It Helps to Treat Patients Like Patients

The first weekend in June last year, when my Substack was still fairly new, I posted an essay from my book IN PRACTICE titled When the Doctor is the Treatment. It touches on what we are still only scratching the surface of - how and why a physician’s demeanor and choice of words can make a very big difference in the clinical response patients have to the medications we prescribe for them.

The right kind of quiet authority, empathy and optimism can make a mediocre medication work well, but a hesitant, detached and noncommittal recommendation can make the same medication ineffective in the eyes of the patient. Eric Cassell tells the story of a physician with severe asthma who got curbside advice and prescriptions from a colleague with no effect on his disease. A second doctor treated him as a patient instead of a colleague and within months, his asthma was under control.

“The difference, I believe, was that the second physician made him become a patient. Once that happened, the new doctor was able to begin “pulling strings” inside his doctor-patient’s body. No one knows how this comes about or how the physician is able to have an influence on the patient’s illness apart from explicit medical or surgical treatments, but this is the process involved. Current research is increasingly revealing the influence of thinking on immunity and other body functions, so there should be little surprise that doctors are also able to affect the patient’s physiological process. No one doubts that doctors have an influence on their patients’ mental processes – we are of a piece, and affecting one part alters the whole.”

I don’t know to what extent this is a teachable skill, but mantling the role and responsibility of the physician doesn’t seem to be a priority in medicine today. If anything, there seems to be this more or less unspoken dogma that a provider is a provider is a provider and we are all interchangeable.

I am in no way suggesting that we should be authoritarian. But I do think we must speak with the authority of knowing what we know. I don’t suggest we put ourselves above our patients. I am careful to position myself at eye level and to find common ground about something that comes up in our conversation. And if I have an angry patient I sometimes even position myself lower than them, for example by sitting on the step to the exam table and speaking more softly than I otherwise would.

I have written many times about the apostolic nature of our profession and I also think most people would make a distinction between their respect for what a judge says in a courtroom or a minister says from the pulpit and what they say off topic in their personal life - opining beyond your expertise is a phenomenon called ultracrepidarianism. When we stick to what we were trained and hired to do, we have the authority of the office we hold, so to speak. And for some people, if we don’t act quite like they expect a physician to act, our advice may not have the full or necessary impact.