Given the nature of medicine, it is natural to assume that humanism would be a central, highly regarded component. Many people in health care, however, feel that humanism is being driven out. At best, they contend, the degree to which humanistic principles are integrated into health care leaves something to be desired, and, at worst, these principles are under assault.
"Humanism can be defined in many ways, but at its core, it recognizes medicine as an interaction between two human beings – not just an interaction between someone with a disease and a person who is an expert in taking care of that disease," Jennifer C. Kesselheim, MD, MEd, MBE, assistant professor of pediatrics at Harvard Medical School, told ASH Clinical News.
There is no doubt that people choosing to enter into a career in medicine are committed to the idea of not just treating, but healing humans, Dr. Kesselheim continued, but the modern day landscape of medicine and health care can make the practical application of these tenets difficult.
"Specifically, there is a lot of concern about technology and medicine, with many people feeling that the time spent at the bedside is shrinking as we rely more on technology," she said. "There are computers in every patient room, and we all have handheld computers in our pockets. This affects our ability to see through the technology and remember the human on the other side of that interaction."
What is Humanism?
The definitions of medical humanism can be as varied as the patients whom physicians treat day-to-day. For Dr. Kesselheim, her preferred definition of humanism comes from The Arnold P. Gold Foundation, a foundation built in support of incorporating humanism into medicine. The Foundation uses the pneumonic "IE CARES" to define the attributes of humanistic health care: Integrity, Excellence, Compassion, Altruism, Respect, Empathy, and Service (see the Sidebar for a breakdown of these qualities).1
According to the Foundation, multiple studies have shown that a physician's ability to apply these attributes improves his or her interactions with patients and may affect patient outcomes. For example, in a 2007 German study of 710 patients with cancer, physician empathy was positively associated with improvements in patient-reported depression and quality of life.2
Linda L. Emanuel, MD, PhD, director of the Institute for Public Health and Medicine, Buehler Center on Aging, Health & Society at Northwestern University Feinberg School of Medicine in Chicago, sees the idea of medical humanism a little differently. In her view, the purpose of medicine is to allow people to be "full human beings – mind, body, and soul."
"People's human narrative often gets interrupted by illness of one kind or another, so the purpose of medical care is to try to put that right for the purpose of continuing their human narrative," said Dr. Emanuel.
In this approach, often called narrative medicine, medical care has the purpose of both "fixing" whatever physical ailment interrupted the patient's narrative, or life story, and of seeing his or her treatment through to the social and psychological realms.
Treating the whole patient in this way recognizes that he or she is more than just a disease, agreed Teresa A. Gilewski, MD, a medical oncologist at Memorial Sloan Kettering Cancer Center, who has made a number of documentaries focused on the human elements of medicine.
"[During the making of one film], I interviewed a woman whose mother had breast cancer. She said that when her mother goes to a doctor, the first question the doctor asks is â€˜How are you feeling?' But the next sentence out of the doctor's mouth is often the one that means the most," Dr. Gilewski said. "That question could be, â€˜What did you do last weekend?' or â€˜How are your grandchildren?'"
"Physicians often underestimate the effect of our words," she added. "When having to impart a lot of scientific information to help someone, many people appreciate when you are viewing them on a more personal level and not just as someone with a particular illness."
Humanism Under Assault
The strictures of today's health-care system are at odds with the tenets of humanistic medicine. "Humanism has been under attack since the era of scientific enthusiasm began, since Western medicine separated treating the mind from treating the body," Dr. Emanuel told ASH Clinical News.
Dr. Emanuel went into the field of palliative medicine and end-of-life care more than 20 years ago, when the specialty was still considered to be on the fringes of medicine.
"In palliative care, we believed that there was no such thing as a patient being beyond hope, because even though no one lives forever, there is always something to hope for, even if it was hoping for one last trip or saying goodbye to family members," Dr. Emanuel said. "We looked at the four big domains of well-being – biologic, psychologic, social, and spiritual – in the patient as well as in the people connected to that person."
However, she noted, even within the field of palliative care, humanism has lost some of its foothold.
Many factors are responsible for the loss of humanism in medicine, according to Fred J. Schiffman, MD, the Sigal Family Professor of Humanistic Medicine at the Warren Alpert Medical School at Brown University. Chief among these – and common to every doctor – is time constraints.
Physicians juggle many responsibilities other than seeing patients, but together these responsibilities chip away at the time doctors can spend with their patients. In many cases, physicians have delegated that time to patient navigators, nurse practitioners, physician assistants, or other qualified colleagues, he said.
"There is no question about the importance of physician presence, but we are being pulled in 12 different directions," Dr. Schiffman said. "We are all victims of over-reaching and over-scheduling." He also agreed with the fact that technology and the use of electronic medical records (EMRs) has eroded humanism.
"Even people who have led the charge for ensuring quality and safety through EMRs now feel that we are collecting unnecessary data and that we have swung the pendulum too far," Dr. Schiffman said. "The EMR has taken us away from the patient encounter."
Humanism on the Defensive
What can physicians do to stem the tide of impersonal, distant medicine? It's not as if humanism isn't part of medical training. "The emphasis on humanism is more prevalent at the beginning of training, then tends to lessen as physicians progress through training," Dr. Gilewski said.
For example, many medical schools now offer programs that focus on human elements and human interactions, but after graduation – as medical students enter their internships and residency programs – they find that, although they spend more time on patient interactions, the emphasis on humanistic elements often drops off, Dr. Gilewski explained.
"One of my colleagues lamented the training climate this way: â€˜It's as if humanism gets sucked out of you as you go through training,'" Dr. Gilewski said. "That time between medical school and becoming an attending is so focused on the science and clinical management of patients – which are extremely important – but, at the same time, so are the day-to-day human interactions that we have as doctors. It shouldn't be an either/or scenario. They should all be intertwined."
There is still hope, though, as medical schools and hospitals are providing more opportunities for health-care providers to learn about humanistic medicine, relying on mentors and role models as exemplars of medical humanism.
One national program aimed at renewing efforts for incorporating humanism is CHARM, or the Collaborative for Healing and Renewal in Medicine.3 CHARM is a group of medical educators, medical center leaders, and experts in burnout research and intervention designed to promote trainee wellness. "This is a group of physicians who have come together to address how trainees should be taught, and how trainees should be cared for," Dr. Schiffman said.
Another program, the Schwartz Center Rounds, offers health-care providers a regularly scheduled time during their fast-paced work lives to openly and honestly discuss the social and emotional issues they face in caring for patients and families.4 Based out of the Schwartz Center for Compassionate Healthcare at Massachusetts General Hospital in Boston, these rounds incorporate and concentrate on the human dimension of medicine, in contrast to traditional patient rounds. There are more than 375 health-care organizations participating in Schwartz Center Rounds program.
Dr. Schiffman also noted the Gold Foundation's Gold Humanism Honor Society (GHHS), a national honor society dedicated to recognizing, supporting, and promoting the values of humanism and professionalism in medicine. This society honors everyone from medical students to physician teachers who have demonstrated excellence in humanistic clinical care, leadership, compassion, and dedication to service.
For example, GHHS launched the National Solidarity Day for Compassionate Care in 2011 as a day to encourage medical schools, patient care facilities, and other organizations to show their support of the importance of kindness to patients. Typically held on or near Valentine's Day, the Solidarity Day expanded to a National Solidarity Week this year.5
Members also participate in the "Tell Me More" program, which was developed in 2014 by GHHS chapter members at the Icahn School of Medicine at Mount Sinai. The project personalizes a health-care provider's interaction with patients by encouraging that person to spend time learning about his or her patients' personal lives and asking three simple questions: What are your strengths? How would your friends describe you? What has been most meaningful to you? The physicians then crafted signs based on these answers to display at the end of patients' beds as a reminder that each patient is an individual.5
"This program allowed us to get to know them as people as well as patients," Dr. Schiffman said.
At Memorial Sloan Kettering Cancer Center, Dr. Gilewski started a monthly "Art of Medicine" lecture series to emphasize some of the human elements of cancer care. "We have multiple lectures and guest speakers, including patients and family members, who offer their perspective on illness, suffering, and grief," Dr. Gilewski said. "The whole point is to highlight this aspect of medicine for everyone working in the institution, not just for physicians, nurses, and pharmacists, but also administrators, assistants, and others. We all know the human element exists, but we often don't pay enough attention to it in a formal way."
A Self-Care Curriculum
Definitions of humanism outline qualities designed to help doctors make the doctor–patient visit more "humane," and it is important to remember that the doctor–patient relationship involves two humans – and both need to be cared for.
Physician stress, like physician empathy, has a tangible effect on patients' experiences and patient–physician communication; the German study from 2007 demonstrated that as physicians' reported stress levels rose, patients were more likely to report a desire for more information from the physician regarding findings and treatment options.2
"Self-care is one of the universal obstacles that all physicians are confronting every day," said Dr. Kesselheim.
The demands of modern-day medical practice can make a physician feel less than human, she said. Today's practicing physicians face more complex administrative duties and a higher demand for detailed documentation than in the past, and, with work-hour restrictions, doctors spend more time doing patient hand-offs.
"In many of these situations, physicians are not getting the privilege of engaging in human connections with their patients but instead are spending time doing documentation or care coordination in the background," Dr. Kesselheim said. "All of that can be draining and can make them feel frustrated."
Human interactions with patients suffer, and a physician's own human experience may no longer be a priority.
"Self-care is hard," Dr. Gilewski noted. "It is not easy to care for people who are ill and for that to not have some sort of emotional impact on the physician. Physicians need to have something to turn to, to help sustain themselves and continue to do this work on a daily basis."
For some physicians, that might be a commitment to physical activity; for others it may be the arts, a love for music, or spirituality. But, for all physicians, self-care should involve open conversations among colleagues about their experiences and day-to-day challenges.
Dr. Kesselheim has piloted a program at 10 fellowship programs across the country, which brings fellows together in a group discussion about cases that illustrate challenges to humanistic medicine. Facilitated by a trained faculty member, these sessions provide an opportunity for trainees to talk through the case and devise coping strategies consistent with the kind of doctoring that is important to all of them, Dr. Kesselheim explained.
A recent session focused on maintaining an appropriate work-life balance as a fellow. In one case, a fellow recalled a stretch of particularly stressful days. He had been looking forward to an anniversary dinner with his significant other, whom he had not seen recently due to weekends spent on-call at the hospital. However, in clinic that day, he had to stay late to meet with the family of a patient whose leukemia had relapsed, causing him to be late for the anniversary dinner. The next day, the fellow's mentor asked to see a first draft of a research grant with a fast-approaching deadline, and the fellow had to admit that he had been unable to work on the draft. So, as he explained during the group discussion, the fellow now has a patient who has relapsed, a disappointed mentor, and an upset significant other.
"When we discussed this case, all of the fellows nodded their heads in agreement because each and every one of them knew that this type of thing happens all of the time," Dr. Kesselheim said. "They don't usually get to talk about it, but in this group they were able to ask how others dealt with these types of conflicts and what tricks or coping mechanisms others had."
Bringing Back Humanism
According to Dr. Emanuel, one of the great questions in medicine is: What would medicine look like if humanism in medicine was what it should be? Certain institutions seem to focus on integrating humanism in medicine, and those often have a physician-leader championing and putting humanism programs in place.
"But, I do not hear discourse about what medicine would look like if humanism were properly integrated," Dr. Emanuel said. "What would every self-respecting health system have in an era where humanism was fully expected to be integrated into medicine? That discussion still needs to happen."
In the meantime, as the role of humanism continues to evolve, there are measures that physicians can take to inject humanism into their everyday routines – for the benefit of their patients and themselves.
For Dr. Kesselheim, one such action is trying to leave all of her other concerns outside the door as she enters a patient's room, turning her entire focus to the patient and the visit. "I try, whenever possible, to turn away from the computer and speak directly to the patient, saving documentation for later if possible," Dr. Kesselheim said. "Even when I feel rushed, I try to make sure to let the patient voice be heard and make sure that the patient is allowed to say everything he or she needed to say during our clinical encounter."
Providing your undivided attention is just one of the many "little things" that physicians can do to promote healthful, healing relationships with patients, Dr. Schiffman said. Other simple tactics include introducing yourself and everyone on the care team as well as greeting each person in the room during a clinic visit.
"Be still, be open and interested," he said. "Turn off your beeper and be in the moment when you examine patients."
Finally, another easy way to incorporate humanism into patient interactions, as demonstrated by the GHHS "Tell Me More" campaign, is to ask patients just one or two personal questions, according to Dr. Gilewski. "It is a classic example, but just ask about their family or work, or if they have been on a trip," Dr. Gilewski said. "It changes the entire tone of the session."
She added that understanding the human aspects of medicine has an unending learning curve that will change as physicians gain more professional and personal experiences.
"Even though a lot of physicians strive for perfection, we will not always be perfect at it," Dr. Gilewski said. "Sometimes it can be hard to reflect on those moments, but that is an important part of medicine as well."â€”By Leah Lawrence
- The Arnold P. Gold Foundation, "What is humanism in health care." Accessed April 3, 2016 from http://humanism-in-medicine.org/about-us/faqs.
- Neumann M, Wirtz M, Bollschweiler E, et al. Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modeling approach. Patient Educ Couns. 2007;69:63-75.
- Alliance for Academic Internal Medicine, "Collaborative for healing and renewal in medicine (CHARM)." Accessed April 3, 2016 from http://www.im.org/p/cm/ld/fid=1403.
- The Schwartz Center for Compassionate Healthcare. "Schwartz Center Rounds." Accessed April 3, 2016 from http://www.theschwartzcenter.org/supporting-caregivers/schwartz-center-rounds.
- The Arnold P. Gold Foundation, "GHHS Solidarity Week for Compassionate Patient Care." Accessed April 3, 2016 from http://www.gold-foundation.org/programs/ghhs/ghhs-solidarity-day/.
The Arnold P. Gold Foundation defines humanism in health care by using the pneumonic IE CARES:
Integrity: the congruence between expressed values and behavior
Excellence: clinical expertise
Compassion: the awareness and acknowledgment of the suffering of another and the desire to relieve it
Altruism: the capacity to put the needs and interests of another before your own
Respect: the regard for the autonomy and values of another person
Empathy: the ability to put oneself in another's situation (e.g., physician as patient)
Service: the sharing of one's talent, time, and resources with those in need; giving beyond what is required
Source: The Arnold P. Gold Foundation, "What is humanism in health care." Accessed April 3, 2016 from http://humanism-in-medicine.org/about-us/faqs.