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The Art of It: For Humanity's Sake

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Vincent Valentine, MD
Univeristy of Texas Medical Branch
Galveston, TX, USA

Are we training a generation of medical students or other healthcare providers who cannot take histories? Over the last several years, a technological explosion of skillful access to electronic information, computerized studies, sophisticated devices and a wide array of biomarkers demanding our attention and analysis to make critical decisions about patient's lives have captivated our attention. The values of blood tests, lab results and interpretations of various procedures along with the electronic medical record have diverted our attention away from the patient. The older model of tending to what a patient says or tells us at the bedside or in the clinic is becoming antiquated. As we try to refine our skills to interpret the massive amounts of information in different formats through different media, the old clinical adage, "if you let the patient tell you what's wrong, they will," will be forgotten and left in the expanding abyss between technological sophistication and downright care and concern for the patient. Most of the important information about a patient's illness will come from their history. The patient must be given the opportunity to talk and above all, we must hear it, listen to it, interpret it, process it, understand it and filter all the noise that comes from this dialogue that may be slowly eroding. In essence, where talk is cheap, communication is the two-way street. It is almost never straightforward. But to hear, listen, interpret and discern their story requires practice and refinement. When medical students and other trainees in health care talk about the fine clinical skills of the master teacher, they're talking about communication which half of it is listening. Most importantly, it is active listening implying no texting, face in the monitor or typing when tending to the patient. The master is the one who still knows how to process the story being told. That's the art of it. If all we do is tend to the electronic medical record, review blood values, send patients for diagnostic exams and refer to consultants then we are merely navigators and dispatchers as we focus on the science of it. As a result, some doctors if not many of us, don't listen. In this new age of rapid pace, genomic-focused and nanotechnological medicine many of us could profit from the old-fashioned practice of listening. We are very quick to interrupt while patients describe their symptoms and ailments. It's been reported that we interrupt patients in 18 seconds. The stethoscope and the handheld ultrasound used to listen and see the bubbles, boils, toils, troubles, thumps and signs emanating from under the skin of the patient have pushed aside the world outside the skin we frequently ignore, that is the words of our patients as they attempt to explain those findings on the inside or what lies beneath.

Is this a side effect of the health care curriculum? Medical education has been governed by a bioscience paradigm brought forth by Abraham Flexner in his report from over 100 years ago in 1911. Beginning in college, we are required to study the sciences: biology, chemistry and physics. In medical school we study: anatomy, physiology, pathology, microbiology, pharmacology, physical diagnosis and specialized rotations. The success of this bioscience model and its breakthroughs cannot be ignored and have included vaccines, antibiotics, chemotherapy, the pharmaceutical explosion, immunosuppression, transplantation, mechanical circulatory devices and ECMO, just to name a few. The progress with cystic fibrosis from World War II to today is a phenomenal marvel of medicine in and of itself. Today's society with its focus on healthcare and healthcare costs thrusted upon us is unfortunate as we must be attuned to the economic sense of what lies beneath. Science has helped us with heart disease, cancer and many of the infectious diseases of the past, but have we really figured all of this out? Tuberculosis was on the path of elimination, it thrives today. New dilemmas have emerged. The threat of longevity, terror of Alzheimer's and the prospect of decades of slow and relentless progressive conditions including our organ recipients and those who exist on new devices do have social, familial and moral implications. We are dealing with these predicaments - there are very few bridges between scientific knowledge and humanistic knowledge. Very few trainees in health care today have carefully studied both the humanities and the sciences.

A little reflection on this shows that we have all experienced pain, directly and indirectly; emotionally and physically. We have seen pain in other people. Many of us if not all of us are afraid of dying. In the ISHLT, we have some acquaintance with death. But we have not witnessed anyone who has died to come back to tell us what death is like. Science and the bioscience paradigm is obviously not enough. We must tend to our patients and their humanity. Focusing on the science is just a part of it. Without tending to the patient's "heart of the matter," soul or their humanity, then we may be shallow and superficial bordering on not really caring for the patient. Turning to art and the humanities beyond the science of it can allow us to explore pain, suffering, disease and death. Our patients live with disease, experience pain and will eventually die. All the science in the world cannot prevent death, suffering and for that matter, pain. Studying the arts, especially literature, the humanities, including fiction, listening to music and watching plays and movies will allow us to gain a deeper understanding and illuminate our understanding of death, suffering and pain. This will show our patients that we care because we will be able to communicate better and listen to their problems by experiences we gain not only by listening to them but through the arts of it all that we cannot otherwise understand, especially when it comes to suffering and death. This will give us a deeper sense of sickness, pain, suffering, death and caring. It is our intention over the course of the next series of issues for volume 8 of the ISHLT Links to delve into the world of the patient with their pain, suffering and death through art, mostly literature to add depth to our understanding of suffering and death. As a result, we just might gain a broader view of our patients' pain, suffering and death. It's not just knowing what we know by what kills people according to modern medicine. Modern medicine interestingly is cadaver-based or death-derived if you will. From whence we understand disease, cancer and infections. Literature, on the other hand, can help us understand how people live and help us better communicate with our patients to sort out what makes people live, not merely prognosticate or determine when our patients will die or the factors that may contribute to their death. This added dimension will help us see the issues of pain, suffering and death and how these issues might actually outpace the limits of science. Focusing on literary works about death and suffering can expand our perspective and nearly all facets of life including history, culture, politics, race, class, gender and as my friend Mary Chrisant will share with us, the importance and implications of religion on the art of pain, suffering and death. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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