Are we doctors, or high priests of healing?

In treating a stubbed toe, the author stumbled upon an enduring truth: that the ancient practice of medicine is influenced by many things other than science.

By Gregg A. Bendrick, MD, MPH
Occupational Medicine Specialist/New Orleans

Years ago, I was stationed at a small US military hospital in northern Japan, pulling an ER shift one Friday evening, when an Air Force fighter pilot brought his wife in. She had stubbed her toe on a bedpost. My brief exam revealed a swollen, tender, ecchymotic great toe. I suggested "buddy-taping" it to the adjacent toe and recommended an over-the-counter agent such as ibuprofen for the pain. I was about to make my exit when it became clear that neither the pilot nor his wife was happy with my treatment and disposition. They wanted an X-ray of the toe to see if it was broken. "It could very well be broken," I advised them, "but my medical management would not be affected by the results of an X-ray."

The pilot, as it happened, was a squadron commander, an Air Force VIP. Both he and his wife had specific thoughts about what should be done for a stubbed toe. Even though an X-ray was not medically indicated from my perspective, an
X-ray made sense to them. As a junior physician, I was not strategically positioned to modify their beliefs.

In an effort to compromise, I offered to write an order for an X-ray to be done the next duty day, two days later on Monday.

This was not acceptable.

I could see where the encounter was going. The pilot would talk to his boss, who would call my boss, who would tell me to make everyone happy and get the X-ray. Recognizing that surrender might be the better part of valor, I called the X-ray technician in from his home.

Fifteen minutes later, we had a film that showed a minimal, nondisplaced fracture. I showed it to the pilot and his wife, who were very interested in the finding and very pleased to have the information. Once more, I explained that the way to treat the problem is to "buddy-tape" the big toe to the adjacent one, and take an anti-inflammatory like ibuprofen for pain and swelling. They declined, saying they just wanted to know if the toe was broken. They could deal with the pain.

The couple left very happy. In fact, they later complimented me on what a great doctor I was. In a real sense, the X-ray had been therapeutic.

The whole episode made no sense to me. I've had other difficult encounters with patients since that time, but this one in particular left such an emotional impact that after all these years I still think about it. Clearly, I felt my authority as a physician had been usurped. I had possibly practiced less than optimal care by ordering what many would consider an unnecessary X-ray. In the end, I had provided no treatment whatsoever for the broken toe.

I later realized, however, that I may have functioned more as a physician in the ancient sense of the term. The couple came to me with a problem that had disrupted their lives. They wanted me to address that problem in a manner that made sense to them. Understanding what patients truly need, and making it available to them, is what practitioners of the healing arts have done throughout the ages. I believe this is what makes the practice of medicine inherently different from other professions such as business, law, engineering, or education.

The doctor-patient relationship is influenced by many things other than the application of scientific principles to biologically based disease, although that is where we must begin. Patients who come to us are not just consulting a technical expert in human
biology. The art of medical practice relates instead to a fundamental need buried deep within human nature which asks, "Why did this happen to me?" and "What can I do about it?" Modern science does not always answer these questions satisfactorily from the patient's point of view.

Understanding that these questions exist, and that they affect patients' behavior, explains in part why people often leave a doctor's office unhappy and with unmet expectations. Understanding these concepts helps to explain why a first-time mother with a febrile child might define an "emergency" differently than the overworked ER physician she comes to for help. It may also explain why alternative therapies, such as unproven treatments for back pain or chronic fatigue, continue to receive so much attention from so many people.

Patients and their families hold ideas and beliefs about an illness that include (1) what caused the problem (the etiology), (2) what is actually happening (the diagnosis), (3) the future course of events (the prognosis), and (4) the manner of its resolution (the treatment). These ideas are influenced by the patient's upbringing, education, culture, and experience. Understanding such beliefs can help us in describing and even predicting a patient's behavior. Similarly, we physicians hold a set of ideas or beliefs about a particular problem, shaped by our experiences in medical school, residency, clinical practice, and continuing education. Sometimes these two sets of ideas come into conflict, as in the case of the "therapeutic" X-ray.

I suspect that a fundamental aspect of what transpires between patients and physicians, transcending all cultures and all times, is an interaction of these beliefs and ideas. A community's "healer" attempts to correct an affliction by diagnosing and treating it within the context of the culture and experience of the people affected. In these situations a physician may be acting more like a priest than a scientist, but in the end, this priestly role may be a crucial part of the physician-patient encounter. Indeed, while we physicians are besieged with demands on our time and infringements on our autonomy, there remains at the core of medicine an almost holy role, a connection forged by a highly developed level of trust, a trust that must be earned.

One could argue whether I should have ordered an X-ray for a stubbed toe at the insistence of a squadron commander fighter pilot at an overseas air base. But now I understand why the situation developed, and why I helped in ways I couldn't have anticipated.

 

Gregg Bendrick. Are we doctors, or high priests of healing?. Medical Economics 2001;16:57.