A partir del volumen 13 número 1 de 2017 la Revista de Medicina y Cine se encuentra alojada en

http://revistas.usal.es

How thick the shield should be: Teaching the subtleties of the doctor-patient relationship using literature and popular movies

Josep-Eladi Baños Díez

Departamento de Ciencias Experimentales y de la Salud. Universitat Pompeu Fabra (España).

Correspondence: Josep-Eladi Baños Díez. Facultad de Ciencias de la Salud y de la Vida. Universitat Pompeu Fabra.

Parc de Recerca Biomèdica de Barcelona. Dr. Aiguader 88. 08003-Barcelona (España).

e-mail: Esta dirección de correo electrónico está siendo protegida contra los robots de spam. Necesita tener JavaScript habilitado para poder verlo.

Received 9 July 2007; accepted 3 September 2007


Summary

The good teaching of the patient-doctor relationship is a difficult task before medical students have clinical experience. Even then, students may follow the bad examples of some tutors and sub-optimal care will follow until they become aware of this behaviour. Literature and popular movies may help medical students to understand what patients expect from their doctors, and how to be careful without themselves suffering for every patient’s disease. In the present review, two literary works and the films which were inspired by them are discussed. They show how doctors should avoid the neglecting of emotional needs of their patients, but also what the consequences are of an excessive implication in medical duties. Both of them may be useful teaching tools to introduce students to the subtleties of medical practice.

Keywords: Patient-doctor relationship, Literature, Popular Movies, Medical education.


Why teach the doctor-patient relationship to medical students in a explicit way?

It is not very original to say that physicians’ work is a complex job and that it is an uneasy task to explain its peculiarities to medical students, especially in the preclinical years. However, it is important to introduce them to these complexities before they enter the clinical period to prevent that their first approach to patients fails because of their inability to understand what patients are asking of their doctors. In their medical studies most students have been trained in diseases, not in patients. As Osler advised, care more particularly for the individual patient than for special features of the disease1. In fact, the question is to consider the sick person rather than exclusively the sickness, or to quote Smyth, to know what kind of person has a disease is essential to know what kind of a disease a person has2. In spite of these clever thoughts, communication between patients and doctors has not adequately evolved in recent years and may be traced to some regrets of the XVIIIth century, as Louis-Courvoisier and Mauron have recently shown3. Still now, many doctors do not view their patients as a whole person, but rather as a collection of organs, cells and molecules3.

The interview with the patient, where physicians gather the information which will help to focus the patient’s problem, is a very important step of the process which leads to diagnosis and treatment. It has been recognised that patient-doctor relationships are those most valued by people after those of the family4. However, traditional medical skills might not be enough to assure an optimal diagnostic and therapeutic process, as inattention to the patient’s personal worries may be ill-perceived by him and renders the following steps difficult. As Platt and Gaspar5 have written, this lack of attention may lead to inadequate clinical-data gathering, lack of adherence and poor therapeutic outcomes. In contrast, focussing on patient’s worries as well as the disease may improve all of these aspects and strengthen the patient-physician relationship5. This effort is risky, as some physicians may get too close to patients, and a deep sharing of their emotions might impair clinical detachment. Yet, some type of connection should be established with patients to improve the successfulness of the therapeutic process6. Obviously, human liaisons are one of the most difficult arts to master.

The so-called doctor-patient relationship constitutes one of the essential axes of optimal clinical care for several reasons. First, people who ask for medical consultation are not only a semiologic package (i.e., only a mere adjoining of the signs and symptoms), but also human beings with emotional problems that doctors should learn to deal with. If not, doctors will only become body repairmen, and humane medical care would not be achieved. It would be naïve to ignore that the development of scientific medicine and the way medicine is practised today have biased medical practice, yielding unexpected and undesirable behaviours. These are shown, for instance, by the paradoxical success of complementary medicines, most of the time frauds with nice names. I say paradoxically because contemporary medicine today offers the best prevention and healing of almost any sickness, compared with the past. In contrast, in the Western world, medicine is now seen critically, as has never happened in recent history (if we ignore, for instance, Molière’s times).

Certainly, something is wrong with medical care today and I believe that forgetting the importance of patients’ care from their point of view is a strong contributor. That means to hear and to listen to the patient and to understand why the sickness is important to him or her, and to attend these small details that worry them the most. In the academic field, we are able to explain, for instance, the genomics of breast cancer, but we often fail to explain how this diagnosis will change the life of the woman that has been just diagnosed. Few activities in medical schools are devoted to these important aspects of medical practice, even when communication with the patient is essential to an adequate professional practice.

It seems clear that hearing the worries, asking about beliefs and prejudices, advising with conviction and giving good or, even more important, bad news, is not explicitly considered in any medical discipline, even when they are considered generic competences of medical curricula. Some students learn them after their training by a good teacher, who is able to transmit his or her own worries to the alumni. Bedside teaching may help, but often the clinical picture is more important than psychosocial aspects of the sick person. Furthermore, inadequate models of some tutors may make the acquisition of these attitudes and competences difficult.

It is doubtless that the developing of empathic behaviours may help medical students early in their career. Following Borrell7, empathy may be defined as the ability of putting himself or herself in the place of the patient and telling this to him or her (“I know how you feel”). This communicative ability is in contrast with dispathy, which is the behaviour where the patient’s suffering is recognised, but it is judged in a way that denigrates the feelings of the patients and decreases their self-esteem7. This may be accomplished when a doctor tells his or her patient, for instance, that he or she only wants economic benefits or when he or she makes jokes about his or her symptoms. Most frequently, this cynical behaviour or deep relativism may be a defensive mechanism against all of the suffering that physicians are confronted with every day. Nevertheless, we should be careful about this situation, as many patients may be considerably disturbed and mistreated. This need of empathic communication has recently received considerable interest and has been submitted to specific programmes to develop it8.


A new didactic approach to understand the doctor-patient relationship: literature and popular movies

Regular lectures may be an inadequate scenario to teach these difficult issues, as they do not favour full interaction with the students. Therefore, alternative methods to approach such issues should be welcomed. Literature and popular movies provide a new way to introduce medical students to the ‘real life’ of their future activities.

Doctors have been an important source of writers in all countries: Anton Chejov (in Russia), William Somerset-Maugham (in the United Kingdom), William Carlos Williams (in the USA), and Pío Baroja (in Spain) are only some examples. Moreover, many works of literature are devoted, or at least linked, to medical topics. Since the introduction of Humanities in medical curricula performed by Penn State University in the late seventies9, an increasing interest in the topic has been noted. In this way, it has been suggested that literature may help to introduce students to difficult topics and improve their abilities to cope with the uncertainties of the medical profession10,11. More recently, attention has also been focussed on the use of popular movies as teaching tools12.

It is not surprising that movies should be considered as an interesting approach in medical education13-18. In recent years, several references to some of them may be found not only in highly reputed, general and specialised medical journals19-21, but also in other academic disciplines, such as general science22, nursing23 or law24. They may be derived from fiction or real stories and may influence public perceptions on health issues, and may also change attitudes that might benefit or be against any topic, even when they are not fully realistic or completely true. For instance, it has been suggested that cinematic depictions of physicians may influence and affect the patient-physician relationship25,26. In fact, movies may also change attitudes regarding medical procedures, as has been shown to be the case of electroconvulsive therapy27.

In this paper, two literary works La Maladie de Sachs and A Taste of my Own Medicine: When the Doctor is the Patient, as well as the movies that were inspired by them, are reviewed. They are two good examples of how this approach may help medical students to better understand their future profession.


La Maladie de Sachs

Martin Winckler (the pseudonym of the French physician Marc Zaffran) published this work, originally in French, in 1998, but an English translation is available28 (Figures 1 and 2). This novel is a remarkable work for many reasons, not only for its literary value but also for its medical interest. It tells the story of Bruno Sachs, a rural, contemporary French physician in his thirties, who practises medicine in a very particular way29. He pays special attention to the personal problems of his patients, not only to just the biological component of diseases. Patients are pictured as whole persons that have worries that are not biological in nature in most cases. In fact, they are ordinary people who are afflicted by ailments that are scarcely shown in any medical textbook. Sachs never refuses to attend any patient even when his medical role is severely limited. One of the main interests of the novel is that Sachs never speaks for himself and we learn about him by means of what people around him say. His patients, his secretary, his mother or his girlfriend explain to us what they think about Sachs and his behaviour. This novel chronicles “in a very sensitive and subtle way, the everyday life of a doctor in a small provincial city, and bluntly describes the doubt, weariness, burnout, but also the satisfaction, and the rich range of emotions of a medical practitioner.”30.

The story was later converted into a film with the same title and directed by Michel Deville (Figure 3). It won the prize for Best Director and Best Original Story at the Film Festival of San Sebastian in 1999, a fact which recognised its artistic value. The film is an example of a neorealist movie and is an excellent tool to show the professional activity and the personal life of a physician, often intermingled. Sachs himself talks to the audience to explain his personal feelings, his frustrations and fears about his failure to achieve happiness. As well as the novel, the film shows a different way of practising medicine and of caring for patients beyond their signs or symptoms. Sachs often involves himself in his patients’ lives and reports the everyday problems that affect them, showing the miseries of life.

The inability of avoiding the complexities of human behaviour and of feeling happiness defines Sachs’s sickness, the title of the movie. Symptoms of his disease are excessive worry for his work of caring for people until the extreme of neglecting himself, and devoting most of his time to doctoring30. This persistent situation makes him hypercritical with his colleagues and patients’ families. He extends his sarcasm to the society as a whole, and the daily conflicts are treated with strong bitterness. Sachs is very critical of the way his peers practise medicine. At times, he may even be considered as a fundamentalist in some of his opinions, such as those which affect professional secrecy or implicates physicians in situations that are not commonly accepted as subjected to medical duties. However, the film is not a hagiographic portrait. Sachs is a human being and he makes mistakes and some of his patients are not very happy with him and disagree with his advice.

What does the movie show us? I recommend seeing it more than once in order to understand all of the messages that it contains. My favourite scenes are those of the man telling Sachs the story of his wife, who is dying in the next room, the great care Sachs takes with a woman submitted to an abortion procedure, or several episodes of his nightshifts (figure 4). Nevertheless, every spectator will choose his or her best scenes, as there are many. In my opinion, the movie may be used as an educational tool to show medical students what doctors are or should be, what we do or should do, what we say or do not say and also what we should refrain from saying.


A Taste of my Own Medicine: When the Doctor is the Patient (The Doctor)

In 1988 Edward Rosembaum, a retired rheumatologist, published an autobiographical book about what happened to him after he was diagnosed with larynx cancer. The title was self-explanatory: A Taste of my Own Medicine: When the Doctor is the Patient31 (Figure 5). In his book, Rosembaum explained the feelings of being diagnosed with a severe disease, the initial mistakes some colleagues made until the definite diagnosis, the long treatment and all of the feelings of uncertainties and fears that followed. The book is specially revealing about how a doctor feels when treated as a patient and how he considers the disease from the eyes of a patient after practising medicine for many years. Additionally, the book includes several situations, such as long delays in being visited or treated, diagnostic mistakes or bureaucratic worries, which add unnecessary suffering for the patients. As the author explains, these events were not considered by him before his disease was diagnosed. When he was obliged to adopt the role of patient, he started to consider the medical profession in a new light. The disease has deeply changed him, and many situations which were neglected in the past now have a completely new consideration.

A few years later, Rosembaum’s book inspired the movie The Doctor, directed by Rhonda Haines in 1991 (Figure 6). Contrary to Le Maladie de Sachs, this film was a rather free version that changed many of the features of the original book. Compared with the book, the movie is pure Hollywood32 and some of its scenes are purely topical about physicians. Here, the main character is Jack McKee, a young and bright surgeon. At the beginning of the film, several scenes show how Dr. McKee is an arrogant and insensitive doctor with a cynical sense of humour that he generously applies to his patients. He also advises the residents against getting too involved with patients and even makes jokes about a colleague, a doctor of the caring type.

His marriage breaks down after his cancer diagnosis and he falls in love with a young woman afflicted with a brain tumour, who finally dies. Contrary to the literary work in which this was inspired, the movie is a personal trip through disease and the health-care system rather than a reflection on the process of becoming severely sick, with the personal consequences of this fact. During this trip, he discovers the long waits for doctor consultations, the failures of hospital information, the mistakes of health professionals, or the delays in receiving important laboratory results.

I strongly recommend that The Doctor be viewed by future physicians, as it is a good tool to discuss some topics that are ignored during the training of medical students33. In this way, the last scenes of the film are specially revealing. Once Dr. McKee is cured, he returns to his job but is remarkably changed. When receiving his new resident physicians, he obliges them to become patients for a full day: they will wear patients’ garments, eat the same food, and be submitted to some diagnostic procedures themselves. McKee is a different man and tries to inculcate his trainees with a new way of treating their patients. For instance, he put them in patients’ gowns which left their bottom sticking out the back (Figure 7). The last message of Dr. McKee is to recognise that patients feel frightened, embarrassed and vulnerable, and they are so confident in their physicians that they put their life in their hands33. His objective is clear: if you feel like a patient, you will be able to understand and to treat them better. In fact, some schools of Medicine have used this approach to teach their students how patients may feel34-36. Young people are generally healthy and, by the time they understand what it means to be sick themselves, many patients will have already been mistreated.


Conclusion

Both literary works and films analyse important aspects of the medical profession, but I would like to focus on the patient-doctor relationship and how to establish the needed distance from the patient’s suffering. Dans32 refers to this barrier as an ‘invisible shield’ and states the core problem: ‘It has to be thick enough so that we don’t live and die with all of our patients, but thin enough so that we are sensitive to their hurts, needs, and feelings”. This compromise between self-preservation and callousness is difficult to achieve and may be a considerable source of suffering for patients and physicians (the so-called Sach’s sickness). However, the thickness of this invisible shield is a critical point that is difficult to learn before having enough clinical experience, but by this time many patients have suffered from the arrogance and insensitivity of some physicians. Obviously, the sooner doctors learn about it, the better patients will be treated. Nevertheless, sometimes some physicians prefer the thickest to the thinnest to avoid becoming involved in their patients’ feelings and worries. As Rosembaum’s experience shows, each of us becomes more sensitive when we have suffered a severe disease in our own skin or in our immediate family. However, medical educators should try to convey the need of such sensitivity in their students, and the implementation of educational activities directed to this aim should be compulsory if we wish to train better doctors. This is a tough task and probably these young and healthy men and women, who are medical students, will not be very receptive to the message. In spite of this possibility, I think that the movies and literary works portrayed in this paper may help them to look at patients in a very different way.


References

  1. Bean WB, editor. Sir William Osler. Aphorisms. New York: Schuman; 1950;
  2. Smyth FS. The place of humanities and social sciences in the education of physicians. J Med Educ 1962; 37:495-497.
  3. Louis-Courvoisier M, Mauron A. ‘He found me very well; for me, I was still feeling sick’: The strange worlds of physicians and patients in the 18th and 21st centuries. J Med Ethics: Medical Humanities 2002; 28:9-13.
  4. Pincock S. Patients put their relationship with their doctors as second only to that with their families. BMJ 2003; 327:581.
  5. Platt FW, Gaspar DL. “Tell me about yourself”: the patient-centered interview. Ann Int Med 2001; 134:1079-1085.
  6. Coulehan JL. Tenderness and steadiness: emotions in medical practice. Lit Med 1995; 14:222-236.
  7. Borrell F. Compromiso con el sufrimiento, empatía y dispatía. Med Clin (Barc) 2003; 121:785-786.
  8. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997; 277:678-682.
  9. Hunter KM, Charon R, Coulehan JL. The study of literature in medical education. Acad Med 1995; 70:787-794.
  10. Calman KC, Downie RS, Duthie M, Sweeney B. Literature and medicine: a short course for medical students. Med Educ 1988; 22:265-269.
  11. Downie RS, Hendry RA, Macnaughton RJ, Smith BH. Humanizing medicine: a special study module. Med Educ 1997; 31:276-280.
  12. González-Blasco P. Literature and movies for medical students. Fam Med 2001; 33:426-428.
  13. Ber R, Alroy G. Twenty years of experience using trigger films as teaching tools. Acad Med 2001; 76:656-658.
  14. Rabinowitz D, Melzer-Geva M, Ber R. Teaching the cultural dimensions of the patient-physician relationship: a novel approach using didactic trigger films. Med Teach 2002; 24:181-185.
  15. Self DJ, Baldwin DC. Teaching medical humanities through film discussions. J Med Humanit 1990; 11:23-29.
  16. Self DJ, Baldwin DC, Olivarez M. Teaching medical ethics to first-year students by using film discussion to develop their moral reasoning. Acad Med 1993; 68:383-385.
  17. Wilt DL, Evans GW, Muenchen R, Guegold G. Teaching with entertainment films: an empathetic focus. J Psychosoc Nurs Ment Health Serv 1995; 33:6-15.
  18. García-Sánchez JE, Fresnadillo MJ, García-Sánchez E. El cine en la docencia de las enfermedades infecciosas y la microbiología clínica. Enferm Infecc Microbiol Clin 2002; 20:403-406.
  19. Alexander M, Hall MN, Pettice YJ. Cinemeducation: an innovative approach to teaching psychosocial medical care. Fam Med 1994, 26:430-433.
  20. Jones AH. Medicine and the movies: Lorenzo’s Oil at century’s end. Ann Int Med 2000; 133:567-571.
  21. Farré M, Bosch F, Roset PN, Baños JE. Putting clinical pharmacology in context: the use of popular movies. J Clin Pharmacol 2004; 44:30-36.
  22. Breithaupt H. Movies for teaching science. EMBO Reports 2002; 3:918-920.
  23. Raingruber B. Integrating aesthetics into advanced practice mental health nursing: commercial film as a suggested modality. Issues Ment Health Nurs 2003; 24:467-95.
  24. Crawford C. Law enforcement and popular movies: Hollywood as a teaching tool in the classroom. J Criminal Justice Pop Culture 1999; 6:46-57.
  25. Flores G. Mad scientists, compassionate healers and greedy egotists: the portrayal of physicians in the movies. J Natl Med Assocc 2002; 94:635-58.
  26. Flores G. Doctors in the movies. Arch Dis Child 2004; 89:1084-1088.
  27. Walter G, McDonald A, Rey JM, Rosen A. Medical student knowledge and attitudes regarding ECT prior to and after viewing ECT scenes from movies. J ECT 2002; 18:43-6.
  28. Winckler R. The case of Dr. Sachs. New York: Seven stories; 2000.
  29. Bamforth I. La maladie de Sachs. BMJ 1998; 317:1666.
  30. Laprand M. Une lecture de la “Maladie de Sachs”. Winckler’s Webzine. Le site personnel de Martin Winckler [homepage on the Internet] [cited 2007 Jul 9] [about 3 p.]. Available from: link
  31. Rosembaum EE. A taste of my own medicine. When the doctor is the patient. New York: Random House; 1988.
  32. Dans PE. Doctors in the movies: boil the water and say “Aah”. Bloomington, IN: Med-Ed Press; 2000.
  33. Alexander M. The Doctor: a seminal video for cinema education. Fam Med 2002; 34:92-4.
  34. Editorial. Students as patients. Lancet 1974; ii:1433.
  35. Magarey C, Cox K, Hunt D, Jacobs P, Knight S, Piggott B, Pryor D, Salek A, Todd P, Williams J. Learning by experience: A student residential workshop in hospital. Med J Aust 1975; 2:516-8.
  36. Franklin D, Griffin K. Doctors as patients: How does it feel? Health 1991; 5:14.

Figure 1: Front of a French edition

Figure 2: Front of a English edition

Figure 3: French poster with Dr. Sachs

Figure 4: Dr. Sachs with a woman he is about to perform an abortion

Figure 5: Original front to A taste of my own medicine: When the doctor is the patient

Figure 6: English poster with Dr. Jack MacKee (William Hurt)

Figure 7: Dr. McKee's colleagues dressed in the attire used by the patients in his hospital