(28) TARRANT COUNTY PHYSICIAN
January/February 2021
(Re)Building a Culture of
Communication in a Changing World
by Stuart Pickell, MD, MDiv, FACP, FAAP
doing nothing but sitting there looking
concerned, but that’s the point. “Being
there” is doing something and speaks
volumes to the parents who simply want
to know that someone cares enough to
exercise everything in their power, limited as
it may be, to effect a cure.
With the Information Age came a
breakneck pace of scientific innovation.
In 1900 the definitive textbook of internal
medicine was Osler’s The Principles and
Practice of Medicine. It had one author:
Sir William Osler. But by the 1950s the
expansion of medical knowledge required
that the definitive textbook—the first edition
of Harrison’s Principles of Internal Medicine
(1951)—had 53 authors.1 The era of
specialization had arrived.
Along with it came a gradual dissolution
of the longitudinal and relational nature of
patient-physician encounters. Increased
specialization meant we could do more to
effect a cure, but the more we could do,
ow we
communicate
with patients has
changed a lot
over the years.
Millennia ago,
having little to offer
by way of effective medical intervention,
healers relied on therapeutic relationships.
What healing occurred was largely due to
the relationship itself. Priests, shamans,
witch doctors, medicine men, and the like
were important threads in the social fabric
of their communities. Caring for
both spiritual and physical needs,
they functioned in roles that we
recognize today as clergy and
physician.
In the second millennia, and
especially after the Enlightenment,
these twin traditions of healing
began to unwind. As scientific
knowledge in general, and medical
knowledge in particular, became
increasingly robust, the role of the
physical healer became distinct
from that of the spiritual healer.
While the physician’s library
of remedial options increased,
it remained limited until the
20th century. Instead, relationships and
trust continued to be the bedrock of the
therapeutic encounter. “Being there”—
itself a form of communication—was as
important as the intervention. A beautiful
illustration of this is Luke Fildes’ 1891
painting, “The Doctor,” depicting a physician
sitting at the bedside of an ill child, the
concerned parents in the peripheral
shadows. The physician appears to be
the more distant physicians became from
their patients.
I trace the origin of this—because it
works as a metaphor on multiple levels—to
French physician René Laennec’s invention
of the stethoscope in 1816. One day he
observed schoolchildren scratching the end
of a hollow stick to hear the amplified sound
at the other end. He applied this acoustic
principle to solve a problem he was facing
regarding the examination of a patient. As
Laennec put it, he had been
“consulted by
a young woman
laboring under general
symptoms of diseased
heart, and in whose
case percussion and
the application of the
hand were of little avail
on account of the great
degree of fatness.”2
Given her age (young)
and gender (female), direct
auscultation was not an
acceptable option anyway, so
recalling the children’s game
he rolled up a piece of paper
and listened to her heart. The
stethoscope was born, a technological
innovation had occurred, and the
physician took the first step away from the
patient.
As medical specialization grew so did
that distance. Now we don’t even need
to be on the same continent. Physicians,
as masters of applied science, assumed
the role of the expert who diagnosed a
condition and recommended a course
Healthcare in a Civil Society 2021
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“The Doctor” by Luke Fildes (1891)