On Humanism in Medicine
Recognizing the Patient as a Fellow Human in Pain


Theresa was two years-old, a child with Down's syndrome and a congenital heart defect. She progressed well, far advanced for her age and disorder. I could only attribute this to her loving family and her own courage and enthusiasm for life. As strong advocates, her mother and father were devoted to her development. Her maternal grandpa and grandmother were also attentive to Theresa's needs, surrounding her with affection.

On this particular day, Theresa was ill. She had been evaluated earlier in the day, but by the afternoon something had gone wrong. The little girl had stopped breathing only footsteps from my office door; her mother carried her draped over her arms like a blue Raggedy Ann doll, running into the office. A call had been made to 911; she was given CPR, intubation, an interosseous line, and a round of heart stimulating chemicals. Yet, her body remained lifeless. She would never wake up.  

As my wife and I gathered at the family's home all we could do was believe that somehow Theresa had left this life and was in the Light, without a shadow, always to be missed but never forgotten. 

Through this tragedy, as a physician I learned more deeply about life, death and depression. I learned to embrace the importance of care and healing for my soul. As osteopathic students and physicians journey through education and practice we can continue to improve upon our own development to emphasize how to care for ourselves and nurture our values. It is imperative that we continue to serve our communities, our loved ones and ourselves. Learning early how to care for our own souls by maintaining our roots, can only strengthen our relationships, allowing us to live in the light.

We are privileged and blessed with the opportunity to listen, touch and serve humanity. This privilege of serving allows us to be equal with each other but especially with our students and our patients. Serving is truly healing. I still struggle with the burden of Theresa's death, but I continue to teach medical students about embracing the courage to protect life, to preserve their own ideology, and to care for their own souls.

I was paralyzed by the haunting shadows of depression and unable to show my strength at the time of Theresa's death, but by stepping out of the darkness into a healing environment I am able to see how Theresa touched my own heart and ignited a flicker of light, which I can now pass on.

I bow to this family, to my colleague, and all my patients who have taught me about love, strength and courage in the most difficult of times. 
- D. Todd Detar, DO '87
Daniel Island, South Carolina

I have witnessed many amazing demonstrations of the strength of the human spirit during my 33-year career as an osteopathic physician, but the one that moved me the most was my trip to Phnom Penh, Cambodia, an area still devastated from the tyrannical reign of Pol Pot and his Khmer Rouge which claimed the lives of two million and virtually eliminated health care services to a population plagued with poverty, injury and widespread chronic disease. As a participant in a medical mission, I spent two weeks working with the staff at Sihanouk Hospital Center for Hope (SHCH), a Center that provides high quality, free medical treatment to mass populations.

Despite what would appear to be a futile challenge, the resourceful and passionate Cambodian people, along with the help of a number of Non-Government Organizations (NGOs) from throughout the world, have slowly started to rebuild their nation's health care system. They have begun with the most basic elements and limited resources, but theirs is an uncompromising will and hope that the country that they love can once again experience the glory of its past.

I was fortunate to experience such passion. For I found that through teaching medicine to the Cambodian people, I was learning how true commitment and relentless courage could change an entire health care landscape. I'm confident that these people will recover and that there are many more lessons to be learned from their spirit.
- James P. Dwyer, DO '75, MBA
Medford, New Jersey

It was my month in the ICU as a medicine resident and I had been summoned to the ED for an ICU admission. It was there where I met Mrs. Smith.

Mrs. Smith had suffered a catastrophic intracranial hemorrhage. She has been intubated and stabilized. The neurosurgical consultation prior to my involvement had determined she was not a surgical candidate due to the extensiveness of her bleed. She was starting to show signs of herniation. I performed my history and physical, wrote my admission orders and waited for Mrs. Smith's transfer to the ICU. I was also on call that night.

Mrs. Smith's family began to arrive at the hospital. I talked with her immediate family about the gravity of her condition. Mrs. Smith had no living will. I told the family she was in critical condition, and despite our best efforts, might die by evening. As the day wore on, additional family members started arriving for Mrs. Smith, all wanting to understand her condition. I asked the family to assemble outside the ICU in a conference room so that I could speak with all of them at once and answer questions.

I was confident thinking about what I would tell the family when we met. Talking to people is my strong suite. However, as I mentally prepared myself and entered the conference room, I was surprised to walk into a room filled with 30 people. All of Mrs. Smith's children, brothers, sisters, nieces, nephews, grandchildren, and their spouses were present. I patiently discussed her condition and its futility. I answered all their questions, sometimes the same one twice. I wanted them to understand and have no doubts about her situation. We talked about withdrawing care and comfort measures, but it was too soon for them to make a decision. We agreed to designate a family spokesperson for updates.

Over the next 24 hours, Mrs. Smith's condition deteriorated noticeably. On the second night, the family wanted to meet with me again. I was post-call, but I agreed to meet with them. Once again we met in the conference room, and once again I was amazed by how many family members were packed into the tiny room. This time the family seemed to listen more and ask fewer questions. They were conflicted about withdrawing care. Her daughters told me Mrs. Smith would give them a 'sign' about what to do.

Day three was Mrs. Smith's birthday. "Surely," her daughters said, "today there would be a sign." Yet, day three passed and there was no sign. So, too, did days four and five pass. On day six, Mrs. Smith's downward decent continued. Her daughters arrived at the ICU, requesting to meet with me again. The daughters informed me that the family had decided to withdraw life support and keep Mrs. Smith comfortable. The daughters then presented me with a birthday present. It was my birthday and they must have heard the staff talking about it. Who would have thought that in the time of their darkest distress that the Smith family would think to get me a gift for my birthday?

Mrs. Smith's daughters gathered all the family members in the conference room for the last time. When everyone was assembled, they told me that they were ready to see her off. Mrs. Smith's immediate family entered the room and said their goodbyes. After the goodbyes, the family stood hand in hand outside her room in a semicircle of love as Mrs. Smith's endotracheal tube was withdrawn. I invited the family back into the room. It was not long after that I pronounced Mrs. Smith's passing from this world. The family thanked me for her care, and I thanked them for allowing me to care for their loved one. Our journey of days had ended.

I have often remembered the Smith family over the years and the valuable lesson that I had the privilege of learning from them. In emergency medicine, I see a lot of older people come through the ED doors; many of them are discarded like a child's used toy - no family to care for them, no one in their lives to love them. The Smith family showed such love, compassion, and selflessness. The family pulled together as a unit and provided warmth and compassion for Mrs. Smith, and even had some room for me in their hearts. All the while as I was caring for Mrs. Smith, I thought that I was preparing her family for her death; in reality, the lessons of love and family were mine to learn.
- Joanne Hullings, DO '96
Bristol, Pennsylvania

Humanism is one of those inborn traits that we often ignore as physicians. We get caught up in diagnosing patients' ailments, dealing with insurance companies and struggling with lab/X-ray tests that can only be puzzling at times. We often forget about those behind our frustrations. They are called patients; and yes, they are human. 

My experience with humanism occurred when a 92-year-old assisted living resident came to my office for her quarterly exam. She so eloquently spoke about the trials and tribulations of nursing home living. The only problem was that I could reiterate her every word before she spoke a single sentence. That's because she started every visit with the same repetitious stories. Our visits would end with gracious salutations and she would be on her way in her wheelchair waiting for her 'driver' to pick her up.

One day I noticed that she was sitting in the waiting room two hours after we had finished. I was angered that my receptionist had not called for the driver to pick her up; however, when I questioned her, she declared that she had called the service only seconds after the patient had enter the room for her exam. The receptionist made me aware that this particular patient always waits two or more hours for her ride. I was astonished! I gasped and quickly gathered up a sandwich and a drink for my patient. The look of surprise and gratitude on her face made me appreciate this lady not as a patient but as a human being. I will no longer take her repetitious stories for granted.
- Brian D. Kuronya, DO '99
Bethlehem, Pennsylvania

Angie was my patient for over 20 years. She had a loving husband and three adult boys who were also patients. Angie's family had a summer home near mine at the shore and occasionally the boys and I went fishing together.

One day Angie came to see me complaining of abdominal pain. A battery of tests revealed colon cancer already metastatic to the liver. I referred her to a surgeon who wanted to remove the tumor and then to begin a course of chemotherapy.

The family was devastated and confounded by treatment options; Angie came to me to ask what she should do. She understood the surgeon's direction, but she wanted my opinion and details about what she should expect post-operative. After answering all of her questions, Angie chose to proceed with surgery. 

Following surgery, Angie began a regimen of chemotherapy. She accepted the side effects of her treatment. The cancer was contained for over one and one-half years, but she then started to decline. When Angie became too weak to come to my office, I made house calls after hours. Whenever I made a house call, I would always spend some extra time with the family.

Eventually Angie was hospitalized with an obstruction; she needed immediate surgery. She refused! She said she had enough and did not want to put her family through additional illness. She was giving up the fight! Her surgeon said she would die within one to two days without surgery. Her sons came to see me and begged me to visit their mother in the hospital and convince her to have the surgery. Without hesitation, I carried out their wishes.

That same night, after office hours I went to the hospital. I embraced Angie. She was pleased to see me. After lengthy conversation - telling her how much her family loves and needs her - she agreed to have the surgery.

The surgery was successful and Angie survived three more months - longer than anyone predicted - and long enough for her to see a newborn granddaughter. She died peacefully at home with her loved ones surrounding her. To this day, her family remains grateful for the extra steps I took so that they could have their mother with them a little longer.

This was but one of many opportunities that arise in clinical practice for us to take that 'extra step' for the welfare of the patients entrusted to our care.
- Anthony LoBianco, DO '60
Philadelphia, Pennsylvania

In October 2000, I had just been appointed chief medical officer/health care manager at a California prison. I had no prior experience in correctional medicine. As I made rounds in the on-site prison hospital, I noticed all patients were locked in separate cells. A 78 year-old man was suffering from metastatic colon cancer and had lost his appetite and was losing weight. I asked how I could be of help to him. Would a compassionate release be possible so he could spend his last days with his family? He told me he was sentenced to life without parole, and a release was not possible. He committed his offense 57 years earlier. He said the only form of food he could eat was Carnation vanilla fudge swirl. I ordered one pint three times a day for him as a nutritional supplement. I secured a television for his cell. When I saw him the next day, he was cheerful and thankful. He said my actions were the kindest things anyone had done for him since his incarceration.

That afternoon I received a call from the acting warden who warned me that I had violated a prison rule by showing preferential treatment or 'over familiarization with an inmate.' He threatened to have me terminated if I did not rescind my orders. Since I was of equal 'rank' to the warden, I explained that I ordered the ice cream as a nutritional supplement, not as a 'treat.' I would not back down.

My car was keyed the next day. There were no witnesses to the incident.

Undeterred, I met with the 'shot callers' the next day in my board room. I was with five multiple murderers and no guards. To show that I had no fear, I asked the men (as if I were J.W. Nordstrom) to consider themselves the 'platinum cardholders' and to inform me about what they perceived as being wrong with the medical system. I limited them to the five most pressing items. When they returned from their housing units, they informed me of their requests, all of which were reasonable. For example, why do the hospital patients only see a library cart once a month? I changed it to twice weekly. I allowed a TV for any patient with a terminal illness with a prognosis of six months or less and affirmed that there would be no upper bunk housing for older and infirm patients. I also instructed my staff not to look at incarceration records, but to treat the patients as they are - patients.  No staff member was to write the word 'inmate' in any medical record. Only 'patient' was to be used as the reference. When I was asked by the 'shot callers' what I wanted as a quid pro quo, my response was "respect for my staff of doctors and nurses - no foul language or intimidation." This was accomplished and conflicts were no longer a problem.

The cycle was completed when I was able to have osteopathic medical students serve a minimum of two-month rotations at the prison and when a waiting list soon appeared. It was gratifying to see the look of appreciation on the faces of the patients and the students alike. The city newspaper did an article about the medical care given by my staff a year later and used the words "dignity and respect" in their description.
- Alan L. Menkes, DO '67
Laguna Beach, California

My case was a 32 year-old construction worker who had previously been admitted to the same psychiatric evaluation unit approximately three months prior to this presentation. That admission was for substance abuse issues. He was referred from the ED, this time under an involuntary petition for crisis care for acute suicidal intent. He had presented to the ED with the following complaint: "If I have to live feeling this bad I want to die." The screener working in the ED diagnosed him as acutely depressed and actively suicidal. He was seen by an emergency department physician, other medical students and residents and sent per the local sheriff to our facility for treatment. He had no evaluation in the form of laboratory or other studies.
 
When I gathered the history from this patient the next morning he related a 30-pound weight loss, malaise, lack of energy and being unable to continue in his work. He reported drinking three gallons of fluid a day and never being able to quench his thirst. His physical exam revealed muscle wasting, clothes very large fitting, a very anhedonic individual to say the least. He stated he truly felt bad but gave no specific intent of ending his life. His concern was that he had cancer. He had never relapsed on any drugs or alcohol since his last stay and had been attending self help groups. When he also admitted to intense hunger and the family history showed diabetes, I was relatively confident the real problem was new onset diabetes. I offered him reassurance that we could help him get care. I arranged a finger stick and awaited his morning labs. I didn't think we would get a random blood sugar off the range of the glucometer--920!  Luckily this individual didn't have ketosis which could have been more life threatening.

Even more alarming than the referral to our facility was the process of referring this patient back to  the hospital. The process took about two hours of begging with various residents and house officers and explaining why he didn't need to be in a residential psych evaluation facility with no medical services except me! Eventually the ED accepted him back and he was admitted to the medical floor. He stopped back several weeks later to pick up some personal items he had left at our facility and thanked our staff for their help.

Patients are treated without really being listened to and examined. Anyone could have diagnosed this individual if they had listened to him, his history and symptoms. My only solace in this case is that the institution he came from was not an osteopathic one. I hope we continue to practice what we have been taught and that our students appreciate our philosophic difference from allopathic medicine.
- Ron Paolini, DO '85
Aiken, South Carolina

Patients need a physician who not only cares for their physical needs, but also their emotional needs. It is easier to think of a patient as a disease rather than a person: "Go see the gall bladder in room 309" or "How's the heart attack in the ICU doing?" Dehumanizing a patient makes it easier to deal with the difficult things that confront us as physicians. However, we should never lose sight of the fact that our patients are people and when they are ill, they are the most vulnerable. They may, at times, be afraid, confused, distracted, angry or even hostile. It is the duty of the physician to help them through their crisis. The physician needs to be compassionate, to offer advice, and to give them hope. When the situation warrants, the physician should help them through their final moments.

The human side of medicine should never be forgotten. Patients should be respected. It is necessary to understand that their questions should be answered honestly and their misconceptions  should be corrected. The manner in which this is done may be as important as the information given.

The human side of patients is exhibited when they take time to show the physician their appreciation - thanks taking the forms of cards, candy, and homemade cakes and cookies. Kindness and caring go a long way, and patients know when a physician cares. They are willing to accept the fact that medicine has limitations and that not all problems can be fixed. Physicians who show concern about patients, regardless of case outcome, are more likely to be respected by the patient and their families.

Humanism is innate, but it can also be learned by example. Students and younger physicians learn how patients react to the way they are treated by more senior physicians. Sometimes we learn from our peers. For example, one of my fellow interns delivered a patient's baby in a clinic. He stayed with her well beyond the end of his shift and helped her through a difficult delivery. She was so grateful that the baby was named Szczygiel after Dr. Gerald Szczygiel. How's that for a first name?

I was asked to write about an experience in my clinical practice that taught me about humanism in medicine. The reality is that it's a lifetime of experiences that teach you. The process never ends.
- Domenic Pisano, DO '72
Bryn Mawr, PA

As a student at PCOM, I had several faculty members who impressed me tremendously and have helped guide my medical career and life in general. Like many medical students, I was unsure of my area of specialization - psychiatry or family practice - and took my rotations seriously. After graduation, I decided to head back to my native New York and to enter New York Medical College's  family practice program (Brooklyn-Queens). This was a 'safe' choice for me; my father's radiology practice was in the neighborhood where I would train.

During the summer of my PGY 1 year, I treated a 73 year-old women for DVT in the hospital. My patient needed follow up care post-discharge and since a therapeutic alliance had been established, I offered to follow her in the clinic. My patient was very compliant in her appointments and I enjoyed her zeal for life. During one of her appointments I shared my plans for community-based research - opening a school-based clinic in one of the local elementary schools. Her eyes lit up! She told me that her great granddaughter, whom she was raising, was a student at the school. She encouraged me and told me that such services were needed in the community.

In the fall of my PGY 1 year, my patient came to an appointment teary eyed. She related that her great granddaughter had been taken away from her and had been placed in foster care. When I asked why this had happened, she mentioned that her neighbors were jealous of her and called the authorities stating that she was using drugs. Suffice to say, I volunteered my services to correct this injustice. I spoke with her lawyers, wrote letters to ACS, did the nine yards. I also had my patient take two drug tests that were analyzed in the hospital's lab. I was convinced there had been a great error.

During the spring of my PGY 1 year, my patient sought treatment for an STD. One of my supervisors recommended drug rehab for her. I looked at my supervisor with incredulous eyes and reluctantly spoke about the issue of drug abuse with my patient. My patient was aghast! "Child, I am old enough to be your grandmother. I have no time for such nonsense." Falsely secure with her answer and somewhat embarrassed, we spoke about the next issue at hand.

This went on for the next two years. During the spring of my PGY 2 year, I decided to continue my training post family practice residency and apply for psychiatry residencies with the goal of sub-specializing in child psychiatry. By the spring of my PGY 3 year, I had secured a position with a program in Manhattan - and I was scheduled to see my patient for the last time.

She began the session by declaring, "Doctor, child, I have something to tell you that will make you very proud. I checked into rehab last week."

Floored - I was absolutely floored. My feelings ran the gamut of emotions. Yes, I was proud that after 50 years she had finally admitted to her addiction to cocaine and cannabis. At the same time, I was furious that I had spent so much time trying to help her regain custody of her great granddaughter. I thought about her daughter who had spent her entire life on drugs, her granddaughter who was in and out of jail due to substance abuse and of her great granddaughter who was mired in the foster care system. What impact did my patient have on these three generations of broken, wounded lives?

The disease of addiction is a serious problem. My patient was in denial and had developed a way to hide her shame. Family practice physicians are at the forefront of diagnosing and helping these patients get the treatment that is needed.
- Ulrick Vieux, DO '99
New Rochelle, New York

I am a forensic psychologist, asked by the courts to evaluate and make clinical recommendations.  At PCOM, I was taught the importance of empathy and rapport. However, like an emergency room physician, my relationship with patients rarely exceeds several hours. The case described below is not a great example of a humanistic relationship, but rather a shining example of humanism and resiliency displayed by a teenage girl whom I shall call Dominique.
 
Dominique is a 16-year-old African American female, currently living with her mother and four siblings. Diagnosed with cerebral palsy, she has had several orthopedic operations and botox treatments to increase the probability that she will stand on her own. When she was 12 years old, she was repeatedly sexually assaulted by her mother's paramour. She was placed in several foster homes, and has recently been reunited with her biological family. 

Despite her physical challenges, sexual assaults, and foster care placements, Dominique has never received behavioral health therapy. Now involved to monitor the reunification process, the courts have asked me to assess Dominique and make recommendations for treatment.

Dominique was evaluated in her home in the presence of her mother. Presenting with a flat affect, she was withdrawn and isolated. She answered questions and established rapport. She described how she crawls up and down the stairs in her mother's house in order to go to the living room. Dominique displayed how she uses the computer and turns the pages of her books and journals with her one functional hand. She recalled recurring dreams in which she is able to walk on her own. Teachers, social workers and physicians contacted for the evaluation report that she is always pleasant and cooperative. Other than school and medical appointments, Dominique does not leave her home.  

I recommended that Dominique participate in individual outpatient therapy at a qualified behavioral health agency specializing in sexual victimization. It is important that services are office- based in order to increase time spent out of her home and to insure her privacy. Dominique wholeheartedly agreed with these recommendations, adding that she would like to speak with a female clinician about 'boys.' Despite her physical challenges, sexual abuse, foster placement, family reunification, continuing medical procedures and court involvements, Dominique is pleasant, crawls when she needs to, reads and journals with her one functioning hand, and wants to speak with another female about 'boys.' She is an excellent example of resiliency, inner strength, and humanism.
- Jordan Weisman, PsyD '03
Philadelphia, Pennsylvania