Humanity before Science: Narrative Medicine, Clinical Practice, and Medical Education

Abstract

A patient saw a physician for the first time. The physician wanted to learn everything about the new patient, and listened attentively without interruption. The patient paused after a while and wept. When asked why, “No one let me do this before,” was the response.1 There is growing public opinion that the current medical care has lost its human aspects, widening the gap between patients' expectations and physicians' performance. Many forces today restrict physicians' ability to reflect on their clinical experiences and relationships. The marketplace speeds up medical work, interrupts continuity with patients, and erodes the autonomy of the physician-patient relationship.2 The current revolution in technology of medical informatics complicates matters further. The cut-and-paste functions of electronic medical records undermine the psychological and therapeutic value of face-to-face personal and compassionate encounters between physicians and their patients. This transformation in the physician-patient relationship did not take place overnight. Modern American medical education in charge of preparing future physicians was transformed by Flexner's report in 1910. Flexner was chosen by the Carnegie Foundation for the Advancement of Teaching to head up a commission to assess medical education in the US.3 Flexner narrowly defined the proper goals of medicine as the “attempt to fight the battle against disease.”4 He argued that the future of pathology, therapeutics, and medicine depends upon those trained in the methods of natural science. Clinicians must be “impregnated with the fundamental truths of biology,” ignoring the human aspects of the disease in favor of biology and natural science. But we know that patients are not just bodies, organs, and tissues. They live meaning-centered lives, and they have complicated emotional and historical relationships with their bodies.5 Flexner's vision of medical education created physicians richly sophisticated in biologic variables and interventions, but all too often they lost touch with the human aspects of health care and the basic tenets of clinical encounters with their patients.5 To understand the gap between patients' expectations and physicians' performance, one must make a distinction between disease and illness.6 Medical philosophers turned to “phenomenology” to better understand the meaning of illness and the moral core of healing.5 Illness is the innately human experience of symptoms and suffering, whereas disease is the clinical perspective of the problem. Flexner's model addresses the alteration in biologic structure and/or function, ie, disease without addressing the psychological and social variables of a disease, ie, illness. This fact was already well recognized in the 1970s when resistance to the Flexner's report started to surface.