#77 Engage to Become a Healer

Book Review “On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients”
This review appeared in the April edition of The DO

When Saul Weiner decided as a young boy that he wanted to study medicine, his learning disability made that road even bumpier than it is for most people. His problem was diagnosed early, and he got help with his learning disability. In addition, he had the incredibly good fortune to have renowned physician and educator Simon Auster as his godfather.

Simon Auster was on the faculty of the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine and taught the course, “Human Context in Health Care,” to thousands of medical students. As his godson, Weiner enjoyed personal access and interaction that challenged him to lean in more completely and engage on a very human level.

Photo by Joan Naidorf

Weiner developed a strong interest in medical education, and is now a professor of medicine, pediatrics and medical education at the University of Illinois at Chicago. In his book, “On Becoming a Healer,” Weiner makes an eloquent effort to identify the challenges of practicing 21st century medicine and to suggest ways to engage with patients despite many inherent obstacles. He writes that this book “speaks to those with an open heart who have not yet found a way to harness such a powerful resource in the service of healing.” (pp. 13)

Weiner identifies several problems in the way physicians are educated that cause them to withdraw emotionally from their patients. The problem, he believes, is multi-factorial with fears of getting overly involved, taking too much time and wanting to appear professional. Weiner laments that the system has created physicians who have become “efficient task completers.”

“The conventions of medical training do not facilitate coming to terms with emotions,” states Weiner. “Rather, trainees bottle up feelings and focus on projecting assuredness as they move from task to task and patient to patient. Emotionally stunted, they are inaccessible to their patients, as they are inaccessible to themselves.” (pp. 27)

To address this conundrum that leaves med students, residents and attending physicians feeling cynical and frustrated, Weiner recommends engagement. “Once we pass judgement,” Weiner writes, “we cease to exercise judgement.” (pp. 75)

Making assumptions about our patients can have disastrous consequences. “If you think that you know why some of your patients don’t take their medications – for instance, that they aren’t taking your medical advice seriously – you have little motivation to explore what’s really going on.” (pp. 15) He believes we stop being curious. Asking our patients “why,” and listening to their responses will lead to shared problem-solving and better results.

Weiner calls this “contextualizing care,” a subject he has researched and written on extensively. “A plan of care is contextualized when it is adapted to a patient’s individual needs and circumstances,” he states. (p.37)

An engaged physician will pick up on clues or comments and approach their patients with appropriate curiosity. Sadly, many physicians don’t ask the extra questions and do not learn the reasons for non-adherence to the plan or a symptom flare-up.

An example is used of a dialysis patient who kept missing her scheduled dialysis slots and would end up getting costly emergency dialysis after hours in the emergency department. She was labelled by the office staff as “non-compliant.” When Weiner inquired directly with the patient as to why she was missing her appointments, he discovered that she had taken on childcare duties for a grandchild that took her to a different part of town. When her dialysis sessions were re-located to a nearby center that was easier for her to get to, she never missed another appointment.

Every chapter of the book starts with one of his godfather Simon Auster’s famous aphorisms which Weiner calls affectionately “Simon-isms.” Simon famously said, “Never forget that you defecate, micturate and fornicate the same as your patients do.” He often expressed this sentiment with more colorful and crude word choices to remind his students of the shared humanity they have with their patients. When students encounter patients who appear dirty, smelly and in some rough situations, we need to remember that it could happen to each of us. “To engage, you must regard your patient as an equal, despite differences in your medical knowledge or overall education.” (pp. 31)

With patient visits scheduled every 15 or 20 minutes and a needy electronic medical record to maintain, Weiner laments that “it appears they (medical residents) are not seeing their patients as existing in a context but rather as tasks that fill their day.” (pp. 174)

No wonder trainees can become detached and cynical when patient interactions are viewed as a list of tasks to complete. Weiner suggests that engaging fully by asking questions and sharing our own experiences with our patients may be the secret weapon that all healers can use to stave off burn-out.

Weiner states he came to see that doctors hide behind their white coats while patients want to connect with a real person who cares about them. (pp. 12) How can mentors break through the walls that medical students and residents erect around themselves?

At the end of his chapters, Weiner includes a series of questions and exercises that educators can use with physicians-in-training to challenge their assumptions and to encourage more engagement. He encourages coffee sessions or short, ungraded, reflective essays where students can be honest and vulnerable.

I was first drawn to this book when I heard Weiner and his friend Dr. Stefan Kertesz host a podcast with the same name as the book. Weiner frames much of the problem for physicians in terms of deficiencies in boundary clarity.

“When their patients are unappreciative or even oppositional, they take it personally, lacking the boundary clarity to recognize this (the troublesome behavior) isn’t about them.” (pp. 27) Self-awareness and clear boundaries enable physicians to engage with compassion.

All physicians who yearn for some of the old-fashioned “magic” of the doctor-patient relationship will enjoy this book. It is very philosophical but draws in many examples from Weiner’s clinical and teaching experiences. It should become a classic for physicians and other healthcare professionals who want to perfect the art of becoming a healer.  It takes us, as the subtitle declares, on the “journey from patient care to caring about your patients.”