Published 1 July 2008, doi:10.1136/bmj.a528
Cite this as: BMJ 2008;337:a528

Analysis

Personal paper

A friend in need: why friendship matters in medicine

¹ Seaport Family Practice, Belfast, ME 04915, USA

Something caught my eye in the news report of David Demuth’s untimely death—something more than the tragedy of his dying at age 58, just a week after receiving the "American Family Physician of the Year" award for 2008.

Some would say small wonder—he provided check-ups for every age group, delivered babies (by caesarean section when necessary), helped out in the emergency department, attended hospital patients, and consulted for subspecialists when they needed a generalist. He made home visits to families in crisis and stood in for an elderly physician in a neighbouring town on weekends "to give him a break." He was the team physician for York (Nebraska) area athletics, volunteered for the York County Drug Task Force and Habitat for Humanity, and raised beef cattle in his spare time.

But the busy doctor left us with more than the example of his self sacrifice. He coached us to "listen to your patients. Most of the time, they’ll tell you what’s wrong with them."¹ He set his own priorities: "I pride myself in giving that individual person his time. After all, they’re interrupting their day to see us. I believe in the saying that patients don’t care what certifications you have on your wall; they know when you care."¹ And his admission that "we become friends and family with our patients"¹ is something we all know is more than cliché.

I grew up in a medical family. My mother was a "stay at home" nurse who returned to her profession after my father died. He was a general practitioner who poured small town values into my veins before his early death. His role as a solo practitioner in a small town—with all of its mixed blessings—cast a long shadow over my career. By his example, he prepared me to become friend and family to my patients.

"A doctor, like anyone else who has to deal with human beings, cannot be a scientist; he is either, like the surgeon, a craftsman, or, like the physician and the psychologist, an artist. This means that in order to be a good doctor a man must also have a good character, that is to say, whatever weaknesses and foibles he may have, he must love their fellow human beings in the concrete and desire their good before his own."

Friendship

If a friend in need is a friend indeed, the family doctor never wants for candidates. "The patient" may claim the need, but such a distinction hides a deep and reciprocal dimension to the doctor-patient relationship. We become friends. Yes, the doctor is paid, licensed, and ethically bound, but these qualifiers cannot rinse the essential humanity from each visit (the word itself suggests friendship). A patient’s longing for understanding and advocacy, coupled with the doctor’s desire to satisfy it, forges the therapeutic alliance. Belief in their shared plan of treatment powers the placebo effect. Why, then, are we surprised when patients call us both doctor and friend? More telling, why does the juxtaposition make us nervous?

Let’s be honest—it is hard to offer friendship to our patients when we lack it ourselves. The demands of the profession become the excuse. Differences in social class and relish for the role stand in our way. We use the excuse that service and action trump conversation and companionship in the work we do, forgetting that the work we do involves people just like us. We ignore this fact until the day we find ourselves washed well downstream of a life altering event—an addiction, an affair, or death of someone we thought we once knew.

What can it mean to be the patient’s friend? They remain relative strangers no matter how purgative their confessions. In the supermarket aisle or post office line, I grope for a patient’s name and inquire about his or her health simply to engage in conversation. The patient is not angling for a night at the movies or a home cooked meal. The rare and modest gifts are never reciprocated. Our awkward hugs reflect a failure of avoidance.

What we give our patients—in spite of our pace and preoccupation—is a sense of connection, the feeling that they are personally known. And to be known and loved in spite of everything is the deepest of human desires. It grows especially keen during illness, when patients are frightened, battered, exhausted, or hopeless, and they suddenly realise that time is running out.

Making a connection requires setting the stage. The patient enters and the door is closed. We rest briefly in our seats for a little conversation. Contact is made with my eyes and—during the physical examination—with my hands, so as to explore what words cannot convey. When time has ended, I help patients rise, dress, and then grip their hands; by these simple signs they know that I am glad to see them and share their burden. They trust that I will grasp the nature of their problems, do what can be done, and stand beside them to the end.

Beyond mere technique, we come to embrace an attitude and posture that prepares us to love our patients, knowing that their desires and fears are no different from our own. We encourage self reflection and, in the process, learn what life can teach. We give them their story and receive gratitude in return.

Of course, the doctor must do his or her work—establish a diagnosis, write the prescription, order tests, and arrange consultations on the basis of sound science and seasoned experience. But most of what flutters about the illness cannot be netted. It is invisible to the coders; it defies compression by templates and scales. It draws us outside the mastery of our authority, expertise, and technical skill. It begs us to be doctors who are family and friend.

Change

Not long ago an elderly patient came to see me. I asked what he had been up to; he eagerly told me about going hunting with his son. But his voice faltered when he recalled his uselessness at helping to haul their prize out of the woods. Tears began to flow for an uncomfortable minute, then five, and despite my efforts to articulate his anguish, the visit passed without a solid lead. How could I describe what had just transpired? He agreed to return in a week, thankful and relieved that his true self—now exposed and "trivial"—was worthy of the doctor’s time.

There are innumerable encounters like these—families bearing the brunt of addiction, dementia, inconsolable grief, domestic brutality, an aging parent’s decline, or test results that confirm their worst fears. Illness forces us to change, or at least acknowledge that change has occurred. Patients know it to be true but cannot draw from their experience. This patient had been a model of consistency—mule headed, habitual, the owner of one thickly painted and immutable self image. It is the image of youthful vigour, attractiveness, success, and longevity. But he now knows it to be a counterfeit, a treasure lost and grieved for.

The task of the doctor as friend is to help patients rework their canvas. They must peer through their layered history and its distortions, resolve ambivalence, and commit to change. It is work done in the presence of another, the friend and guide in the person of the doctor. Because we have witnessed change—and thus qualify as experts—patients pin their hopes on us. Our great challenge is to pin it back. This is what Kafka captured in A Country Doctor, when the old man admits, "if they misuse me for sacred ends, I let that happen to me too." We wrap ourselves in mystery; we wield the healing force tooled in motivational interviewing and hovering in the wings of each clinical encounter.

What I am talking about is genuine friendship—it is a bond that hinges on listening and waiting and letting another take the lead. It knows the luxury of time and right timing. It matures with affection and mutual regard; it accepts the risk of self disclosure and unveiled emotion. Its purpose is more than the pretext; we enjoy one another, even when in pain.

The human element in medicine credits the doctor with more than a tally of cases and encounters. We have stories and anecdotes, pearls on a string that hang from the neck of a life in practice. Each shimmers with its own light. Each grew of grit. We cannot take responsibility for the transformation, but we know its worth. And we let poets like WH Auden distil our contribution:

Two way street

We lose nothing by loving our patients, but what could we gain? We might learn something about friendship, something that has evaded us outside our careers. We could see a future where we, like our patients, inevitably change, suffer, and decline. We will discover chinks in our armour, flaws in its design that keep us socially stuck and isolated. We can expect kindness and warmth from the less injured more emotionally evolved of our patients who once seemed to need our care. We will open ourselves to the full scope of human drama and the many choices at our disposal for responding to life’s tribulations.

I don’t believe in the idea of "physicians of the year." Dr Demuth—like the rest of us—fell into his circumstance, worked tirelessly, and knew that the time he gave to his patients was expensed from his own account. Who of the next generation of physicians will emulate that? And who can blame them?

But there issomething to strive for, something remarkable in Dr Demuth’s long habit of being friend and family for his patients. Something that never cost him the respect of colleagues or skills required for the job. Throughout his career he cultivated what we sense to be our own instinct, our compass—that deep resonance that compels us to squeeze the hand of the afflicted and make a connection that is now being studied and "proved" in emerging research on relationship centred care.

But the bulwark of science is never enough. Let us hope that successive generations of physicians will continue to respond with moral courage to their patients in crisis—and those simply in need of comfort and companionship—as whole doctors who care for a friend in need.

Cite this as: BMJ 2008;337:a528

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Competing interests: None declared.

Provenance and peer review: Not commissioned; not externally peer reviewed.

References

1. Champlin L. 2008 Family physician of the year lives specialty’s ideals. AAFP News Now 3 Oct 2007.

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