THE ART OF MEDICINE
Dr. DAVID GOLDBLOOM
Born in Montreal, Dr. Goldbloom was raised there and in Halifax. Advised by his father, Richard, to study something other than science "and learn about the rest of the world" even if he eventually intended to practise medicine, Goldbloom took an undergraduate degree at Harvard in government and won a Rhodes Scholarship. At Oxford, he studied physiology, earning an M.A., and then returned to Montreal to study medicine atMcGill University. By then, he had married the former Nancy Epstein, an ophthalmologist and daughter of Dr. Nate Epstein, who had been recruited from Montreal to become founding chairman of the psychiatry department at McMaster's medical school. In 1985, after hearing a lecture by the Clarke Institute's director Paul Garfinkel, Goldbloom moved to Toronto, practising first at Toronto General and then becoming chief of staff at the Clarke. When the Centre for Addiction and Mental Health (CAMH) was created in 1998, he was named its physician-in-chief, serving in that position for five years before becoming its senior medical advisor.
It isn't often that you encounter a physician who begins a conversation with the statement, "Medicine cures almost nothing." Such is the view, however, of Dr. David Goldbloom, senior medical advisor at the Centre for Addiction and Mental Health in Toronto and professor of psychiatry at the University of Toronto.
For Goldbloom, the art of medicine is about engaging patients in ways that allow doctors to understand, and to offer help and hope. Can hope be offered in every case? "I think it's rare you can't provide them with some kind of hope." But hope, he cautions, does not necessarily mean cure.
"This search for the cure plays into the mythic aspirations of people who are ill," he says. "The daily toil of medicine is rarely about cure. The daily toil of medicine is about helping people live /with what they have, facilitate their best possible adaptation to it, minimize the intrusion of their symptoms on their functioning and their quality of life and maintain the hope that things will improve. That is the art of medicine."
Even people who are dying, Goldbloom insists, have hopes — hopes about what the nature of their death will be like. Palliative medicine, he says, has taught the medical community a great deal about hope. The idea that hope is extinguished if the patient is terminal is based on a much too narrow construct — that hope is cure. Goldbloom cites the instructive epithet of 19th-century American sanitarium physician Edward Trudeau: "to cure rarely, to relieve often, to comfort always."
It is understanding, he says, that generates a diagnosis. But diagnosis is only a small part of the art of medicine's complex equation. Diagnosis pinpoints the disease, "but the illness is the context." And diagnosis is based on a two-word principle: pattern recognition. "That is what doctors do, day in and day out," Goldbloom says. Andif they couldn't do it, if every patient presented with symptoms that defied pattern recognition, "they'd be terrified," he says.
The art of medicine extends the challenge. It asks physicians to graft that highly reproducible pattern onto the unique pathway that constitutes a human life and context and experience.
It isn't uncommon to find patients who will tell friends and family, "I have a great doctor." But what, Goldbloom asks, do they mean by that? What they typically mean is that "he or she spends time with me. They really listen to what I'm saying. And they know their stuff. Few patients have the ability to evaluate their doctor's medical skills, whether diagnostic or surgical. But they know if they have a good or bad doctor, and that judgment taps directly into the art of medicine.
In one well-known experiment about care, doctors were asked to approach their patient and either stand or sit by the bedside. Both the standing doctors and the sitting doctors stayed in the room for precisely the same length of time. But in every instance, patients perceived doctors who sat as having stayed longer.
Goldbloom maintains that the humane side of medicine can be taught, but "the worst place to teach it is in the classroom." The best place, he suggests, is on rounds, in clinics or in doctors' offices. Medicine, historically, has been an apprenticeship profession, but "there's been some erosion of that concept." In part, it's the result of the explosion of scientific knowledge, which new doctors are expected to absorb and master.
For one year, Goldbloom taught part of a course in the art and science of clinical medicine at the University of Toronto. The mandate involved leading students into the hospital for first time and letting them interview and examine patients. "My first inter-view took about six hours," Goldbloom recalls of his own student days. "I had to take a dinner break in the middle, and I still left out the abdominal exam."
For his teaching gig, Goldbloom found himself at Toronto Western Hospital's neurosurgical unit. He initially feared that all the patients' ailments would be too similar medically but, while they were, the students were nevertheless exposed to a diverse range of people. He remembers one older Chinese patient who had broken a vertebra in his neck, but had not been paralyzed and was making a good recovery. The student assigned to interview him did a good job. At the end, Goldbloom told the man this was the students' first day in the hospital — did he have any advice to give them about being a good doctor?
"You must love your patients," the old man said. "Here, I see some who do and some who don't."
For Goldbloom, it was an extraordinary moment and he felt privileged to have been part of it as a witness. Months later, he had occasion to bump into several of the students in the room that night, and the elder Chinese gentleman's remarks were "etched like granite" in their memories.
Loving every patient — or even giving them the impression that they are loved — is a tall order, he allows. The demands on a physician's time constitute one limiting factor. But so is the social reality that not all patients are loveable. Part of the challenge of the art of medicine, he suggests, is "finding things to like in people you don't like. Even with a pest, there has to be something you can connect with. You have to work at it because, if you don't, the patient will pick up on your negative attitude. You might be withholding or punitive or avoidant. You might take a holiday when he or she is booked for an appointment."
Doctors therefore require a level of self-awareness, because just as there will be patients they don't like, there will be patients they may like too much. They give them too much time and attention, or stray into ethical boundary violations. Both can impact on their ability to be a good physician.
Not long ago, a colleague of Goldbloom had to deliver a negative medical report to a young woman. The patient had a difficult condition for which there was no known remedy. His colleague agonized over how to deliver the news. He read books by other doctors on that very subject. He sought the opinion of other doctors. And he spent many hours just thinking the issue through, weighing how best to convey the difficult prognosis.
"There is no one single right way to do it," he says, "but there are many bad ways to do it." During his years as a student on a surgical rotation, he watched one presiding resident march in to see a post-operative patient and announce without preamble, "You've got cancer. I'll see you in a while."
"Why did you do that?" an incredulous Goldbloom later asked the resident.
"Because in my experience, after you tell them they have cancer, they don't hear anything else you say anyway. So I let them stew and then go back and talk to them."
Of course, there was a time when it was normative for physicians not to tell patients, particularly the elderly, that they had cancer. A conspiracy of silence would reign. The children would be informed, but the patient himself was kept in the dark, even though, in most instances, he knew the truth anyway. "It was like there was some magical belief that if you didn't say the word cancer, it was not true. People would whisper the word or call it "the big C."
Goldbloom cites another seemingly small but hugely significant aspect of the art of medicine: the ability to remain silent and listen. Studies show the average length of time it takes a doctor to interrupt a patient is 12 seconds. "Imagine, you go to see your physician for the first time and even before you've begun, he or she has interrupted you."
Compare that, he says, with how communication was handled in years past. Both Goldbloom's father and grandfather were pediatricians. His father, Richard, once wrote an essay called "The Lost Art of Consultation — Let's Dust Off the Old Striped Trousers," which recalled the style of consultation used by his father, Alton. In those days, Alton Goldbloom practised out of an office on Montreal's Crescent Street. If he was seeing a patient for the first time, he would invite the parents, the sick child and their family doctor to meet with him in conference. Then, he and the family doctor would retire to a private salon to discuss the case in more detail, before returning to present their joint findings to the family.
"That," Goldbloom acknowledges, represented "optimal communication." Today, a consultant physician often gets a one-sentence referral letter saying that the patient has pain, please assess and treat. "So you examine the patient and send a report to the referring doctor and never have a face-to-face conversation or even a phone call."
It's unlikely that the profession will ever return to the older model, Goldbloom concedes. Similarly, it's unlikely to arrest the continuing trend toward subspecialization. "A subspecialist," he quips, "is someone who knows more and more about less and less. You can't reverse that steam engine and it's necessary to advance knowledge."
But what it also necessitates, he says, is the supervisory role of the primary care physician, someone able to quarterback and integrate the work of a team that may include half a dozen or more specialists.
When he is ill himself, Goldbloom visits Toronto internist Howard Abrams. "I consider him a great doctor. Why? Because when he examines me, I feel examined in a good way. He makes me feel like he has all the time in world for me, like I am his only patient. He's never preoccupied. He listens. And there is something so relieving in knowing that an experienced physician has laid hands on you. It's extraordinarily comforting."
More than most medical fields, he maintains, psychiatry is cloistered in secrecy, "so people get away with things they might not in other areas. But there's a reason operating theatres are called theatres. It's a theatre. They used to have stadium seating." When his father-in-law taught family psychiatry at the Jewish General Hospital in Montreal, he would do demonstrations for students every week in an auditorium, in front of 200 people, showing how to interview entire families.
On occasion, Epstein would interview healthy families with no dysfunction, just to trip up his students. That, says Goldbloom, is "an important reminder that doctors will see patients who are fundamentally healthy, and that part of the art of medicine and part of being a doctor is to reassure people that they are healthy." His own father used to describe the practice of pediatrics as the "treatment of anxious parents of healthy children." Frequently, when parents brought a child suffering from headaches, the pediatrician would say, 'In my experience, it's not uncommon in these situations for one or both parents to fear the child might have a brain tumour.' At which point one or the other parent would burst into tears."
The point, says Goldbloom, is that part of any doctor's mission is "to expose the hidden agenda. And that's as true in internal medicine as it is in psychiatry."
What future generations of doctors need more of, Goldbloom suggests, is time observing clinicians at work. "What students clamour for is independence, especially in doing procedures. But they spend less time observing someone taking a history. After all, the physical exam simply confirms what you should know from taking a good history, and that's the art of listening and synthesizing."
When working with his own students, final year residents in psychiatry, Goldbloom makes a practice of doing a complete assessment of patients every four or five weeks, while they observe. Many of them, he says, "may not have seen a full assessment performed in three years. That to me is an indictment of our educational system, but I'm a voice in the wilderness."
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