientific or technical research. That is, to understand what my patients and I have been through, I have tried to surmount the difficulty described by physician and poet William Carlos Williams:20 It is difficult to get the news from poems yet men die miserably every day for lack of what is found there.
The news I get from the Journal of the American Medical Association-or even Social Science and Medicine-is not sufficient to the complex work of understanding the human relationships on which healing depends. As a prologue to probing the seasons of a few of my own clinical relationships with patients in detail, let me reproduce and briefly comment on three poems that reflect some of the contradictory truths we know and feel about the passage of time. These three poems will help illuminate a few aspects of the seasons of the geriatric patient /physician relationship. The poem ”October Light” by Charles Simic expresses the unfolding of continuous seasons of lives and of relationships; it connotes the ways in which memory can color and refract present-day reality, bringing to life that which may already have retired into the past.I6 Set in the autumn, looking backward, tinged with regret and loss, this poem helps to remind doctors of the lived experience shared with patients, the intense attachments that can form over long stretches of sunlight and darkness, and the inevitable losses that must be endured.
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OCTOBER LIGHT That same light by which I saw her last Made me close my eyes now in reverie, Remembering how she sat in the garden With a red shawl over her shoulders And a small book in her lap, Once in a long while looking up With the day‘s brightness on her face, As to appraise something of utmost seriousness She has just read at least twice, With the sky clear and open to view, Because the leaves had already fallen And lay still around her two feet.
The poem occurs in the instant during which the light, in the speaker’s present-day October, reminds him or her of a woman last seen in a garden. The visual image-specific, highly detailed, filled with meaningful particulars (a red shawl, a small book, the bareness of the trees>-consorts with the deep universal fount of loss, for the action of memory (which is what the poem is ”about”) connotes, by definition, loss. As the speaker remembers, seemingly in a flash, the image of someone in a cool outdoors, reading and thinking while facing the sun and reflecting its light, the reader (you who are reading this article in the Clinics in Geriutric Medicine!), by virtue of the strength of the poem, similarly might enter a reverie or at least the affective state of memory and realization of time’s losses. Although the speaker does not say if the person recollected is now dead or far away, the tone of the poemits autumnal setting, the recently fallen leaves, the mournful last line-suggest an elegy, a requiem. In the minute or so it takes to read the words of the poem, the reader absorbs, as if by intravenous bolus, very complex intimations about the speaker and the woman in the poem, about change, and about one’s own experience with the passage of time. Although this poem is not specifically about medicine or doctors or illness, it concerns the experiences doctors and patients have together. It marks the stratum within lives that recognizes, responds to, regrets, rages against, or simply regards the course of time, the evanescence of the present, the pressure (or the blessing) of the future to incur, and the temporary nature of all our gifts and maybe of all our pain. The clinical realizations that this poem endows on its reader are that human events and emotions are banked in time, accrue meaning sedimentally, and take on significance at the intersection between one person’s authentic life and another’s. The next poem, ”The Snow Man” by Wallace Stevens, offers a contradictory view, true nonetheless, of the seasons of human knowing.I7 Instead of Simic’s gradually unfolding October, Stevens presents a glit-
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tering and arrested January-unconnected to that which comes before it or after it, experienced not as part of a sequence but rather literally ”frozen” in time. THE SNOW MAN
One must have a mind of winter To regard the frost and the boughs Of the pinetrees crusted with snow; And have been cold a long time To behold the junipers shagged with ice, The spruces rough in the distant glitter Of the January sun; and not to think Of any misery in the sound of the wind, In the sound of a few leaves, Which is the sound of the land Full of the same wind That is blowing in the same bare place For the listener, who listens in the snow, And, nothing himself, beholds Nothing that is not there and the nothing that is.
Stevens’s listener / snowman/ poet beholds that which is present in the snow. Not projecting onto the scene something that is not there, the listener is able to absorb the truth of the moment without coloring it with his or her own ascription. This state of blank attentiveness and empty openness to that which lays outside the self is achieved by becoming the scene: by having a mind of winter and by having been cold a long time, the snowman can regard and behold, on the one hand, and then can not think of any misery in the sound of the wind. Compared to Simic’s evolutionary seasonal transformation, Stevens’s grasp of time is an unchanging, epiphanic realization of only that which is present-now-in the beheld. Instead of being revised by memory and accessed through reverie, this view of the real appears whole, selfcontained, untrammelled by any observer, untouched by any experience other than its own. The epiphanic visitation of understanding-that which leads to the ”Aha!”-is not unknown to doctors. We arrive at diagnoses as if through inspiration; we suddenly ”get” an understanding of a patient or of our response to a patient. In the Same way that poems can be experienced as if administered intravenously, so too can a doctor’s appreciation of a patient’s meaning be apprehended by the sudden and simultaneous absorption of the patient’s body words, findings, gestures, and silence^.^,^ Not sequential and not tainted by memory or past experience (of either the patient or the doctor), this form of knowledge adds a fresh dimension to what is learned in time. If time can be experienced both sequentially and epiphanically, it also can be experienced cyclically. Going nowhere, cyclic time defies the positivist urges in doctors and patients for progress, for resolution. (The
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paper on which one writes in the hospital chart is ordinarily stamped ”Progress Notes” or ”Continuation Sheets,” implying that the accounts recorded on its pages document movement, that the events will ”get” us somewhere.) Instead, events of illness are often antiprogressive: they stagnate, they repeat, they recur, they relapse. Only the inexperienced doctor expects diseases to get better; only the newly stricken patient expects the disease to ever leave him or her alone. The phenomenologists of illness have taught us that, because one does not have a body but rather one is one’s body, one’s experience of illness is inseparable from one’s experience of oneself, and so is lived with rather than lived through and beyond.I9 T. S. Eliot’s “Burnt Norton,” the first section of Four Quartets, presents the inevitable stillness present in time even as it passes, even as we age.5 At the still point of the turning world. Neither flesh nor fleshless; Neither from nor towards; at the still point, there the dance is. But neither arrest nor movement. And do not call it fixity, Where past and future are gathered. Neither movement from nor towards, Neither ascent nor decline. Except for the point, the still point, There would be no dance, and there is only the dance.
Sickness emphasizes the stillnesses in our lives. When one absorbs the fact that one has a serious illness, one inhabits one’s life without its blocks and corners and deadlines and prospects. Neither Stevens’s arrest nor Simic’s movement, Elliot’s still point may be the mode of authentic medicine. Beyond the interventions and the triumphs and the failures, trying to get well and attending to sickness can bring us, patients and doctors, to the core of meaning within our lives. Although not often glimpsed, and when seen not often recognized (for so many words and actions impede our line of sight), the stillness of meaning is present when patients look full in the face at their losses, when doctors bear witness to their patients’ sufferings, and when patients and doctors together behold the possible, the inevitable, and the things that can be done to heal. The news found in these three poems helps me understand the seasons of several of my relationships with patients. I chose three patients to present here who have been in my practice for 12 to 18 years, who have baffled me, enlightened me, brought me challenges to and confirmations of competence, and in whom I feel a great investment. (I have changed all names, recognizable circumstances, and identifying information to protect the patients’ confidentiality.) Their care does not revolve around dramatic events, and their diseases and medical care are all rather routine. What drew me to reflect on them and to inspect their medical records was my sense that our alliance had meant something to us both in our work together. I reviewed their hospital and office charts with the following questions in mind: What, in retrospect, have I seen this patient through? What has this patient taught me, brought me through, revealed to me over time? What stages has our relationship
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passed through, and what kind of work has o u r alliance been able to perform at each stage? Provisional answers to such questions about particular clinical relationships might help me to ruminate on more general questions about the geriatric patient-physician relationship: How does a doctor grow to understand what is important for a patient? How does a patient come to trust a physician’s loyalty and competence? What d o doctor and patient d o together that deepens their commitment to one another? And, to turn instrumental, is there a relation between commitment and effectiveness of care? Mrs. Pauline Walton
Mrs. Pauline Walton first came to the hospital in 1966 with right foot pain. (Even then, in the mid-l960s, she was described in the chart as ”married Negro woman” and she, herself, chose the word ”Negro” with which to specify her race.) During the 1960s and 1970s, she came sporadically to the hospital for the care of several seemingly unrelated injuries (a fractured leg, an acute wrist injury, unexplained dizziness), chronic back pain, hypertension, and obesity. In 1988, she chose me to be her internist on her sister’s recommendation, and for the first time in twenty years, there were consecutive notes in her chart written in the same handwriting. I can see by my early notes that, at first, I found the patient hostile and baffling. She had many complaints about medications and their cost, about diagnostic procedures like mammograms and pelvic examinations, and about the low-fat diet I had recommended. With vast anger condensed into her 4’11” frame, she would sit in my office depleting it of good will, extracting joy from the atmosphere until we were suffocating together in blame and outrage. I can remember how she would sit in the office chair, erect, hatted head chin up, vault-like handbag on lap, ample bosom an imposing barrier, snapping out derisive judgments about us all. No daughter was grateful enough, no sister kind enough, no son-in-law successful enough to meet her standards. I wondered what she said about me to others. By listening to her angry outbursts about her family members, I came to fathom her explosive pain, although I did not know its source. Initially, we moved on parallel tracks as I hounded her about her weight and cholesterol and she refused simple things like influenza shots and nutrition counseling out of suspicion and pessimism. Luckily, she was patient with me, and by a year into our relationship, I was hearing things about her father’s illness, her money troubles, and her sapping pain. I characterized her in the chart as being on a pilgrimage to get relief from pain, the imagery signaling to me now that I had turned a corner toward engagement, that I had entered imaginatively into her world. What had seemed like random anger was falling into hstorical and familial place, gradually making sense to me. I moved through her life, able, with her help, to see it from its beginning, and so the present began to be transparent. I tried for Simic’s sequentiality, his tying of present to past, his ability to recognize the unfolding of living in relation. Of course, what came with sequential knowledge was the knowledge that we, too, were part of an unfolding relation. We were engaged on a journey, as I joined her on her pilgrimage. Through a series of medical problems-gastrointestinal bleed, hypercholesterolemia, glaucoma, the persistent weight above 220 pounds, and a failed
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attempt to have an umbilical hernia repaired (the surgeons would not do it unless she lost some weight, and she would not)-she was loyal in her visits to me. I would be confused sometimes about why she came to her appointments: she would have stopped her medications, missed the visits to the consultants, lost the nutritionist’s guide to fat-free cooking, and yet she would keep the quarter-annual visit. What punctuated the visits and even the chart notes (previously filled with calorie counts and LDLs) was talk about her complex family relations with her only daughter Annette, her father, and her sisters. Annette married a man Mrs. Walton disliked. The wedding itself was an ordeal for Mrs. Walton. In retrospect, I see that the change in her family constellation occasioned by her daughter’s marriage brought up disclosures about her own family. She told me, and I wrote cryptically in the chart, that her husband had betrayed her in love many years ago and that she had had to leave him. When a sister threatened to move into her apartment or when her daughter and her new husband had to temporarily share her home, she became inflamed, savage in her blame, and physically more symptomatic. I was impressed with her anger, the scope of it, its ominous range. Maybe I was a little frightened of her myself. And then she made a choice to abandon her anger: she detached herself from her daughter, she did not permit her son-in-law to provoke her. I watched her choose to live for herself, to empty herself of the rage, and to once again feel some pleasure. She lost some weight, she stopped smoking cigarettes, did without chocolates, resumed her solitary hobbies (television soap operas, keeping house), and felt gratitude for simple luck. I watched this change with wonder. I realized that a person could choose such a transformation, and I felt freer by her example. Over the years, her back pain improved somewhat, her joints hurt only intermittently, and she recently was able to lose significant amounts of weight. She has alternated between seething anger and calm acceptance. The more power she has mobilized in her own life, the more pleasure she has found in it. She grew to be able to talk about her rage and to describe herself as both “mean” and depressed, allowing me to treat her depression with some success. By meeting me at relatively short intervals for talk, she showed me her introspection, her deep view of her own past. Only recently did I learn the details of her marriage and the meanings of her only pregnancy. The story was prompted by her announcing, with unbounded pleasure, that Annette was pregnant for the first time. Until she was 42 years old, Mrs. Walton had not been pregnant and did not miss motherhood. And yet, Annette’s birth brought her and her husband profound joy. The baby quickly became her father’s “sweetie pie,” and for some time after her birth, Pauline’s husband’s abusive drunken spells seemed to stop. The spells resumed some years later, however, with my patient bearing the brunt of his violence (and in retrospect perhaps explaining all those early injures). After her husband broke her left eye-socket and nearly cost her her eye, Pauline threw him out of the home. About a year or two later, her husband called Pauline to ask if she would have him over for dinner. He told her what he would like to eat-ham, potato salad, collard greens. The family of three had a sweet dinner together, and 2 days later, on a Monday, Pauline‘s husband walked onto the Bruckner Expressway at 8:OO am, dying instantly in the inevitable crash. I could imagine, with epiphanic specificity, the three of them sitting down to that dinner recollected in such detail; I could imagine the shock of identifying the body at the morgue; I could wonder about the sequelae: would it be grief, loss, a sense of delayed justice,
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indifference? Although I expected (and even for a while imagined) Mrs. Walton to be looking back with sadness at her reawakened thoughts of her husband's horrible death, she was, in fact, quite finished with him and with his memory. She harbored no sentimentality at all toward her marriage or her husband's death. I had to mobilize the way of knowing of the Snow Man, desisting from projection, refusing to hear misery in the wind. I had to position myself in her landscape (now having had over a decade of visits to it), to regard what I saw there, and to behold nothing that was not there. The seasons that we experienced were the initial hostile stand-off, the provisional widening of the content of our conversation to include the patient's family concerns and disappointments, a concurrent development of my sense of growing interpretive ability, and a recent stage of deep recollection of painful content that lends intimacy to the relationship. These seasons do not follow one another in an orderly fashion. Instead, chronic spells of hostility or sameness find themselves suddenly interrupted by epiphanic moments that deepen the relationship. As the doctor/reader of Mrs. Walton's present, I have to suspend notions of a final interpretation, allowing her own gradual and irregular revelations of the past to make sense of the present. And in view of her recollected past, both mourned and scorned, I can join all the more authentically in her present joy and triumph. Mrs. Ruby Nelson
Another patient, Mrs. Ruby Nelson, illuminates the power of the epiphanic to break through a chronic misrepresentation. This 82-year-old obese, diabetic, hypertensive woman with osteoarthritis has been in my practice for around 15 years. I had "inherited her from a departing colleague, and I did not feel early on that I had a comprehensive grasp of her problems or her treatment. Our early years together were marked by disagreement over silly things: she insisted on brand name medicines, even when generics were just as good, and I bristled at the extra work and cost. She, too, never took seriously the need to address her obesity. Consequently, her diabetes was ill-controlled and her degenerative knee disease disabling. One morning, as she sat on the examining table waiting for me to take her blood pressure (which was invariably alarmingly high and triggered in me anxiety, fear of reprisal, great impatience, and the felt duty to scold), she mentioned that she sang in the church choir. I do not know why, but I asked her to sing me a hymn. This woman, whose body habitus I routinely described as "morbidly obese," was transfigured into a form of stateliness and dignity as she raised her heavy head, clasped her hands, and sang in a deep dark alto about the Lord, on the banks of the river, bringing her home. From then on, I would do anything for her and she for me. A moment of epiphany indeed, those few bars of mournful powerful song transported us into a new geography of respect and value together. The change in my appreciation of Mrs. Nelson brought about by this transfiguration was sudden, extraordinary, and lasting. I experienced a vertiginous change in orientation toward her, as if we had both been spun about in the universe and then let back gently down to Earth. Instead of feeling confronted with a difficult patient whom I felt I did not know well, I valued the time I spent with her as if with a friend. Instead of ascribing her solemn demeanor to sullen withdrawal (as I had been doing), I reinterpreted her solemnity as dignified power. Her adamant insistence on continuing her treatment in exactly the same way as she had with her prior physician struck me no longer
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as a dismissal of my own competence and a longing for the old doctor, but as a fierce commitment to be as well as she possibly could be. I detail this change in order to underline the power of epiphanic moments, to suggest that a physician’s entire stance vis-8-vis a patient is brought about by deep and mysterious processes of interpretation, and to describe the benefits achievable through the simple act of putting one’s feelings toward a patient into words. Since then, Mrs. Nelson has developed symptomatic cerebrovascular disease, requiring multiple hospitalizations to stave off strokes. She has remained for me, throughout her many weeks in the hospital, a figure of great dignity and spirituality. Despite the recommendations of the social workers and visiting nurses to move her to a skilled care facility, I backed her deep desire to return to her own apartment, knowing, now, something about the power of her passion. The extra telephone calls and paperwork required of me to maintain her extensive home care felt not like a chore but like a gift I wanted to give. She is now back home, anticoagulated, her blood pressure effectively controlled, TIAs for the time being absent. She continues to ask me to do her little special favors in the office, and I am always grateful that she asks.
Mrs. Nellie Trent Mrs. Nellie Trent is a rare case of prolonged uncertainty and cyclic disease. Now 96 years old, Mrs. Trent had an undiagnosed illness for at least 20 years. Early in our relationship, I discovered an iron-deficient anemia and hemepositive stool that, as a newly trained internist, I knew how to evaluate. After a rigorous work-up, however, with endoscopy, colonoscopy, abdominal ultrasounds, liver imaging and in consultation with a gastroenterologist I trusted, no source of the bleeding was documented. We had reached a fork in our diagnostic path: the next intervention would have been to do an angiogram in search of an arterio-venous malformation or ectasia (abnormalities of the blood vessels that can cause chronic and difficult to visualize bleeding), and then to surgically remove the part of the intestine involved. Mrs. Trent firmly refused to consider surgery at her age (then in her early ~ O S ) and , so no further diagnostic testing was done. I remember how attached I became to this slim, quick, independent woman invariably described by physicians as “appearing younger than stated age.” In her early 20s, she had left her friends and family in California to care for an ailing mother, devoting her life to this task. When I ran seminars for medical students on interviewing skills, Mrs. Trent was happy to spend an afternoon talking with small groups of students. My own knowledge of her was enriched by that which she said to the students and that they wrote for me. I grew to respect her faith, her decisiveness, her generosity and gratitude toward physicians for the care we gave her. An odd scribbled note in the margin of one of my chart notes from 10 years ago that reads, ”What would we do without the Father helping our doctors?” is a clue to the mutuality of our tonic relationship. Consequently, I accepted her authority in saying ”no surgery,” and found ways to manage her illness within her own perimeters of care. For almost 20 years, I would hospitalize Mrs. Trent when her hematocrit dropped low enough to cause her symptoms. (A nurse’s note from 9 years ago describing her as ”stable, quiet, pale, and anemic” oddly captures her presence.) Eventually, a repeat endoscopy visualized pinkish punctate areas in the second part of the duodenum which may, in fact, have been the offending arteriovenous malformations. What impressed me on reviewing this long medical
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record was the cyclic sameness of hospitalization after hospitalization, new house staff seeming to copy old admission notes of their colleagues from five or six years ago. The questions were always the same: angiogram? surgical consult? and, as a marker of the times, competence? surrogate? Notes from 1989 are nearly identical to notes from 1999: the name and telephone number of her neighbor, the litany of iron tests, the little graphs detailing the rise and fall of the hemoglobin. The only thngs that change are the outward manifestations of the hospital: lately we can transfuse out-patients, so the number of hospitalizations has decreased; endoscopy reports of this decade are accompanied by still frames of the video record, illustrating the patient’s chart with color pictures of her own anatomy. Mrs. Trent’s own hstory acts as a homuncular instance of our medical practice in general. Eliot‘s fixity rules the dance, his still point embodied in the life of this changeless, ageless woman. Because of Mrs. Trent‘s strength and decisiveness, her doctors respected her wishes and allowed a medical management with little movement, little jar. That she has endured-in the same apartment, attending the same church (“The largest colored church in NY,” she had said), on the same medicines, with the same deep beliefs-has been a still point for my own practice. Every 3 months, unless a hematocrit of 18 intervenes, I see Mrs. Trent, and I repeat the same note I have written for decades. I have learned not to add new medications, not to do more than is acutely necessary. Because I realized that I ought not chase definitive repair, I have been schooled in a tempo of living with a disease and set of symptoms, curbing my internist’s desire to fix what is broken and learning the wisdom not of progress but of acceptance. My review of Mrs. Trent‘s chart allowed me to relive my own uncertainties and early uneasiness with tempered care. Of course, in retrospect, no one can argue with our management: the patient continues to live with her A-V malformations without experiencing the catastrophic sequelae that we all feared. In retrospect, her decisions were good and prudent ones. She charted her course, and we all were attentive enough to listen to her directions. By now, Mrs. Trent has become somewhat cognitively impaired. She still lives alone in the apartment that she used to share with her mother, and she still does her own shopping and regularly attends church and events at her social club. Her neighbor and friend looks in on her every day. When, in 1991, she chose her health care proxy, we spoke about her beliefs and wishes regarding heroic medical care in the face of futility, and I recall being impressed with her matter-of-factness and her balance of hope and realism. More and more frequently, we openly reflect on our longevity and our mutual trust and friendship. The last time Mrs. Trent was sitting in my office, her neighbor with her, I said to the patient, ”We’re just two old hens.” We all laughed, and the neighbor added softly, ”Three old hens.”
SUMMARY AND FUTURE DIRECTIONS
This exercise of carefully reviewing the course of medical relationships suggests some future directions for research into the patientphysician relationship. I have been moved by the evident-ven captured in so bureaucratic a text as a hospital chart-of deep human relations over long periods of time with patients. The actual review of these charts and the task of writing an account of what was found there
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brought me through an affective and factual retrospect. These three patients-still in my practice and sure to become sicker as they age-will benefit from the light cast on their past and on the trajectory of our clinical journey together. These three patients will benefit from my investment of reflection, assessment, and interpretation, because I now bring to their care new hypotheses to be tested, fresh insights to be probed, and many questions to be posed about the past, present, and future. In addition, perhaps, to our ongoing attempts to dissect the patientphysician relationship with our quantitative and semiqualitative methods of interaction analysis and survey instruments, we can allow ourselves the privacy and the brilliance of ruminating about one relationship at a time, recognizing what is singular to each patient and to each doctor as called forth by their particular relationship. In addition to our models of transactions and evolution, let us allow for the frameworks of the epiphanic, the cyclic, and that found only in reverie. As Henry James writes in the preface to Roderick Hudson, ”Really, universally, relations stop nowhere.”12No matter where the clinical relationship starts, the journey through time embarked on by a doctor and a patient stops nowhere, not even at death. Let us do our work in full view of all that it entails, all that it connotes, all that it can give. References 1. Adelman RD, Greene MG, Charon R, et al: Issues in the physician-geriatric patient relationship. In Giles H, Coupland NM, Wiemann JM (eds): Communication, Health and the Elderly. London, Manchester University Press, 1990, p 126 2. Beckman HB, Carter WB, Connor EM, et al: Research on the medical interview. In Lipkin M, Putnam SM, Lazare A (eds): The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995, p 473 3. Cartwright A Patients and Their Doctors: A Study of General Practice. London, Routledge and Kegan-Paul, 1967 4. Connelly J: Being in the present moment: Developing the capacity for mindfulness in medicine. Acad Med 74:420424, 1999 5. Eliot T S Four Quartets. London, Faber and Faber, 1959, p 15 6. Gore J, Ogden J: Developing, validating and consolidating the doctor-patient relationship: The patients’ views of a dynamic process. British J Gen Pract 48:1391, 1998 7. Gulbrandsen P, Hjortdahl P, Fugelli P: General practitioners’ knowledge of their patients’ psychosocial problems: Multipractice questionnaire survey. BMJ 314:1014, 1997 8. Huag MR Elements in physician/patient interactions in late life. Res Aging 18:32,1996 9. Hawkins AH: Literature, medicine, and ”epiphanic knowledge.” J Clin Ethics 5283, 1994 10. Hornung CA, Massagli M: Primary care physicians’ affective orientation toward their patients. J Health SOCBehav 20:61, 1979 11. Hull F M How well does the general practitioner know his patients? Practitioner 208:688, 1972 12. James H: Preface. In Roderick Hudson. The Novels and Tales of Henry James: The New York Edition, vol 1. New York, Charles Scribner and Sons, 1907, p vii 13. Leopold N, Cooper J, Clancy C: Sustained partnerships in primary care. J Fam Pract 42129, 1996 14. Marks JN, Goldberg DP, Hillier F: Determinants of the ability of general practitioners to detect psychiatric illness. Psycho1 Med 9:3376, 1979
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15. Roter DL, Hall JA: Doctors Talking with Patients; Patients Talking with Doctors: Improving Communication in Medical Visits. Westport, CT, Auburn House, 1992 16. Simic C: October Light. The New Yorker, October 24, 1994, p 66 17. Stevens W. The Snow Man. In Poems. New York, VintageiRandom House, 1959, p 23 18. Stewart MA. Patient-doctor relationships over time. In Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA, Sage Publications, 1995, p 216 19. Toombs SK: The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht, The Netherlands, Kluwer, 1993 20. Williams WC: Asphodel, That Greeny Flower. In Pictures from Brueghel and Other Poems. New York, New Directions, 1962, p 161 21. Yaffe MJ, Stewart MA: Factors influencing doctors’ awareness of the life problems of middle-aged patients. Med Care 23:1276, 1985
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THE SEASONS OF THE PATIENTPHYSICIAN RELATIONSHIP Rita Charon, MD, PhD
All patient-physician relationships-their climates, methods, and goals-change over time. The patient grows up: the neonate becomes a toddler; the first-grader becomes an adolescent; the middle-aged adult becomes an elder. Medical attention, as a matter of course, accommodates to such biologic and social changes in individual patients’ lives. Immunizations give way to attention to home safety; school readiness gives way to preparation for fertility; prevention of heart disease gives way to the prevention of falls. The older patient’s relationship with his or her doctor proceeds through stages as well. The young-old patient presents medical and social issues that differ from those of the old-old or the oldest-old. For example, gynecologic screening strategies or advance directive guidelines differ for the 60-year-old woman and the 90-yearold woman. That which makes sense in terms of biology, epidemiology, cost-effectiveness, and ethics changes as the older patient ages. The doctor, too, grows up: the exhilaration and terror of internship give way to the confidence and heroism of the full stride of one’s profession, which in turn may give way to the resignation and modesty that can mark the older physician’s practice. Older doctors have been found to know more than do younger physicians about their patients’ relational difficulties7and to be less ageist with older patients,l and are hypothesized to be more understanding of their older patients because of their shared life experience.8The young internist just out of residency training, newly challenged by each clinical combination, may relate to a patient and his or her illness with a manner and set of goals different ~
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From the Department of Medicine and the Program in Humanities and Medicine, College of Physicians and Surgeons of Columbia University, New York, New York
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from those of the aging internist who gazes, in the middle distance just beyond the patient, at retirement. The young doctor might feel obliged to display his or her new powers (if only the powers to memorize the lists and master the drills), either for the sake of the science itself or to demonstrate that technical competence has been achieved. The older doctor, conversely, might have become accustomed to improvisation or to watchful waiting. In part as a result of life experience and in part as a result of having witnessed countless illnesses and countless deaths, the aging doctor might have scaled back his or her expectations of medicine’s power and might have developed a corresponding respect for the power of sickness and the power of time.
RESEARCH IN THE DEVELOPING CLINICAL RELATIONSHIP
The companion variables to the age of the physician are the longevity and the evolution of the doctor-patient relationship. Considerable literature supports the common-sense notion that long attendance with a physician is valuable3,lo*11, 14; however, longevity is not always a predictor for depth of physicians’ knowledge of their patients’ predicamentsZ1More important, perhaps, than the duration of the therapeutic alliance is its evolution and quality: How has the relationship grown? Has it stalled or deepened? Do its participants continue to surprise one another? Does it accrue worth for doctor and patient as time goes by? Here, too, little research has been accomplished, in part because of the methodologic challenge of studying doctor-patient relationships over the years and decades in which they evolve. Most research on the doctor-patient relationship is performed crosssectionally, capturing interactive dimensions of a doctor-patient relationship at one point in time without reference to that which preceded it.2,l5 Such methods have illuminated in considerable detail the ways in which doctors and patients talk to one another, establish agendas for their visits, handle disagreements, convey emotion, and perform their clinical work. Questions about the evolution of the effective or ineffective relationship, however, cannot be addressed through snapshot methods. Recent conceptual and qualitative work suggests some of the characteristics of the sustained partnership between doctor and patient and the possible stages through which such relationships move.6,l3 This developing area of research posits the importance not only of length of attendance but also of such elements as a focus on the whole person, physician’s knowledge of the patient’s personal history, empathy, trust, and shared decision-making. Two reported studies have collected longitudinal data on doctor-patient relationships over time, audiotaping doctor and patient at every interview over a period of l or 1.5 years (Michele Greene, DrPH, and Ronald Adelman, MD, unpublished manuscript, 1998).18 Both these studies fail to show smooth or incremental development of
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such dimensions as patient-centeredness or supportiveness, suggesting instead a rather chaotic and highly unpredictable path on which these doctor-patient pairs travel. Rather than dismissing hypotheses about the evolution of trust, empathy, or patient-centeredness (or their opposites-suspicion, hostility, or boredom), these preliminary studies suggest that whatever occurs between a doctor and a patient over a period of years or decades is not a graphable gradual process but, instead, is a series of wide swings from sudden intimacy to dull detachment, each relationship as particular and singular as the lives of its participants. Such preliminary research suggests two principles in studying the development of the doctor-patient relationship: that each relationship must be studied on its own rather than as typical of or generalizable to other relationships, and that the temporal frame within which to inspect these developmental events is probably marked in decades and not months or years. If chronologic or developmental models for the evolution of the patient-physician relationship have failed to guide productive research, perhaps investigators need to adopt nonlinear narrative frameworks for examining these living processes. Because so little is known about the development of the doctorpatient relationship, I have started to ask other internists to reflect with me about patients they have cared for over long periods of time and about ways in which they find themselves changing as physicians as they age. A physician in his 35th postgraduate year (PGY) writes, "I think I'm much more understanding and have a better perspective on what is possible and makes sense. I've had more life experience. I'm much more interested in [my patients] as people." A PGY 30, in describing a man who for the second time in his life has all but risen from the dead, says that he has grown to know what his patients want and to tailor care based on this intimate knowledge of what they have chosen through the years. In describing an older patient with multiple medical problems who has been under her care for 10 years, a PGY 11 writes, "I am now able to focus more on her emotional needs and worry less about her lab tests. At some point, I realized she did not expect me to cure her of her pain (or diabetes mellitus [DM] or hypertension [HTN]). I think I have changed as a person and this has changed me as a doctor." A PGY 20 writes, "[I have become] more patient, hopefully a better listener. I have a better idea of what death and dying are. I can see/understand what patients mean when they refer to themselves as parents, now that I myself am a parent." A PGY 8 writes, "I have come to see medicine more through the eyes of the patient than the eyes of the profession." These few comments from a pilot study support the realization that the therapeutic relationship is, at heart, an intersubjective undertaking; that is, a relation between two human beings, two selves. Doctors and patients undergo a great deal at one another's hands: patients go through acute crises, recoveries, or chronic disabilities while doctors go through diagnostic uncertainties, clinical mistakes, occasional victories, and therapeutic defeats. In it for the long haul, doctors (at least the
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generalists among us) and their patients routinely have relationships that last 30 or 40 years, outlasting many other nonfamilial relationships in their lives. They live through one anothers’ joys and losses, the doctor accompanying the patient through diseases and recoveries and the patient accompanying the doctor through the large stages-marriage, parenthood, and the like-in his or her life. (I remember a woman internist in her late 30s saying, ”When my father died, it was my patients who saw me through it.”) They age together, doctor and patient, slowly weaving between them at times a tapestry of complex narrative richness.
THE NEWS ONE GETS FROM POEMS
Framing the doctor-patient interaction within a context of intimate human relationships rather than within a context of technical interchange provides a deep and rich tradition of knowledge and experience as background and inspiration. While dwelling on the seasons of my relationships with patients over almost 20 years, I have found my sources of clarity and insight in ordinary human understanding of personal relations rather than in scientific or technical research. That is, to understand what my patients and I have been through, I have tried to surmount the difficulty described by physician and poet William Carlos Williams:20 It is difficult to get the news from poems yet men die miserably every day for lack of what is found there.
The news I get from the Journal of the American Medical Association-or even Social Science and Medicine-is not sufficient to the complex work of understanding the human relationships on which healing depends. As a prologue to probing the seasons of a few of my own clinical relationships with patients in detail, let me reproduce and briefly comment on three poems that reflect some of the contradictory truths we know and feel about the passage of time. These three poems will help illuminate a few aspects of the seasons of the geriatric patient /physician relationship. The poem ”October Light” by Charles Simic expresses the unfolding of continuous seasons of lives and of relationships; it connotes the ways in which memory can color and refract present-day reality, bringing to life that which may already have retired into the past.I6 Set in the autumn, looking backward, tinged with regret and loss, this poem helps to remind doctors of the lived experience shared with patients, the intense attachments that can form over long stretches of sunlight and darkness, and the inevitable losses that must be endured.
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OCTOBER LIGHT That same light by which I saw her last Made me close my eyes now in reverie, Remembering how she sat in the garden With a red shawl over her shoulders And a small book in her lap, Once in a long while looking up With the day‘s brightness on her face, As to appraise something of utmost seriousness She has just read at least twice, With the sky clear and open to view, Because the leaves had already fallen And lay still around her two feet.
The poem occurs in the instant during which the light, in the speaker’s present-day October, reminds him or her of a woman last seen in a garden. The visual image-specific, highly detailed, filled with meaningful particulars (a red shawl, a small book, the bareness of the trees>-consorts with the deep universal fount of loss, for the action of memory (which is what the poem is ”about”) connotes, by definition, loss. As the speaker remembers, seemingly in a flash, the image of someone in a cool outdoors, reading and thinking while facing the sun and reflecting its light, the reader (you who are reading this article in the Clinics in Geriutric Medicine!), by virtue of the strength of the poem, similarly might enter a reverie or at least the affective state of memory and realization of time’s losses. Although the speaker does not say if the person recollected is now dead or far away, the tone of the poemits autumnal setting, the recently fallen leaves, the mournful last line-suggest an elegy, a requiem. In the minute or so it takes to read the words of the poem, the reader absorbs, as if by intravenous bolus, very complex intimations about the speaker and the woman in the poem, about change, and about one’s own experience with the passage of time. Although this poem is not specifically about medicine or doctors or illness, it concerns the experiences doctors and patients have together. It marks the stratum within lives that recognizes, responds to, regrets, rages against, or simply regards the course of time, the evanescence of the present, the pressure (or the blessing) of the future to incur, and the temporary nature of all our gifts and maybe of all our pain. The clinical realizations that this poem endows on its reader are that human events and emotions are banked in time, accrue meaning sedimentally, and take on significance at the intersection between one person’s authentic life and another’s. The next poem, ”The Snow Man” by Wallace Stevens, offers a contradictory view, true nonetheless, of the seasons of human knowing.I7 Instead of Simic’s gradually unfolding October, Stevens presents a glit-
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tering and arrested January-unconnected to that which comes before it or after it, experienced not as part of a sequence but rather literally ”frozen” in time. THE SNOW MAN
One must have a mind of winter To regard the frost and the boughs Of the pinetrees crusted with snow; And have been cold a long time To behold the junipers shagged with ice, The spruces rough in the distant glitter Of the January sun; and not to think Of any misery in the sound of the wind, In the sound of a few leaves, Which is the sound of the land Full of the same wind That is blowing in the same bare place For the listener, who listens in the snow, And, nothing himself, beholds Nothing that is not there and the nothing that is.
Stevens’s listener / snowman/ poet beholds that which is present in the snow. Not projecting onto the scene something that is not there, the listener is able to absorb the truth of the moment without coloring it with his or her own ascription. This state of blank attentiveness and empty openness to that which lays outside the self is achieved by becoming the scene: by having a mind of winter and by having been cold a long time, the snowman can regard and behold, on the one hand, and then can not think of any misery in the sound of the wind. Compared to Simic’s evolutionary seasonal transformation, Stevens’s grasp of time is an unchanging, epiphanic realization of only that which is present-now-in the beheld. Instead of being revised by memory and accessed through reverie, this view of the real appears whole, selfcontained, untrammelled by any observer, untouched by any experience other than its own. The epiphanic visitation of understanding-that which leads to the ”Aha!”-is not unknown to doctors. We arrive at diagnoses as if through inspiration; we suddenly ”get” an understanding of a patient or of our response to a patient. In the Same way that poems can be experienced as if administered intravenously, so too can a doctor’s appreciation of a patient’s meaning be apprehended by the sudden and simultaneous absorption of the patient’s body words, findings, gestures, and silence^.^,^ Not sequential and not tainted by memory or past experience (of either the patient or the doctor), this form of knowledge adds a fresh dimension to what is learned in time. If time can be experienced both sequentially and epiphanically, it also can be experienced cyclically. Going nowhere, cyclic time defies the positivist urges in doctors and patients for progress, for resolution. (The
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paper on which one writes in the hospital chart is ordinarily stamped ”Progress Notes” or ”Continuation Sheets,” implying that the accounts recorded on its pages document movement, that the events will ”get” us somewhere.) Instead, events of illness are often antiprogressive: they stagnate, they repeat, they recur, they relapse. Only the inexperienced doctor expects diseases to get better; only the newly stricken patient expects the disease to ever leave him or her alone. The phenomenologists of illness have taught us that, because one does not have a body but rather one is one’s body, one’s experience of illness is inseparable from one’s experience of oneself, and so is lived with rather than lived through and beyond.I9 T. S. Eliot’s “Burnt Norton,” the first section of Four Quartets, presents the inevitable stillness present in time even as it passes, even as we age.5 At the still point of the turning world. Neither flesh nor fleshless; Neither from nor towards; at the still point, there the dance is. But neither arrest nor movement. And do not call it fixity, Where past and future are gathered. Neither movement from nor towards, Neither ascent nor decline. Except for the point, the still point, There would be no dance, and there is only the dance.
Sickness emphasizes the stillnesses in our lives. When one absorbs the fact that one has a serious illness, one inhabits one’s life without its blocks and corners and deadlines and prospects. Neither Stevens’s arrest nor Simic’s movement, Elliot’s still point may be the mode of authentic medicine. Beyond the interventions and the triumphs and the failures, trying to get well and attending to sickness can bring us, patients and doctors, to the core of meaning within our lives. Although not often glimpsed, and when seen not often recognized (for so many words and actions impede our line of sight), the stillness of meaning is present when patients look full in the face at their losses, when doctors bear witness to their patients’ sufferings, and when patients and doctors together behold the possible, the inevitable, and the things that can be done to heal. The news found in these three poems helps me understand the seasons of several of my relationships with patients. I chose three patients to present here who have been in my practice for 12 to 18 years, who have baffled me, enlightened me, brought me challenges to and confirmations of competence, and in whom I feel a great investment. (I have changed all names, recognizable circumstances, and identifying information to protect the patients’ confidentiality.) Their care does not revolve around dramatic events, and their diseases and medical care are all rather routine. What drew me to reflect on them and to inspect their medical records was my sense that our alliance had meant something to us both in our work together. I reviewed their hospital and office charts with the following questions in mind: What, in retrospect, have I seen this patient through? What has this patient taught me, brought me through, revealed to me over time? What stages has our relationship
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passed through, and what kind of work has o u r alliance been able to perform at each stage? Provisional answers to such questions about particular clinical relationships might help me to ruminate on more general questions about the geriatric patient-physician relationship: How does a doctor grow to understand what is important for a patient? How does a patient come to trust a physician’s loyalty and competence? What d o doctor and patient d o together that deepens their commitment to one another? And, to turn instrumental, is there a relation between commitment and effectiveness of care? Mrs. Pauline Walton
Mrs. Pauline Walton first came to the hospital in 1966 with right foot pain. (Even then, in the mid-l960s, she was described in the chart as ”married Negro woman” and she, herself, chose the word ”Negro” with which to specify her race.) During the 1960s and 1970s, she came sporadically to the hospital for the care of several seemingly unrelated injuries (a fractured leg, an acute wrist injury, unexplained dizziness), chronic back pain, hypertension, and obesity. In 1988, she chose me to be her internist on her sister’s recommendation, and for the first time in twenty years, there were consecutive notes in her chart written in the same handwriting. I can see by my early notes that, at first, I found the patient hostile and baffling. She had many complaints about medications and their cost, about diagnostic procedures like mammograms and pelvic examinations, and about the low-fat diet I had recommended. With vast anger condensed into her 4’11” frame, she would sit in my office depleting it of good will, extracting joy from the atmosphere until we were suffocating together in blame and outrage. I can remember how she would sit in the office chair, erect, hatted head chin up, vault-like handbag on lap, ample bosom an imposing barrier, snapping out derisive judgments about us all. No daughter was grateful enough, no sister kind enough, no son-in-law successful enough to meet her standards. I wondered what she said about me to others. By listening to her angry outbursts about her family members, I came to fathom her explosive pain, although I did not know its source. Initially, we moved on parallel tracks as I hounded her about her weight and cholesterol and she refused simple things like influenza shots and nutrition counseling out of suspicion and pessimism. Luckily, she was patient with me, and by a year into our relationship, I was hearing things about her father’s illness, her money troubles, and her sapping pain. I characterized her in the chart as being on a pilgrimage to get relief from pain, the imagery signaling to me now that I had turned a corner toward engagement, that I had entered imaginatively into her world. What had seemed like random anger was falling into hstorical and familial place, gradually making sense to me. I moved through her life, able, with her help, to see it from its beginning, and so the present began to be transparent. I tried for Simic’s sequentiality, his tying of present to past, his ability to recognize the unfolding of living in relation. Of course, what came with sequential knowledge was the knowledge that we, too, were part of an unfolding relation. We were engaged on a journey, as I joined her on her pilgrimage. Through a series of medical problems-gastrointestinal bleed, hypercholesterolemia, glaucoma, the persistent weight above 220 pounds, and a failed
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attempt to have an umbilical hernia repaired (the surgeons would not do it unless she lost some weight, and she would not)-she was loyal in her visits to me. I would be confused sometimes about why she came to her appointments: she would have stopped her medications, missed the visits to the consultants, lost the nutritionist’s guide to fat-free cooking, and yet she would keep the quarter-annual visit. What punctuated the visits and even the chart notes (previously filled with calorie counts and LDLs) was talk about her complex family relations with her only daughter Annette, her father, and her sisters. Annette married a man Mrs. Walton disliked. The wedding itself was an ordeal for Mrs. Walton. In retrospect, I see that the change in her family constellation occasioned by her daughter’s marriage brought up disclosures about her own family. She told me, and I wrote cryptically in the chart, that her husband had betrayed her in love many years ago and that she had had to leave him. When a sister threatened to move into her apartment or when her daughter and her new husband had to temporarily share her home, she became inflamed, savage in her blame, and physically more symptomatic. I was impressed with her anger, the scope of it, its ominous range. Maybe I was a little frightened of her myself. And then she made a choice to abandon her anger: she detached herself from her daughter, she did not permit her son-in-law to provoke her. I watched her choose to live for herself, to empty herself of the rage, and to once again feel some pleasure. She lost some weight, she stopped smoking cigarettes, did without chocolates, resumed her solitary hobbies (television soap operas, keeping house), and felt gratitude for simple luck. I watched this change with wonder. I realized that a person could choose such a transformation, and I felt freer by her example. Over the years, her back pain improved somewhat, her joints hurt only intermittently, and she recently was able to lose significant amounts of weight. She has alternated between seething anger and calm acceptance. The more power she has mobilized in her own life, the more pleasure she has found in it. She grew to be able to talk about her rage and to describe herself as both “mean” and depressed, allowing me to treat her depression with some success. By meeting me at relatively short intervals for talk, she showed me her introspection, her deep view of her own past. Only recently did I learn the details of her marriage and the meanings of her only pregnancy. The story was prompted by her announcing, with unbounded pleasure, that Annette was pregnant for the first time. Until she was 42 years old, Mrs. Walton had not been pregnant and did not miss motherhood. And yet, Annette’s birth brought her and her husband profound joy. The baby quickly became her father’s “sweetie pie,” and for some time after her birth, Pauline’s husband’s abusive drunken spells seemed to stop. The spells resumed some years later, however, with my patient bearing the brunt of his violence (and in retrospect perhaps explaining all those early injures). After her husband broke her left eye-socket and nearly cost her her eye, Pauline threw him out of the home. About a year or two later, her husband called Pauline to ask if she would have him over for dinner. He told her what he would like to eat-ham, potato salad, collard greens. The family of three had a sweet dinner together, and 2 days later, on a Monday, Pauline‘s husband walked onto the Bruckner Expressway at 8:OO am, dying instantly in the inevitable crash. I could imagine, with epiphanic specificity, the three of them sitting down to that dinner recollected in such detail; I could imagine the shock of identifying the body at the morgue; I could wonder about the sequelae: would it be grief, loss, a sense of delayed justice,
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indifference? Although I expected (and even for a while imagined) Mrs. Walton to be looking back with sadness at her reawakened thoughts of her husband's horrible death, she was, in fact, quite finished with him and with his memory. She harbored no sentimentality at all toward her marriage or her husband's death. I had to mobilize the way of knowing of the Snow Man, desisting from projection, refusing to hear misery in the wind. I had to position myself in her landscape (now having had over a decade of visits to it), to regard what I saw there, and to behold nothing that was not there. The seasons that we experienced were the initial hostile stand-off, the provisional widening of the content of our conversation to include the patient's family concerns and disappointments, a concurrent development of my sense of growing interpretive ability, and a recent stage of deep recollection of painful content that lends intimacy to the relationship. These seasons do not follow one another in an orderly fashion. Instead, chronic spells of hostility or sameness find themselves suddenly interrupted by epiphanic moments that deepen the relationship. As the doctor/reader of Mrs. Walton's present, I have to suspend notions of a final interpretation, allowing her own gradual and irregular revelations of the past to make sense of the present. And in view of her recollected past, both mourned and scorned, I can join all the more authentically in her present joy and triumph. Mrs. Ruby Nelson
Another patient, Mrs. Ruby Nelson, illuminates the power of the epiphanic to break through a chronic misrepresentation. This 82-year-old obese, diabetic, hypertensive woman with osteoarthritis has been in my practice for around 15 years. I had "inherited her from a departing colleague, and I did not feel early on that I had a comprehensive grasp of her problems or her treatment. Our early years together were marked by disagreement over silly things: she insisted on brand name medicines, even when generics were just as good, and I bristled at the extra work and cost. She, too, never took seriously the need to address her obesity. Consequently, her diabetes was ill-controlled and her degenerative knee disease disabling. One morning, as she sat on the examining table waiting for me to take her blood pressure (which was invariably alarmingly high and triggered in me anxiety, fear of reprisal, great impatience, and the felt duty to scold), she mentioned that she sang in the church choir. I do not know why, but I asked her to sing me a hymn. This woman, whose body habitus I routinely described as "morbidly obese," was transfigured into a form of stateliness and dignity as she raised her heavy head, clasped her hands, and sang in a deep dark alto about the Lord, on the banks of the river, bringing her home. From then on, I would do anything for her and she for me. A moment of epiphany indeed, those few bars of mournful powerful song transported us into a new geography of respect and value together. The change in my appreciation of Mrs. Nelson brought about by this transfiguration was sudden, extraordinary, and lasting. I experienced a vertiginous change in orientation toward her, as if we had both been spun about in the universe and then let back gently down to Earth. Instead of feeling confronted with a difficult patient whom I felt I did not know well, I valued the time I spent with her as if with a friend. Instead of ascribing her solemn demeanor to sullen withdrawal (as I had been doing), I reinterpreted her solemnity as dignified power. Her adamant insistence on continuing her treatment in exactly the same way as she had with her prior physician struck me no longer
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as a dismissal of my own competence and a longing for the old doctor, but as a fierce commitment to be as well as she possibly could be. I detail this change in order to underline the power of epiphanic moments, to suggest that a physician’s entire stance vis-8-vis a patient is brought about by deep and mysterious processes of interpretation, and to describe the benefits achievable through the simple act of putting one’s feelings toward a patient into words. Since then, Mrs. Nelson has developed symptomatic cerebrovascular disease, requiring multiple hospitalizations to stave off strokes. She has remained for me, throughout her many weeks in the hospital, a figure of great dignity and spirituality. Despite the recommendations of the social workers and visiting nurses to move her to a skilled care facility, I backed her deep desire to return to her own apartment, knowing, now, something about the power of her passion. The extra telephone calls and paperwork required of me to maintain her extensive home care felt not like a chore but like a gift I wanted to give. She is now back home, anticoagulated, her blood pressure effectively controlled, TIAs for the time being absent. She continues to ask me to do her little special favors in the office, and I am always grateful that she asks.
Mrs. Nellie Trent Mrs. Nellie Trent is a rare case of prolonged uncertainty and cyclic disease. Now 96 years old, Mrs. Trent had an undiagnosed illness for at least 20 years. Early in our relationship, I discovered an iron-deficient anemia and hemepositive stool that, as a newly trained internist, I knew how to evaluate. After a rigorous work-up, however, with endoscopy, colonoscopy, abdominal ultrasounds, liver imaging and in consultation with a gastroenterologist I trusted, no source of the bleeding was documented. We had reached a fork in our diagnostic path: the next intervention would have been to do an angiogram in search of an arterio-venous malformation or ectasia (abnormalities of the blood vessels that can cause chronic and difficult to visualize bleeding), and then to surgically remove the part of the intestine involved. Mrs. Trent firmly refused to consider surgery at her age (then in her early ~ O S ) and , so no further diagnostic testing was done. I remember how attached I became to this slim, quick, independent woman invariably described by physicians as “appearing younger than stated age.” In her early 20s, she had left her friends and family in California to care for an ailing mother, devoting her life to this task. When I ran seminars for medical students on interviewing skills, Mrs. Trent was happy to spend an afternoon talking with small groups of students. My own knowledge of her was enriched by that which she said to the students and that they wrote for me. I grew to respect her faith, her decisiveness, her generosity and gratitude toward physicians for the care we gave her. An odd scribbled note in the margin of one of my chart notes from 10 years ago that reads, ”What would we do without the Father helping our doctors?” is a clue to the mutuality of our tonic relationship. Consequently, I accepted her authority in saying ”no surgery,” and found ways to manage her illness within her own perimeters of care. For almost 20 years, I would hospitalize Mrs. Trent when her hematocrit dropped low enough to cause her symptoms. (A nurse’s note from 9 years ago describing her as ”stable, quiet, pale, and anemic” oddly captures her presence.) Eventually, a repeat endoscopy visualized pinkish punctate areas in the second part of the duodenum which may, in fact, have been the offending arteriovenous malformations. What impressed me on reviewing this long medical
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record was the cyclic sameness of hospitalization after hospitalization, new house staff seeming to copy old admission notes of their colleagues from five or six years ago. The questions were always the same: angiogram? surgical consult? and, as a marker of the times, competence? surrogate? Notes from 1989 are nearly identical to notes from 1999: the name and telephone number of her neighbor, the litany of iron tests, the little graphs detailing the rise and fall of the hemoglobin. The only thngs that change are the outward manifestations of the hospital: lately we can transfuse out-patients, so the number of hospitalizations has decreased; endoscopy reports of this decade are accompanied by still frames of the video record, illustrating the patient’s chart with color pictures of her own anatomy. Mrs. Trent’s own hstory acts as a homuncular instance of our medical practice in general. Eliot‘s fixity rules the dance, his still point embodied in the life of this changeless, ageless woman. Because of Mrs. Trent‘s strength and decisiveness, her doctors respected her wishes and allowed a medical management with little movement, little jar. That she has endured-in the same apartment, attending the same church (“The largest colored church in NY,” she had said), on the same medicines, with the same deep beliefs-has been a still point for my own practice. Every 3 months, unless a hematocrit of 18 intervenes, I see Mrs. Trent, and I repeat the same note I have written for decades. I have learned not to add new medications, not to do more than is acutely necessary. Because I realized that I ought not chase definitive repair, I have been schooled in a tempo of living with a disease and set of symptoms, curbing my internist’s desire to fix what is broken and learning the wisdom not of progress but of acceptance. My review of Mrs. Trent‘s chart allowed me to relive my own uncertainties and early uneasiness with tempered care. Of course, in retrospect, no one can argue with our management: the patient continues to live with her A-V malformations without experiencing the catastrophic sequelae that we all feared. In retrospect, her decisions were good and prudent ones. She charted her course, and we all were attentive enough to listen to her directions. By now, Mrs. Trent has become somewhat cognitively impaired. She still lives alone in the apartment that she used to share with her mother, and she still does her own shopping and regularly attends church and events at her social club. Her neighbor and friend looks in on her every day. When, in 1991, she chose her health care proxy, we spoke about her beliefs and wishes regarding heroic medical care in the face of futility, and I recall being impressed with her matter-of-factness and her balance of hope and realism. More and more frequently, we openly reflect on our longevity and our mutual trust and friendship. The last time Mrs. Trent was sitting in my office, her neighbor with her, I said to the patient, ”We’re just two old hens.” We all laughed, and the neighbor added softly, ”Three old hens.”
SUMMARY AND FUTURE DIRECTIONS
This exercise of carefully reviewing the course of medical relationships suggests some future directions for research into the patientphysician relationship. I have been moved by the evident-ven captured in so bureaucratic a text as a hospital chart-of deep human relations over long periods of time with patients. The actual review of these charts and the task of writing an account of what was found there
THE SEASONS OF THE PATIENT-PHYSICIAN RELATIONSHIP
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brought me through an affective and factual retrospect. These three patients-still in my practice and sure to become sicker as they age-will benefit from the light cast on their past and on the trajectory of our clinical journey together. These three patients will benefit from my investment of reflection, assessment, and interpretation, because I now bring to their care new hypotheses to be tested, fresh insights to be probed, and many questions to be posed about the past, present, and future. In addition, perhaps, to our ongoing attempts to dissect the patientphysician relationship with our quantitative and semiqualitative methods of interaction analysis and survey instruments, we can allow ourselves the privacy and the brilliance of ruminating about one relationship at a time, recognizing what is singular to each patient and to each doctor as called forth by their particular relationship. In addition to our models of transactions and evolution, let us allow for the frameworks of the epiphanic, the cyclic, and that found only in reverie. As Henry James writes in the preface to Roderick Hudson, ”Really, universally, relations stop nowhere.”12No matter where the clinical relationship starts, the journey through time embarked on by a doctor and a patient stops nowhere, not even at death. Let us do our work in full view of all that it entails, all that it connotes, all that it can give. References 1. Adelman RD, Greene MG, Charon R, et al: Issues in the physician-geriatric patient relationship. In Giles H, Coupland NM, Wiemann JM (eds): Communication, Health and the Elderly. London, Manchester University Press, 1990, p 126 2. Beckman HB, Carter WB, Connor EM, et al: Research on the medical interview. In Lipkin M, Putnam SM, Lazare A (eds): The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995, p 473 3. Cartwright A Patients and Their Doctors: A Study of General Practice. London, Routledge and Kegan-Paul, 1967 4. Connelly J: Being in the present moment: Developing the capacity for mindfulness in medicine. Acad Med 74:420424, 1999 5. Eliot T S Four Quartets. London, Faber and Faber, 1959, p 15 6. Gore J, Ogden J: Developing, validating and consolidating the doctor-patient relationship: The patients’ views of a dynamic process. British J Gen Pract 48:1391, 1998 7. Gulbrandsen P, Hjortdahl P, Fugelli P: General practitioners’ knowledge of their patients’ psychosocial problems: Multipractice questionnaire survey. BMJ 314:1014, 1997 8. Huag MR Elements in physician/patient interactions in late life. Res Aging 18:32,1996 9. Hawkins AH: Literature, medicine, and ”epiphanic knowledge.” J Clin Ethics 5283, 1994 10. Hornung CA, Massagli M: Primary care physicians’ affective orientation toward their patients. J Health SOCBehav 20:61, 1979 11. Hull F M How well does the general practitioner know his patients? Practitioner 208:688, 1972 12. James H: Preface. In Roderick Hudson. The Novels and Tales of Henry James: The New York Edition, vol 1. New York, Charles Scribner and Sons, 1907, p vii 13. Leopold N, Cooper J, Clancy C: Sustained partnerships in primary care. J Fam Pract 42129, 1996 14. Marks JN, Goldberg DP, Hillier F: Determinants of the ability of general practitioners to detect psychiatric illness. Psycho1 Med 9:3376, 1979
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15. Roter DL, Hall JA: Doctors Talking with Patients; Patients Talking with Doctors: Improving Communication in Medical Visits. Westport, CT, Auburn House, 1992 16. Simic C: October Light. The New Yorker, October 24, 1994, p 66 17. Stevens W. The Snow Man. In Poems. New York, VintageiRandom House, 1959, p 23 18. Stewart MA. Patient-doctor relationships over time. In Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA, Sage Publications, 1995, p 216 19. Toombs SK: The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht, The Netherlands, Kluwer, 1993 20. Williams WC: Asphodel, That Greeny Flower. In Pictures from Brueghel and Other Poems. New York, New Directions, 1962, p 161 21. Yaffe MJ, Stewart MA: Factors influencing doctors’ awareness of the life problems of middle-aged patients. Med Care 23:1276, 1985
Address reprint requests to Rita Charon, MD, PhD College of Physicians and Surgeons of Columbia University Division of General Medicine PH 9-East, Room 105 630 West 168th Street New York, NY 10032