Treatment is a two-way street
I was reading about the relationship between the pioneering psychologist Erik Erikson and the iconic painter Norman Rockwell. Erikson, who gained fame for explaining eight crucial stages of psychosocial development throughout life, was Rockwell’s psychotherapist.
Both men lived in the idyllic Massachusetts town of Stockbridge, where Rockwell painted one of his most recognizable works, “Stockbridge Main Street at Christmas,” depicting picturesque Main Street during the Christmas season. Stockbridge Main Street was also home to the famous Austen Riggs Centre, a stronghold of psychoanalytic practice and long hospital stays. Rockwell’s wife was hospitalized at Austen Riggs for treatment for depression and alcohol use disorder. Rockwell himself fell into a deep depression, which led to a chance meeting with Erikson and subsequent outpatient treatment with him.
Rockwell was fussy about his paints, a perfectionist at heart. In a depressed state, his obsession was unbearable, he thought too much of his technique and questioned the quality of his work. Erikson brought Rockwell out of depression and helped impart the 1950s social setting in Rockwell’s paintings. In the audio recordings, Rockwell can be heard telling his son Tom how Erikson helped revitalize his painting, even giving Rockwell advice on how he should start the lineage of the famous “Rockwell.”Family tree.“
One wonders if the relationship between the two men had any meaning for Erikson. Erikson was born in Germany and immigrated to the US at age 31. He never met his biological father; in fact, he was initially misled about his paternity. As Erikson struggled with his identity, he changed his name several times, eventually coming to “Erik Erikson” and later coining the term “identity crisis”. According to Jane Tillman, Ph.D. Director of the Erikson Institute, Rockwell’s paintings helped infuse Erikson’s identity by allowing him to reflect on art that was quintessentially American.
Tillman’s account leads me to believe that the doctor-patient relationship is, at best, a two-way affair, a two-way street. Although high-functioning doctor-patient relationships are not of the same magnitude as the one between Erikson and Rockwell, who ended up being good friends, they do have a special quality of give-and-take. My premise is that while the doctor is the ostensible healer, the patient helps to heal the doctor, usually through subtle means discovered after the doctor reflects on the patient’s visit or upon termination of the relationship.
The idea first occurred to me as a psychiatric resident. I tested a young woman for a relationship problem. I think the initial session went pretty well. I asked her if she would be back to discuss some issues in more depth. “I won’t see you again,” she replied. Puzzled, I asked why. “Look at your plants,” she said angrily. “They’re half dead. If you can’t give your plants a little TLC, how do you expect to care for me?”
I was shocked. I did not get an answer. It is true that I never had much of a talent for gardening, but the patient rightly pointed out that my inaction, not watering my plants, was inexcusable. It had a profound effect on me and led to my later interest in horticulture, perhaps overcompensating for a perceived failure.
As a doctor, I find it much easier to give advice than to receive it, which is not surprising. If I have to see a doctor for personal reasons, the conversation starts stilted until I tell them I’m a doctor too. When telling the doctor that I am a psychiatrist, there is often an enthusiastic sharing of stories about difficult or unusual patients. Bruce Springsteen would say that the collective stories of doctors are “The Ties That Bind”.
I recently moved to Charlotte, North Carolina and had my initial visit with a Primary Care Physician (PCP) who went to medical school and trained in my hometown of Philadelphia. He told me that his wife trained in emergency medicine at the same institution where I attended medical school and did my residency. We share a good laugh as we discuss the various characters known to visit emergency departments who aren’t actually in crisis, and how difficult it was to decide whether to prioritize their medical or mental health needs.
The conversation quickly turned serious. The PCP informed me that at least half of his patients had co-occurring mental health issues that were not addressed primarily due to time constraints (he was only allowed 15 minutes per visit). He also confessed that he did not feel comfortable playing the role of quasi-therapist. I told him that in the past, I was a consultation liaison psychiatrist and was routinely called in to assess medical surgery patients. I informed the PCP that he could easily brush up on psychiatry and recommended a couple of manuals that he could read, including The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physicianconsidered a classic.
Investigate confirm that physicians who can emotionally engage with patients have better outcomes and higher patient satisfaction scores. When a patient perceives that her doctor cares and listens to her concerns, she is more likely to comply with medical recommendations and return for follow-up visits. But there is very little research indicating that giving credit to the advice and reflections of our patients makes us better doctors. Can patients stimulate our personal growth, as Rockwell did with Erikson in his search for identity?
The short answer is that doctors they can become better doctors being patient. When doctors trade in a white coat for a hospital gown, they learn the importance of empathy and language and gain an appreciation of the trauma of illness and treatment trauma. Renowned author and speaker Danielle Ofri, MD, PhD, echoed the same sentiment; she dedicated a whole book to the lessons he learned from his patients. She believes that one of the most important is learning what it feels like to truly be a patient; in her case, the humiliation and helplessness she felt during and after the birth.
In addition to assuming the role of patient, listening carefully to our patients, especially the poor and others who are disadvantaged, helps physicians grow, because learning to overcome barriers to high-quality treatment (barriers such as poverty, poor access to care, time limits on interactions, red tape) and general mistrust in health care systems) allows physicians to take more personalized approaches to health care. Clearly, if we accept our patients as teachers, they infuse elements of humanism in our training and practice. It is known that patientsdefine our work, exemplify our values and shape our identities“, just as Rockwell helped Erikson. It is not unreasonable to expect physicians who are exposed to diverse communities to develop strong clinical skills, become patient advocates, and contribute to a vibrant medical workforce.
That it’s been said that medicine is an art whose magic and creative capacity reside in the interpersonal aspects of doctor-patient relationships. Yet all too often, medical practice is hampered by tasks that need to be completed and patients who need complex services. During the day, we lose sight of the special role we can play in patients’ lives. Only when we rediscover our passion for the practice of medicine and accept our mission… to serve the suffering — that we realize that we have the power to transform patients and, in doing so, transform ourselves.
Arthur Lazarus, MD, MBA, is a member of the Medical Leadership Magazine editorial board and associate professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.