In his famous address to Harvard medical students in the fall of 1925, Dr. Frances Peabody stated: “the secret of the care of the patient is in caring for the patient.” While few would argue the wisdom of this beautifully crafted, and often quoted aphorism, medicine struggles to uphold this simple credo. It would seem straightforward enough, and yet repeatedly, and for the most part, unwittingly, we still sometimes manage to get it wrong. Too often, patients bemoan feeling processed, not really being heard; suddenly being defined according to what they have as a patient and not who they are as a person.
I was recently discussing this with one of my colleagues, a physician who has been in practice for nearly 30 years and holds several cross appointments within the faculty of medicine. While our discussion began on a rather cerebral note — the culture of contemporary health care, the role of technology, mounting workloads and crushing time pressures — things turned personal when she began to reflect on her own experiences as a patient. Of note, even the subtleties of patienthood, she said, could be abrasive; being examined, talking with certain doctors, “and the gowns … the gowns are a problem.” And yet, through the lens of patienthood, these things are completely routine, even mundane. But through a personhood lens, they look entirely different.
Take the medical gown for instance. The moment someone enters into hospital, their usual attire and rational for choosing it—comfort, allure, status, affiliation—is replaced by a drab gown, theoretically meant to fasten at the back, Designed for Ease of Defecation (D.E.A.D.) being an appropriate acronym, given that people, under normal circumstances, would not want to be caught dead wearing them. And yet, the instant one is hospitalized, the overarching schema, worldwide, regarding clothing is organized around bodily excretions. For persons, clothing is about pride, modesty, an expression of our unique individuality; values that are critical in maintaining our sense of self and personhood. Entering hospital begins an insidious transformation from person to patient, wherein those values are suddenly displaced. Individuality must yield to uniformity, and modesty, for anyone who has every worn such a gown knows all too well, is left behind.
Being cloaked in a gown that is incapable of hiding ones nakedness has existential consequences. So too does having to relinquish control over who sees, probes, and evaluates the integrity, or lack thereof, of ones body. While nakedness describes a state of not being clothed, it also conveys the notion of lacking protection and hence being vulnerable.
Reflecting on a recent visit to her medical oncologist, a woman with metastatic breast cancer reported feeling upset with the medical student who examined her mastectomy scar. Without intending her to feel “naked to mine enemies,” the assault she felt was nevertheless real. Perhaps it was his first opportunity to see what a chest wall looks like following the removal of a cancerous breast tumor, or to carefully palpate the remnants of a suture line. But the patient's response leaves no doubt that the scar being examined extended much deeper than any physical injury. While the student was likely mindful of anatomical landmarks and signs of infection or abnormal healing, what may not have been on his radar was the experiential landscape of living with Stage IV, terminal breast cancer; a landscape invariably marked by fear, sadness and loss.
Without being attentive to the emotional consequences of illness and disease, even technically competent care runs the risk of inflicting similar harm. This accounts for why patients sometimes find health care encounters abrasive; or why, accurate diagnostic and therapeutic steps notwithstanding, medicine can fall short of meeting patients' needs.
Optimal therapeutic effectiveness — perhaps a modern day version of the secret of caring for the patient — requires that health care professionals provide the right care, consisting of appropriate evidence based approaches, within a context that feels safe for patients and families.Footnote 1 But it also demands, by way of invoking aspects of our own humanity — such as compassion, empathy, respect, and humility — that we pay attention to persons.
One can only speculate on how Peabody might have responded to this contemporary rejigging of his conventional wisdom. While it remains focused on caring, it speaks to the centrality of persons and the notion of personhood within this therapeutic calculus. After all, patients are people; and people have feelings; and those feelings matter. Admittedly, nowhere near as eloquent as Peabody, but hopefully of some utility. Patients are people with feelings that matter.Footnote 2 And now the secret is out.
