Daniel M. Lichtstein, M.D., MACP

Professor of Medicine

Regional Dean for Medical Education

University of Miami Miller School of Medicine

Objectives 1. To better understand the role of humanism

in medicine

2. To understand the role and importance of civility in medicine and in our personal lives

3. To use anecdotes to illustrate examples of humanism and civility

In accordance with the guidelines of the Florida Medical Association/Accreditation Council for Continuing Medical Education, Dr. Lichtstein

has indicated that he has no conflict of interest to disclose that will affect his ability to present

an unbiased presentation.

The planning committee for this activity has also indicated that they have no conflict of interest to disclose which influenced their ability to plan an

unbiased presentation.

“Filling buckets”

“Each of us identified the core mission of medicine, making a meaningful difference in someone else’s life-healing if possible, alleviating suffering and fear if not, or simply caring-as the ingredient that filled our buckets.”

Matthew Press, M.D., Timothy Judson MPH, and Allan Detsky, M.D., PhD

JAMA, May 14, 2014

Timothy Judson: M-3 student

Dr. Press: Junior Faculty

Dr. Detsky: Senior Faculty

“The Language of Experience”

“Experience teaches us to recognize what really matters to people, to sift through the routine and the remarkable, to separate the trivial from the true essence of a patient’s needs. To recognize that to serve our patients we must adapt to them, to learn to see things through their eyes, to work on their terms. Medical school teaches us to speak the universal language of medicine, but our patients teach us to understand it.”

Jesse Raiten, MD A Piece of My Mind

JAMA, September 10, 2014

What is humanism?

What is humanism in medicine?

Humanism in Medicine

From the Arnold P. Gold Foundation (2013) “Humanism in medicine describes relationships between

physicians and their patients that are respectful and compassionate. It is reflected in attitudes and behaviors that are sensitive to the values, autonomy, cultural and ethnic backgrounds of others.”

“A humanistic doctor demonstrates the following attributes” (I.E., C.A.R.E.S.)

Integrity Excellence Compassion Altruism Respect Empathy Service

Bernard Lown, M.D. Renowned Cardiologist and Nobel Peace Prize

Winner

The Lost Art of Healing Bernard Lown, M.D.

Anatole Broyard, essayist, wrote this to his doctor shortly before his death from prostate cancer:

“I wouldn’t demand a lot of my doctor’s time. I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh to get at my illness, for each man is ill in his own way…Just as he orders blood tests and bone scans of my body, I’d like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness.”

Fernando González 20th century Colombian philosopher

Oblivion A Memoir

Héctor Abad

González’s description of the ideal doctor:

“The professor of medicine must be out on the road, observing, handling, seeing, listening, touching, struggling to heal, with a string of apprentices… Yes, young doctors: it is not about being kind and sending out large bills and selling vitamin pills…it is about sending you out to heal, to invent, and in a word, to serve.”

The Best Possible Day NY Times 10/5/2014

“People want to share memories, pass on wisdoms and keepsakes, connect with loved ones, and to make some last contributions to the world. These moments are among life’s most important, for both the dying and those left behind.”

From “Being Mortal: Medicine and What Matters in the End”

Atul Gawande, M.D.

More from “Being Mortal” Atul Gawande, M.D.

Referring to Gerasim, Ivan Ilyich’s servant in Tolstoy’s “The Death of Ivan Ilyich, 1886”, as Ivan was fading: “This simple but profound service-to grasp a fading man’s need for everyday comforts, for companionship, for help achieving his modest aims…” Gawande: “As people become aware of the finitude of their life, they do not ask for much…they ask only to be permitted to keep shaping the story of their life in the world-to make choices and sustain connections to others according to their own priorities.”

“Time Will Tell”

“Instead of hoping to indefinitely stave off death, we can hope for the most meaningful and peaceful end of life.”

Bryan Sisk, MD

A Piece of My Mind

JAMA, March 17, 2015

A close colleague’s definition of humanism

“…to forge a bond with our patients and their families that makes them feel respected and very active partners in the doctor-patient relationship. Competence, compassion and empathy are also givens if one is truly practicing the art of medicine. Integrity, altruism and a true sense of service are also characteristics that anyone in the healing arts should have in abundance.”

James M. Cooper, M.D.,FACP

“Vocabulary of Caring”

Beneficence: Latin for “active kindness”

Empathy: “in feeling”

Sympathy: “like feeling”

Compassion: “to suffer with”

Penelope S. Fisher, M.S., R.N. Clinical Instructor, Department of Otolaryngology

UMMSM, Sylvester CCC

2014 recipient of the first “Penelope S. Fisher Award for Outstanding Humanism in Clinical Care and Clinical Education”

In 2006, she started a primary nursing program that paired nurses and physicians with patients so that patients would see and interact with the same nurse at every visit.

More about Penelope Fisher…

A patient’s wife wrote to thank her for her patience and kindness after contacting her about her husband’s sarcoma:

“I just want to thank you for generously giving me your time and even pulling your car over so we could

talk.”

She keeps a drawer of notes from patients and family members and says “…after all the things we endure with our patients, some tell you how you helped them and that is quite possibly the greatest moment of all.”

More…

She goes on to say:

“In our daily world we may only get one minute to make the difference in an interaction, transaction or

intervention that changes an outcome. All of our outcomes must be founded in the value of human beings, individually, collectively and generally. For it is then we

have truly practiced in the meaning of the art and science of caring.”

Paul Farmer, M.D., PhD Professor of Medical Anthropology, Harvard Medical School

Founding Director, Partners in Health

Medical Director of a hospital in rural Haiti, the Clinique Bon Sauveur

He advocates for equitable health care for the most vulnerable and most needy

“Anyone who wishes to be considered humane has ample cause to consider what it means to be sick and poor in the era of globalization and scientific advancement.”

Sir William Osler Turn of the century educator

Osler’s motto, according to one of his medical students

“Do the kind thing and do it first.”

Osler’s letter to the parents of a young man who died of smallpox

An act of compassion (humanism)

A young man he had just met

Smallpox was diagnosed; disease progressed rapidly, and the patient expired

Osler wrote a detailed and factual letter to the young man’s parents describing exactly what had occurred, and that their son received excellent care

Explained that as he was dying, the man talked about his mother and died peacefully

30 yrs later, the man’s sister expressed gratitude on behalf of her mother for the letter he had sent

Humanism does not always have to directly involve patients

Osler kept pre-stamped postcards handy at all times

Would drop a quick note of congratulations or best wishes to a colleague or student

Sometimes, he would just write: “I am thinking of you.”

William Wordsworth 18th-19th century English poet

“The best portion of a good man’s life is his little, nameless, unremembered acts of kindness and of love.”

John Gregory, M.D. Mid-18th century Scottish physician

One of the first physicians to have a major influence on American bioethics.

Taught that the practice of medicine required sympathy.

“Tenderness, gentleness, flexibility…”

Of the physician’s character, “The chief quality is humanity…”

Anecdotes from colleagues

The mother of one of my colleagues is a pediatric intensivist: a decision to disconnect a baby from a ventilator

A colleague who stood by a patient with alcoholism for years to help him maintain sobriety and reconnect with his family

In a letter to the physician, the patient said, “With your help and encouragement I have become a better father, friend and person than I ever dreamt of becoming.”

Personal anecdotes

An elderly woman with unexplained pre-renal azotemia

An elderly woman discharged to home after a nursing home stay for a hip fracture

Home visits at the end of life

“Choosing Civility” The Twenty-Five Rules of

Considerate Conduct P.M. Forni

Co-founder of the Johns Hopkins Civility Project

Henry James Anglo-American writer, 19th century

“Three things in human life are important: the first is to be kind. The second is to be kind. And the third is to be kind.”

From a medical school applicant’s personal statement

A physician the applicant had spent time with shadowing said,

“If you learn nothing else from me, learn to always treat your patients with kindness.

Every man is someone’s son. Every woman is someone’s daughter.”

From a physician reflecting on the care her mother received in the hospital

“…being on the other side made something painfully clear. I realized that the face-to-face contact, the words, the silence, the facial expression, the touch-all that make up the human interaction of the physician-cannot take place behind the scenes. …the palpably human presence of the physician is critical to addressing the patient’s (and family’s) vulnerability during any state of illness.”

“The Other Side” Ann Intern Med

September 16, 2014

What is civility? A few examples from “Choosing Civility”

Respect for others

Care

Consideration

Courtesy

Politeness

Kindness

Fairness

Self-control

Justice

Selflessness

Etiquette

Community service

Honesty

Morality

Moderation

Listening

Compassion

Lending a hand

“What is civility?”…

Dr. Forni concludes:

“civility is complex”

“civility is good”

“whatever civility might be, it has to do with courtesy, politeness, and good manners”

“civility belongs in the realm of ethics”

You know it when you see it!

Anecdote

What should you do when you are planning to retire or leave your practice?

What is your responsibility?

Is that enough?

Practicing civility

Patients:

Wish to say goodbye

Express their thanks

Ask for guidance about their care

Have one last “check-up” with you

Physicians:

Say “thank you for entrusting your care to me”

What to do “if you need me”

Express confidence in your “replacement”

Thank you!

If anyone has any comment or anecdote to share…