As physicians, we often get caught up in the technology, and while technology and basic science research are key-—even crucial—in understanding disease and developing therapies, we can never lose sight of the fact that we are treating people, not cytokines or chemical equations. Ideally, we treat people with diseases, not disease in people; and it’s important not to lose sight of that difference.

Twenty-first century medicine has become a very complex animal. It is a science grounded in scientific evidence and best practices, all emanating from randomized, controlled, clinical trials and computerized databases. It is a business, a business in which the ideal time for the patient encounter has been quantified by actuaries (it’s an unbelievable seven minutes, for your information); where electronic records speed up rendering of care; where health care providers refer to sub-specialists at the drop of a hat; and where there’s no time in those seven minutes to really think about what’s going on. It is, in fact, a commodity, a very fragmented commodity whose availability has been analyzed, priced, and rationed by a system which has done little to fix it and, in fact, has little vested interest in trying to. End of diatribe.

The point of this harangue is to introduce the idea of what medicine traditionally was and hopefully still is, and what must be preserved. Medicine is also an art—a scientific art to be sure—but an art nonetheless. Nowhere is the art of medicine so crucial, so vital, and at the same time so rewarding as it is in the longitudinal care of patients. This is especially true for patients with chronic illnesses and certainly for those patients with illnesses which medicine has a hard time pigeonholing like fibromyalgia, irritable bowel syndrome, chronic fatigue [syndrome], and others which for years were thought to be psychogenic in origin. In recent years, as the roles of doctors have shifted, people have started to look at the workings of the doctor-patient relationship—to analyze, criticize, and reformulate it. It is within the dynamic of this relationship that the art of the practice of medicine is to be found. Interestingly, an extensive literature exists in psychiatry addressing the nature of the patient/therapist relationship. Much less has been written about this in the context of "medical" illnesses. Given how much we now understand about the fine, almost nonexistent, line between the physiologic and the psychologic, this is unfortunate.

Physicians and patients have been around for a long time. In most early cultures, the healers—shaman or physician—traditionally occupied a position of some respect in society for several reasons. First, they performed a service that was perceived as valuable, if not necessary, for the survival of the society. Second, they were possessed of certain skills, gifts, or training which other members of the society did not have. Whether this was due to the vertical transmission of a presumed ability, as in the patrilineal inheritance patterns of primitive tribal shamans, or to the accumulation of skill and knowledge in academies of learning, as was the case in Greek and Roman civilization, mattered little. The doctor was different, and this difference set him apart. (It was almost always a "him." There were healers who were women as well. In most European cultures they were called witches. Interesting sociological point.)

Physicians have not been free from criticism over the years, however. They have been portrayed as foppish narcissists in literature innumerable times, and at times when they seemed particularly impotent, such as during the Black Death, they were occasionally run out of town or left hurriedly, leaving their patients behind. The message is clear: patients may need us, but their respect must be earned.

Time and progress have altered our relationship with patients. Perhaps the two leading factors in this alteration have been technology and commerce. Technology has brought discoveries about the very nature of disease and about better treatments for those diseases to the bedside, resulting in longer life and better quality of life—all good things. The "bedside" in question, however, is much more crowded than before. The physician and patient are now joined by monitoring devices, laboratory data, quality assurance and risk management personnel, and not least of all by insurers trying to provide cost-effective care. It’s a crowded bedside and a crowded interaction.

What are the components of this relationship? First of all, it is non-linear. I don’t do something to the patient, nor does the patient do something to me. We act in concert, and one’s actions continually modify and influence the other’s. Interestingly enough, this kind of interaction is characteristic of the way quantum mechanics describes the world: a situation in which at any given moment every actor is simultaneously acted upon in an infinite series of transactions. How do we act in concert? While the patient is talking about a symptom, I may be observing how he is sitting or fidgeting, how comfortable or frightened he looks, and what he says and how relevant (or seemingly irrelevant) it is to the symptom at hand. Much of the information a patient transmits is non-verbal and may seem irrelevant. To miss this information is to lose part of the data.

It would be a mistake not to recognize that there is a piece missing in this narrative. Something else is going on here. She may have had a friend recently diagnosed with colon cancer, or she may be at the age at which her father died of that disease, or she may be having personal problems which are generating guilt. Regardless, dismissal of her complaint as something simple misses the point. Exploration of a missing piece and reassurance based on the facts and on an understanding of the emotional issue will be far more effective. Appraisal of the patient is incomplete if only the history and physical exam are taken at face value.

Second, there is the concept of caring. The physician has to genuinely care about what’s happening to the patient, and there needs to be intentionality—which means an intention on the part of the physician to heal. There also needs to be empathy—a "feeling with" the patient which can only come from knowing the patient and caring about him. Knowing the patient doesn’t always require years of interaction; it simply requires being interested and listening. The physician must also respect and appreciate the uniqueness of each patient.

Third is trust. This clearly cuts both ways. The patient needs to trust the doctor, and the doctor also needs to trust the patient in terms of his/her reporting of symptoms and the patient’s willingness to follow a diagnostic/therapeutic plan. After we present a set of options to a patient for his/her care, she will often ask, "What should I do?" or "What would you do if it were you, doctor?" Some patients will even say something like, "You tell me what to do, doctor." That interchange is the moment where trust becomes the linchpin of the discussion. Patients desperately want to put their trust in someone whom they feel knows more than they do and who can help them. They want that trust to be honored on a human level, and, as physicians, we owe them that. Patients don’t have to think we are infallible, which is a good thing since none of us is, but they do have to trust us. And we need to trust them, to honor and validate symptoms such as pain, which is hard to quantify objectively in the course of routine daily practice.

Fourth is empowerment. The doctor/patient relationship is, by its very nature, an unequal one. One party has knowledge, and one party seeks advice. One party is ill, and one is healthy. For patients with chronic illnesses, a critical dimension is added—loss of control. Something has happened, and now something is wrong with their bodies, and their lives have often been dramatically changed. The sense of not being in control of one’s health is a devastating one, and part of the doctor’s job is to try to restore some sense of control for the patient. Giving patients information, listening to them, validating them, and fostering their participation are all sources of empowerment —helping patients to actualize their ability to knowingly participate in change for their own benefit.

Fifth is teaching. The word "doctor" comes from the Latin docere, "to teach." Giving a patient the facts about her condition, as opposed to simply saying, "do this," is a form of empowerment. Some patients with chronic illnesses may even know more about their illnesses than their doctor does. The internet has made available a flood of information about every medical condition, some of it correct, a lot of it not. Being able to help patients sort through this data is an important skill. Being willing and able to learn from them is a skill in itself.

Lastly there is advocacy. The patient needs to know that you’re on his side and that you are his point person. Patients with illnesses are often adrift in a sea of sub-specialists, tests, procedures, diagnoses, and the like. They need one person to act as a touchstone, through whom all this information can be filtered and to whom they can turn for advice and help.

The patient I sent to the oncologist checks back with me to be sure I know what’s going on. She knows that I don’t know the correct dosing of the chemotherapy she’s getting, but she needs to know that the oncologist has communicated with me and that I’m okay with this. Another patient comes in to be sure that I agree with another doctor’s plan of treatment, and a third calls to say that he was told he needs a procedure, but he won’t have it unless I agree. Aside from feeding the narcissism that helped drive many of us into medicine in the first place, actions like these are among the highest compliments one can receive. When it works (and it takes effort to make it work), the relationship between doctor and patient is a truly special one —the creation of a magical space in which an ongoing process of healing occurs and can occur independent of whether or not there is, or can be, a cure for the underlying condition.