Comfort in Touch

Several thoughts dawned on me when I came across this statement: “In addition to the medicines administered to alleviate symptoms, it is important to remember the comfort that is provided by holding the patient’s hand, continuing regular examinations, and taking time to talk.” [Harrison’s Principles of Internal Medicine]

We all know that touch heals, that massage soothes the body and the spirit. This is why facilities that offer spa and massage are so popular these days.  Multinational firms espouse touch therapy as seen in tv ads.  The Johnson & Johnson tv ad shows that touch enhances the ties between the mother and her child....

Building rapport and establishing trust with the patient leads to openness, definitive health care and improved health outcomes.  During my medical clerkship in a private hospital, we were made to rotate in one of the government hospitals for our OB-Gyne exposure and training.  One of my fond memories from that rotation was about the gracious young woman whom I was tasked to put an intravenous (iv) line. She was experiencing labor pain at that time.  Careful not to add to her pain (since I was told by experienced women that labor/ delivery pain is the most excruciating pain that a human can ever experience), I was able to gently insert the line on my first attempt.  I touched her hand and applied light pressure and tried to distract the patient by conversing with her.  I was taken aback when after the procedure, the soon-to-be mom graciously thanked me and told me  that she felt no pain at all and that my hands were gentle and light.  The patient was kind enough to thank me for what I did.  The simple, spontaneous and kind gesture of the patient was a great boost to my self-confidence in performing venipuncture. The experience was not traumatic for the would-be-doctor.  At the time when she was in terrible pain, she said that charming ‘thank you’ and reassured me that it was okay with her.  This experience taught me that a patient can also reassure his/her own doctor and free him/her from worries coming from inadequacies.  But then it also made me wonder why she said it.  Was she simply being kind?  Or was it because previously she was not treated as gently that for her the difference was noticeable?  How are patients under the social service/ “charity” service being treated?  Will she be treated differently if she were a pay patient?  I hate the label “charity” and find it discriminating. It connotes that the patient is at the mercy of the institution that subsidizes her treatment/ procedure.

The Doctor As A Friend

In the beautiful poem prepared by Biomedis Oncology entitled, “Life Has Changed Since I Learned That I Have Cancer”, the cancer patient realizes that the doctor can be his friend.  In cancer treatment a  warm and open relationship with the physician is a must since the patient will be needing strength and “friendship” to go through tough times.  Cancer management is chronic and very stressful not just for the patient but also for the patient’s family and even for the physician himself.  In full, the aforementioned poem goes:

Life has become better because I have learned that faith can get me through pain and suffering

I have learned to look at my weakness and aim for perfection

I have learned to be strong and fight my own battle

I have learned to value the presence of my family and friends

I have learned that my doctor can be my friend  [emphasis mine]

I have learned that people care for me

I have learned that I have so much to share with others

I have learned that I have so many reasons to be happy

In spite of cancer, I have learned that LIFE CAN BE BETTER.

Doctors are often told to emphatize but cautioned to sympathize with a patient so as not to be weighed down by the patient’s burdens. Doctors are advised to keep a certain distance from his patients to maintain professionalism.  But sometimes it is difficult to abide this suggestion. 

One of the memorable patients I had during my residency training was the cancer patient who was admitted for chemotherapy session.  He was different because he was alone and appeared lonely, aloof and slightly unkempt. Cancer patients usually come for treatment accompanied by family members and friends for moral support.  I didn’t know what issues he had with his family but I think they should have been there for him at that time.  Feeling sorry for him, I would stay slightly longer in his room during my morning rounds to engage him in small talk.  I think he appreciated it and so he warmed up to me. The following month I was transferred to a different unit/ ward for another rotation.  One morning, I was informed by a nurse who also knew the patient, that he was readmitted for several days already and that he was critically ill.  I visited him in his room and was saddened at the sight:  he was intubated and appeared almost lifeless.  I said hi and prayed for him. He could have heard me because hearing is usually the last sense to go. That same day  before noon time he passed away.  I had a heavy heart that day because I lost a  patient and a friend.  His family surrounded him during his last few days.  But they could have been there for him much earlier when he could see them, talk with them and hear them better.   Had my friend waited for my last morning visit prior to going back to His creator?

            Wouldn’t it be nice if the doctor could share a laugh with his patient?  As the cliché goes:  “Laughter is the best medicine.”  I love the film biography of Patch Adams.  The Bible says, “A happy heart makes the heart cheerful, but heartache crushes the spirit.” [Proverbs 15:13]  “The most wasted of all days is that on which one has not laughed.” [God’s Little Devotional Book for Women]

            I would like to believe that I am not unsightly but neither am I gorgeously attractive.  But hey, I am God’s work of art. [Ephesians 2:10] and beauty is relative. One heartwarming experience I had in the cancer ward was when the relative of my patient remarked that she really enjoyed my morning rounds.  I was paid a nice compliment when she further said that “my eyes have warmth”.  I was not sure what she saw in them that morning.  Maybe her vision was not 20/20. I consider my eyes to be too small.  In fact in the recent international convention that I attended I was mistaken to be Chinese/ Korean.  For me, I was merely doing my job each morning.  Perhaps I was consciously putting a smile on my face because I was very much aware that I was in the cancer unit.  But then I realized that the manner by which we, healthcare providers, present ourselves at the patient’s doorstep really matters.  After all, the patient and their relatives stay confined in a small room for long hours waiting for an upsetting medical verdict or hoping for a hastened recovery from illness.  And all that they can see are the doctors, nurses and support staff coming in and out of the room to check on the patient from time to time.  They are fortunate if the members of the medical team really spend quality time with the patient and his family.  But what if they are the type who just do the “routine” daily visits? Some hospital people are too robotic that they tend to do the same things over and over again to an extent that at times they lose the keenness and the human “touch”.  The patient and his family tend to notice the “details”  in the way health care is being delivered.  The smallest detail may be magnified;  the seemingly harmless remark may be taken out of context.  This is because an illness heightens the sensitivity of the patient and his relatives.  Several emotions may surface:  fear, anger, grief…

            The unexpected remark also turned my ordinary and stressful day into something extraordinarily wonderful.  Appreciation from peers or from patients/ relatives is always welcome and is in fact a positive reinforcement for a good deed.  Whereas the patient needs a pat on the hand or a reassuring word, the doctor also needs the support mechanisms be it from colleagues, superiors, family, or even from those under his care. 

            The most cherished token that I received from a patient during my residency was a small handwritten note from an elderly woman, E.M., in the outpatient department.  This note came with a papier mâché bird which my patient requested her daughter to make for me.  My patient was aware that I was about to complete my residency training that month and so she decided to give me a parting gift.  When I read the note, I really had difficulty in holding back the tears.  And I thanked her for both the note and the bird.  I realized from this experience that although health professionals may sometimes consider their practice as mere work, for other people especially for patients, it can hold a special meaning.  My patient saw me as more than her doctor.  She considered me as her friend.  She was grateful for what I was doing for her.  I think this experience taught me that people should see beyond their work.  We should not work because we are out to impress people or because we are compelled/ required to do things. Let us see the “people” who will benefit from our work.  This way we can manage to go on with our “work” even though there are times that we are exasperated or fatigued with what we usually do. 

Consultation and Follow-ups

            In the stirring account, “Living and Dying with Cancer” authored by Angela Armstrong-Coster, Ben suffered indignity from the medical incompetence of an uncaring physician.  There was an inexcusable delay in arriving at the correct diagnosis and in providing the definitive treatment simply because the doctor who initially saw Ben was grossly incompetent not to look at the chest xray. This resulted in the six-month delay, “well outside the optimum six-week window for beneficial treatment.”

            The moving story taught me that the doctor should never underestimate the capacity of the patient and his family to understand his illness. The healthcare provider must be careful not to give a false sense of security by sugarcoating the apparently bleak and frightening medical truth.  Communication with the patient and his family must always be honest, straightforward and clear.  Medical jargons should be relayed in layman’s terms. Discussion should be open and dynamic.  Clinical decision-making, treatment options, end-of-life issues should involve the patient and his family.

Taking Time to Listen and to Talk

The show, “Sex and the City” was such a big hit because it dealt with various types of relationships between male and female friends both in a funny and profound way.  “While Carrie’s (Bradshaw played by Sarah Jessica Parker) relationships with men may be charged and difficult, her relationships with Charlotte (York), Miranda (Hobbes), and Samantha (Jones) are always strong and vibrant.  She is supportive, a good listener, and seldom judgmental- which enables each of her friends to confide in her in ways that they might not confide in one another.” [Sex and the City: Kiss and Tell]  I think  a good doctor must be like Carrie Bradshaw.  Doctor-patient relationships may be varied depending on the case/ illness that the patient has, severity of the illness, age, sex and personality of the doctor and the patient, and a host of other factors.  These relationships may be light and easy or tense and difficult to handle.  But strength and dependability of the doctor must be constant.  The doctor should be there to listen and support the patient.  He may give the diagnosis and offer the course of management but he should accede to the rights, wants, needs and decisions of the patient- in a nonjudgmental manner. 

In the 4^th Back to the Cross (BTC) International Medical Congress I was fortunate to have attended last September 5-8, 2007 in Camp John Hay, Baguio City, Dr. Harvey A. Elder discussed about the necessity of taking a “spiritual history” and making a “spiritual diagnosis” and giving the appropriate “spiritual therapy”.  Dr. Elder told the BTC participants that there was a patient who did not want to take his medications because he gave away his four children for adoption and subsequently was consumed with guilt and loneliness over what he did.  According to Dr. Elder, in order to make the spiritual diagnosis, one should look into the cause of the loss of self-worth.  Is it because of performance trap, approval addiction, blame game, or shame?  What are the patient’s laments?  Further, he stated that the doctor should listen well to the patient’s history:  his coping mechanisms, burdens and resources.  And listening must be done with curiosity and without judgment.

In the same medical congress, I remember listening to one speaker (I’m not sure if it was Dr. Yang Chen or Dr. Harvey Elder or another speaker) who shared with us the story of the guilt-ridden doctor who failed to “listen” to his patient well.  The particular doctor saw his patient in the typical way, “de kahon” style.  The following day, the doctor learned that the patient took his own life.  Had the doctor been a good listener he could have noted the telltale signs that the patient was depressed and suicidal.  He could have prevented the death had he looked closer and had been more sympathetic and generous with his time and his help. 

Dr. Jesus G. Lizardo, a noted plastic surgeon, wrote in the book “The Healing Cut”:  “Devotion to the specialty must be absolute and there must be an easy communication with people and a compulsive regard for detail.  Goals are constant- possible perfection and patient satisfaction.”

There are many psychosomatic complaints that manifest as illness.  There are times that the laboratory tests are exhausted and all these turn out to be unremarkable or “normal”.  Sometimes, the problem lies in the emotional burdens and not on physical problems.  These must be surfaced and the patient must be guided and motivated to accept these problems upfront so he can start the healing process early on. 

This mind-body-spirit link that can either heal or consume an individual is discussed thoroughly in the book “Deadly Emotions”  by Dr. Don Colbert.  “Medical research is showing more and more that there may be a mind-body connection to most diseases and ailments, not just a few.  …The manifestation of long-term stress may also be in the form of physical diseases or ailments.  …Unmediated chronic stress has been linked to a long list of physical problems:  heart and vascular problems, gastrointestinal problems, headaches, skin conditions, genitourinary tract, pain and inflammation, lung and breathing problems, and immune impairment.”

“A Harvard Medical School study of 1,623 heart-attack survivors concluded that anger brought on by emotional conflicts doubled the risk of subsequent heart attacks compared to those who remained calm.” [M.A. Mittleman]

“The Harvard School of Public Health conducted a twenty-year study that involved more than seventeen hundred older men. The study found that the men who worried about social conditions, health, and personal finances had a significantly increased risk of coronary heart disease.” [L.D. Kubzansky, I. Kawachi, A. Sapiro III, et al.]

“A heart disease study at the Mayo Clinic found that psychological stress was the strongest predictor of future cardiac events, including cardiac death, cardiac arrest, and heart attack.” [T. G. Allison, D. E. Williams, T. D. Miller, et al.]

            The doctor can influence the way his patient thinks.  If the patient understands his illness he is better equipped in dealing with the pain/ suffering.  Uncertainties and ignorance about the disease can create greater anxiety and might result in delays in clinical decision-making and in difficulty in the healing process itself. 

            Dr. Ben Johnson in the book “The Secret”  states that, “We’ve got a thousand different diagnoses and diseases out there.  They’re just the weak link.  They’re all the result of one thing:  stress.”  Rhonda Byrne in the same book says that, “All stress begins with one negative thought.”  Further, Dr. John Hagelin declares that, “Our body is really the product of our thoughts.” 

The world would have been denied the pleasure of listening to the classical music of the great George Frideric Handel  (works include Messiah and Water Music) had it not been for the Duke’s capacity to listen and insistence to convince the father of the young Handel to allow him to pursue his love of music.  Handel’s father initially  wanted him to study law.  Subsequently, Handel studied both law and music. [Classical Music]

The Doctor as Refuge

“Carrie (Bradshaw) is a blithe spirit- smart, questioning, striving.  She is always on the go, ever vital, ever dynamic;  and because she is complex, not just any man will do.  And so we root for her to be with the one who is ‘strong enough to catch her’…” [Sex and the City: Kiss and Tell]   In a way, Carrie is like our typical patient:  inquisitive, smart, complicated.  The right man for Carrie is analogous to the doctor fitted for a particular patient.  The doctor must be strong enough for the patient so that he can “catch” the latter during his time of illness, weakness, uncertainty and incapacity.

We always consider the Lord, our God, the Great Physician and the Greatest Healer.  But a doctor can become an “extension” or “reflection” of the Lord.  A beautiful prayer I chanced upon at Papemelroti  describes the humility and acceptance of the doctor’s role in the healing process.  Likewise, it tells of the need for grace from above in order to deliver this gargantuan task with aplomb and with continued zeal.  This is the prayer entitled, “A Doctor’s Prayer”:

Dear Lord,

You are the greatest Healer,

All life and health comes from You

Without Your blessing and Your grace,

There is nothing I can do.

I thank You for this noble role,

My service unto Thee,

Stand by me with my patients,

‘Til the work is done daily.

Give me knowledge, wisdom and skill

Provide the best care needed

For each person’s best interest, stand

Let me lend a helping hand

To those who cannot pay,

Bringing good health to all

Send them fit for homeward’s way.

Protect with Your mighty angels,

Those under my care.

When their need of me is greatest,

May I always be there.  [emphasis mine]

When my zeal is at its lowest,

Tiredness meeting me at every turn,

May You then be my Healer,

Renewed joy and vigor earn.

All this I ask from You, Lord,

That I may a good doctor be,

That in my life as a physician,

May they see You in me.

I had learned from my mother about this sad story:  that of a security guard working with a family friend.  The guard’s wife had been sick for months.  Because the couple had no money to spend for medical consult and treatment, their hands were tied and the loving husband could not afford to bring his wife to the doctor.  The security guard was tempted to stealthily keep scrap metals so he could sell them and save enough money for his wife’s treatment.  My mother’s friend discovered this and so he talked with the security guard.  The guard broke down and honestly shared what drove him to do it.  Being kindhearted, the employer listened and believed the story of the poor man.  He accompanied the guard to their house and saw for himself the sorry state of the wife.  Subsequently, he went out of his way to facilitate the referral and admission of the sick woman to the hospital.  He also gave the couple some money to spend for medical treatment. 

Dr. Jeff Ho is one selfless neurologist doctor who serves as refuge to his patients in Davao City.  He has been conducting free clinics on Sundays and has been seeing senior citizens anytime of the week without asking for any professional fees.  [Philippine Daily Inquirer]

To stay or not to stay

            I have the privilege of working as a company physician on weekends.  Sometimes, patients come past the designated clinic hours. One patient probably is grateful because the nurse-on-duty and I examined her and managed her case the best way we can.  Because her case was “complicated” (this is an understatement), I was able to leave the company’s premises way past my appointed clinic hour.  But I was grateful for opting to stay and manage that case.  It was life-saving for me and my family.  When our car drove along the route that we usually take, we saw the stalled vehicles ahead of us.  In my estimate,  the road accident had happened in less than an hour or so.  It gave me the goosebumps because there were four cars that collided with each other and they were in the middle lane.  We usually take the middle lane for safety reasons.  Had I not opted to stay and see to my patient, my sister, mother and I could have figured in that vehicular accident!  My patient saved me and my loved ones.

To share or not to share

            I am a very private person and it is quite embarrassing for me to share my inner thoughts and emotions.  I sincerely hope that this narrative does not appear to be egotistical.  I must forewarn readers that I am not “nice” all the time because I am human (tao lang po).  A few years back, one of my best friends was in fact brutally honest to tell me, in her exasperation with me , that I was very stubborn and that I was literally giving her headaches.  But honestly, I love my friend and I know she meant well. And I think she can be as equally stubborn as I am sometimes.  I decided to share this article because of the following reasons.

This may somehow be influential in changing the mindset of people (doctors, hospital staff, patients, families).  I hope that the doctors and other healthcare providers (including support staff) will see a different approach to treatment, one that is individualized/ customized to the patient’s particular needs.  Patients and their families should be helped in dealing with their anxiety, fears and anger, in understanding their illness, treatment and prognosis.  Medical truths may be alien to them and these should be explained in a manner that is easy for them to digest.  Patients and their families should be handled with care because oftentimes they are fragile or difficult.  This is a given because they are dealing with the stress of illness and uncertainties or worse, with death and dying.   Therefore, healthcare providers must be humble enough to realize this and must be courteous and accommodating to patients and relatives in spite of their endless queries and demands. 

Delays in treatment and in the delivery of definitive health care should be avoided.  The medical profession deals with precious lives.  People are not commodities.  Hence, excellence must be strived for in providing the medical services.  Gentle and compassionate disclosure and persuasion must be weighed with scare tactics.  Some doctors are careful not to frighten their patients and families.  But sometimes, miscommunication, misunderstanding and delays in decision-making and definitive treatment stem from this. 

I would like to reaffirm that the medical profession is noble and should never be looked at as merely a way to earn big bucks.  Being a doctor provides a person the chance to live life to the fullest and to witness and experience the entire spectrum of life:  the joy and vigor of new life, burden of sickness, pain and suffering, dying and death. I think we should cherish life including its inequities because life experiences give us the opportunity to be whole and to be the best individuals that we can possibly be.   It would be fulfilling if we could make a difference in the lives of others through our exemplary work.  My favorite quote is by Henry van Dyke:  “Be glad of life because it gives you the chance to love and to work and to play and to look at the stars.”

            Having worked at the Department of Health (DOH), I was witness to inequities and disparities in the delivery of health care.  Medical services are sometimes inadequately provided or worse, not available to those who badly/ urgently need it.  Many complaints are attributed to miscommunication and uncaring attitude and management of the patients and to inept handling of families.  There are hospital frontliners who are complacent with their work and rude to the patients or to their relatives.  Most likely these rude staff or their loved ones have not gotten sick yet.  I hope there will be changes in the manner of service delivery in hospitals.

            On the other hand, my work at the DOH also had given me glimpses of the bravery and dedication of the public health workers (PHWs).   It was a pleasant surprise to learn that there are many patriots among health professionals.  I had heard of the doctor (a well-off and prominent doctor) who undauntingly stayed in the war-torn and remote area in their province because he was needed by the sick and underprivileged only to be mercilessly killed after years of selfless service to the community by bandits who were falsely using religion and politics to further their own selfish causes.  There was the young doctor who could have chosen to reside in the city and live comfortably but decided to stay in the rural area because he felt the need for health advocacy in the said community.

            Doctors need care and affection from those who surround them.  We are  human and as such, can be vulnerable.  We also cry.  We get angry.  We can also laugh.  We can learn as much from our interaction and experiences with peers, patients and their families. 

I was terrified when illness struck my own family.  But I was lucky to have had caring, compassionate and competent doctors to guide my family to recovery.  I am indebted to them and I am grateful.  This article is my humble tribute to the doctors  who held the hands of my loved ones when they were patients themselves. 

            To God be the glory!

 ----------------------------------------------------------------

For Further Reading:

Dan L. Longo, MD, Eugene Braunwald, MD, et al., Approach to the Patient With Cancer,  Harrison’s Principles of Internal Medicine, 16^th Edition,  McGraw Hill Medical Publishing Division, Volume 1, 437.

 Biomedis Oncology, Life Has Changed Since I Learned That I Have Cancer

 Proverbs 15:13, The Holy Bible

 God’s Little Devotional Book for Women, Eagle, Honor Books, Inc., Great Britain, 1998, 82.

 Ephesians 2:10, The Holy Bible

 Angela Armstrong-Coster, Living and Dying with Cancer, Cambridge University Press, Cambridge, United Kingdom, 2004, 30-32.

Amy Sohn, Revised Edition Text by Sarah Wildman, Sex and the City: Kiss and Tell; Melcher Media, Inc., Pocket Books, New York, USA, 2004, 19.

 Dr. Harvey Elder, 4^th International Back-to-the-Cross Medical Congress

 Maria Socorro Naguit, Editor,  Compiled by The Audiovisual Communications and Publications Committee, Department of Surgery, UPCM-PGH, UP Manila,  The Healing Cut; Anvil Publishing, Inc., Pasig City, Philippines, 1999, 137.

 Don Colbert, MD, Deadly Emotions, Thomas Nelson, Inc., Nashville, Tennessee, USA, 2003, 25.

 M. A. Mittleman, M. Manclure, J. B. Sherwood, et al.  “Triggering of Acute Myocardial Infarction Onset by Episodes of Anger,” Circulation, 92 (1995): 1720-1725.

 L. D. Kubzansky, I. Kawachi, A. Sapiro III, et al., “Is Worrying Bad for Your Heart?  A Prospective Study of Worry and Coronary Heart Disease in the Normative Aging Study,” Circulation, 94 (1997): 818-824.

T. G. Allison, D. E. Williams, T. D. Miller, et al.  “Medical and Economic Costs of Psychological Distress in Patients with Coronary Artery Disease,” Mayo Clinic Proceedings, 70 (1995): 734-742.

Rhonda Byrne,  The Secret,  ATRIA Books, Beyond Words Publishing,  Oregon, USA,  2006, 125, 127.

John Stanley, Classical Music:  The Great Composers and their Masterworks, Octopus Publishing Group Ltd, London, Great Britain, 2005, 90.

Papemelroti prayer

Naveed Santos, Doctor Who Serves as a Low-Profile, Anti-Poverty Warrior, Philippine Daily Inquirer, January 28, 2006, A14.

Henry van Dyke, Hallmark Cards