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May 9, 2013 | Posted By Wayne Shelton, PhD

In the fall of 1970 Philip Tumulty, a Johns Hopkins’ internist, gave a lecture to the 3rd year medical school class at Johns Hopkins. His lecture was published in the same year in the New England Journal of Medicine under the title of “What is a clinician, and what does he do?” (Tumulty PA. What is a clinician and what does he do? N Engl J Med. 1970 Jul 2;283(1):20-4.) In this classic piece, this eminent physician of his era claimed that the primary role of the clinician is to “manage a sick person with the purpose of alleviating the total effect of his illness”. 

This paper, probably better than any other paper I have ever read gets to the essence of what a patient needs from an expert clinical caregiver; it lays out eloquently and robustly the characteristics of a good clinician and what is involved in excellent clinical care of patients. As Tumulty says, it is not a diseased body organ that shows up for physical diagnosis and treatment; rather, it is an anxious, fearful, wondering person concerned about her personal life, including her family, work, friends as well as her hopes and dreams. This means the clinician must be a thoughtful and systematic fact finder, a careful listener, a keen analyst of the facts and a prudent planner regarding which tests and treatment options make the most sense for this particular patient. Moreover, Tumulty rightly assumes that these skills should be embodied in the clinician as natural traits that the clinician genuinely enjoys performing. 

Tumulty’s normative characterization of a good clinician, admittedly in somewhat ideal form, reflects what most of us as patients want from our physician especially when we, or our loved ones, are sick. There are many physicians who live up to this standard and who are richly appreciated by their patients. But all too often, this is not the case. For much of what counts as the physician-patient relationship in major hospitals in today’s healthcare system, I fear these expectations have become unrealizable ideals, which means our traditional notion of the physician-patient relationship may have become antiquated.

My interest in the physician-patient relationship stems from my work as a clinical ethics consultant, which I began doing when I arrived at the Albany Medical Center is 1994.  Many of the value laden impasses that we see in ethics consultation stem from breakdowns in the management of the sick patient, especially the communication transactions between the physician and patient, and perhaps more so between the physician and the patient’s family surrogates when the patient lacks capacity. There is considerable evidence accumulated since Tumulty’s article in 1970 that corroborates his basic view that effective communication with patients and their families is crucial to the provision of efficient and quality health care. However, since 1970 we have witnessed a new era of scientific and technological breakthroughs that have transformed medical care. These dramatic changes have placed enormous demands of physicians in terms of mastering the new diagnostic and therapeutic techniques. The importance of managing the full range of concerns around the patient’s illness often gets lost in the mix, which can give rise to conflicts, disagreements, stress and confusion, which in turn can lead to extended length of stays and unnecessary costs. Given the context of contemporary health care and the urgency of learning how to provide excellent patient care consistent with economic efficiency, the traditional understanding of the role of physicians to manage the illness of sick patients needs revision and updating.

My sense is that it is time to rethink how we conceptualize the physician role in the management of a sick patient. The management of sick patients and their families in today’s health care setting requires a team effort. Both patients and their families require intensive support and ongoing assessment in the hospital setting. The physicians in charge of the treatment plan may only have a few minutes each day for direct interaction. The physician’s medical expertise is absolutely essential to the proper medical care of patients, but it is not a sufficient condition for proper management of the patient’s illness. This requires the work of a fully integrated team. 

I propose that in a hospital setting where complex, technical information has to be disclosed to and processed by sick patients and stressed family surrogates, the team should be led by a clinician, perhaps a social work or nurse practitioner, who is a communication specialist, that is, a clinician who manages and coordinates the flow of communication between the physician in charge, the team members and the patient and family. This means that when patients come into the hospital they would from the outset have someone who can say: “I will be seeing you each day and I will be responsible for helping you get the answers to your questions and getting you the support you need.” In effect, this individual would be saying to the patient, “I will be responsible for coordinating the management of the your illness which will allow your physicians to accomplish your treatment goals most effectively.”  The physician will still be at the helm of the ship but it will be with the understanding that his or her expertise must be employed in concert with a highly coordinated team effort. “ 

This new team configuration, with a new clinical role created to specialize in communication, could be a new way of framing the physician and patient relationship. Indeed, I think it will be necessary if we wish to properly manage the sick patient’s illness in today’s large, complex hospital setting. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
7 comments | Topics: Clinical Ethics, Communication, Consultation, Doctor-Patient Relationships

Comments

sheila otto

sheila otto wrote on 05/09/13 4:52 PM

Entering the hospital is like landing on a new planet. In most tertiary centers, the multiple doctors do not have a prior relationship with the patient and in this setting, your commentary makes sense. We often wonder how anyone makes it through the complicated hospital course without an advocate.
Farzaneh Zahedi

Farzaneh Zahedi wrote on 05/13/13 10:20 PM

Hi! Prof. Shelton, lack of communication skills is a problem in my country too; however, I think a problem is emerging subspecialties which grows day-by-day. It seems that physicians ignore the integrity of the patient and focus on specific parts of body! I wonder whether a team can fill the big gap between patients and physicians.
Heddy-Dale Matthias, MD

Heddy-Dale Matthias, MD wrote on 05/17/13 1:31 PM

Call me old school, perhaps, but when I was a full time intensivist, I met with the families twice a day, after morning rounds and late afternoon rounds, if they wished. I had clipboards in the waiting room and told them all to write down any questions they had during the interim. I found that the patients/families were relieved to know they would see me everyday for questions. This approach seemed to work well. Often, all the families needed was a short progress report. Other times we would meet for longer. By doing this on a daily basis, little problems did not become big problems, and the communication lines were always open. I considered this my duty. There are times that NPs and social workers can be helpful, for certain, but nothing can replace the physician. I have found that the primary care physician, in my case the intensivist, is responsible for making the coordination of medical care, and communicating the plan with the patient/family. The worst thing that happens in a university hospital it that there is often no one physician assuming primary care. (Hospitalists make this an even worse problem.) I'd rather we concentrate on educating physicians do be primary care physicians (no matter what their specialty) and behaving like one for the patient and family. I think we allow this bad, patchwork behavior on the part of physicians, to the detriment of our patients. If I'm sick in the hospital I want one doc to know everything that is going on with me and communicating that to me. I want to hear it from the physician, not the social worker or nurse practitioner. Despite our high tech world, we physicians cannot abrogate this responsibility to others.

Sign me old fashioned,

Heddy-Dale Matthias, MD
Larry Bridgesmith

Larry Bridgesmith wrote on 05/18/13 5:46 AM

Excellent analysis and recommendations! In our complex adaptive system called health care, communication and interdisciplinary collaboration are key skills leaders must possess. If the physician doesn't possess it, a clinical specialist must. The patient deserves and can only be well served by a collaborative approach. Sub-specialists without collaborative skills will only lead to greater patient dissatisfaction and poorer medical outcomes. Thanks Wayne.
Stephen Offord MD

Stephen Offord MD wrote on 05/20/13 9:29 PM

Hi Wayne. I enjoyed the article. The lecture you referenced was from 1970- achieving good communication must be a longstanding challenge. Employing a communication specialist is intriguing. I see no reason not to try it. If it doesn't seem to help, you tried. If it works you're a genius.
Stef

Stef wrote on 01/28/14 3:48 PM

I randomly came across this article when I was debating about the physician-patient relation with my co-workers.
First of all, thank you Wayne for this great article.
Yes the physician has a major role in this relation but i believe we should consider social workers as a professional solution to fill in the gap between the patient and the physician.
I think we might understand that the it will be for the good of a patient to divide the tasks. It's better if a physician is concentrated on curing and healing the patient and let the post-treatment phase to social workers. A social worker adopts collaborative and exploratory approaches in order to maintain a patients' ability to cope in society from a psychological, physical and social perspective.
I believe sincerely that social worker might change the healthcare system and the physician-patient relation in a good way. I believe social workers should be paid more (http://www.gradschools.com/search-programs/social-work-msw/social-worker-salary)considering the work they do and the level of education many receive.
Andrew Cooper

Andrew Cooper wrote on 10/27/14 7:03 PM

Nice article, I particularly think this is a very important point you made here "a clinician who manages and coordinates the flow of communication between the physician in charge, the team members and the patient and family." Particularly because the physician may be in charge of many patients and may not have that much time to be with the patient and explain everything, also their job is usually to get the job done so their patient communication skills may not be the best, it is always nicer when there is someone who is a trained communicator that can talk to the patient and get the points across that are needed especially between the different members of medical staff that would be talking to the patient.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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