- © 2004 Canadian Medical Association or its licensors
Evidence-based medicine became ascendant when I was a medical student. One was ignorant if one didn't cite journals as if quoting from the Bible. Preceptors were dinosaurs if they taught according to “experience”; only teachers who buttressed bedside lectures with fact were believable. Morning rounds were trivia wars, the winning team being the one that came up with answers supported by the most recent literature.
It seems to me that it was only the family medicine people who dwelled on the importance of relationships. They were the ones who invoked the centrality of the physician–patient relationship as a core teaching. I remember thinking: What is the evidence to support the importance of a good, trusting relationship? Where are the data?
I had to learn the hard way.
My first few months in practice were spent in a vain attempt to convert all my patients to a new way of doing things. I had assumed my practice from a retiring doctor who assured me that his patient profile was, for the most part, congenial. I knew from the first that his patients were sad to see him go: they told me so. My initial zeal in changing medications met with considerable resistance. As per my training, I wanted to HOPE-ify everyone who met the criteria. I dutifully explained statistics and was frustrated when my patients confessed at follow-up appointments that they hadn't filled their prescriptions. After one of the town priests developed jaundice as a side-effect of a drug I had prescribed, it became impossible to convince anyone of the benefit of lowering cholesterol.
They don't understand, I thought. So I tried harder to convince them I was right. Not even invoking the fear of death worked: each time I tried to change medication regimens or treatment plans I'd get baffled looks. Occasionally I'd be told, “Dr. Retired doesn't do it that way.”
One day I overheard one patient say to another, “I sure hope Dr. Retired comes back.”
That night I phoned up Dr. Retired. “They won't let me be their doctor,” I said. “They expect me to be you.”
He began to ask about certain patients. Had Mrs. So-and-So reconciled with her mother? Had Mr. X finally decided to buy a new car?
How should I know? I asked Dr. Retired if he was paying attention. “Don't you understand?” I pleaded. “How can I get them to listen to me?”
“Listen to them,” he said.
The next day I stopped forcing medicine onto people whether they wanted it or not. I began to ask my patients about their lives. How were they doing? Could I help them with anything? I wrote fewer prescriptions, but I'm sure my patients were more satisfied.
After a few months of this I cautiously recommended the addition of a single drug to treat a patient's problem instead of unleashing the entire pharmacopoeia on the poor sod. And, in an incremental way, I became evidence-based — but only after doing the hard work of relating to my patients.
The family medicine people were right: the physician–patient relationship is important. I only wish I'd learned this some easier way — some way other than practice.
— Dr. Ursus