Public health and clinical medicine need to work together, but often don’t. Making patients the VIPs of the system is the best way to integrate these two disciplines and improve both public health and individual wellness.
Sometimes this requires large efforts; other times a small gesture can be enough.
During my medical school training at Columbia University, I treated an older man, a survivor of Auschwitz, whose lungs were full of fluid from severe heart failure. He wasn’t a candidate for a heart transplant, and we wanted to make it easier for him to breathe and give him more time with his family.
I asked my father — a wonderful cardiologist, a consummate clinician, and my secret weapon as a medical student — if there was something I could do. He suggested draining the fluid out of the man’s lungs. “If it reaccumulates in a few days, there’s not much you can do,” he told me. “But sometimes it can buy the patient two or three months. That doesn’t work often, but it’s worth a try.”
So that’s what I did. Unfortunately, the fluid was back in just a couple days. I knew the man well enough to talk with him and let him know what was happening. He said to me, “What I really want is a sip of beer.”
I walked to a bodega in nearby Washington Heights, bought a can of beer, and gave him a sip. He savored that sip with a blissful smile. The nurses were upset, but the attending physician wrote an order the next morning: “Patient may have a sip of beer.”
Years later, when I became New York City’s director of tuberculosis control, we made the patient the VIP of the program. This meant making sure that services revolved around the needs of the patient, and not those of doctors, administrators, or clinics. We met patients wherever they were, including public parks, bridge underpasses, and crack dens. We provided food, financial incentives, and housing if needed.
Our outreach workers built human bonds with each patient. Not only was that the right way to care for these patients, it helped them finish a lengthy treatment regimen and kept them from developing drug-resistant organisms or spreading tuberculosis to others.
The concept of patient as VIP is essential. It doesn’t mean that the patient is always right. And of course the doctor isn’t always right. But it is always right to have an open conversation: to listen, understand, and have empathy.
Clinicians listen to their patients, try to understand their problems, and learn how to give the best treatment possible. In public health, we listen to the community of patients and clinicians, and to the community at large, and try to learn the best way to move forward to benefit the most people and save the most lives.
The Ebola epidemic in West Africa posed an unprecedented clinical and public health challenge. Not only did it unexpectedly hit densely populated urban areas, it hit hardest in communities with 70 percent illiteracy, a mistrust of both government and modern medicine, and burial practices that helped spread the Ebola virus. The only way the affected countries and global health community were able to stop the epidemic was by treating patients as VIPs and providing them — and their communities — with the services they said they needed most.
When public health and clinical medicine work together in this way, it becomes clear that we are all in this together. At some level, our fates depend on how well other people do in caring for their own health, and on how well we as a society do in caring for those who are sick.
Health care faces many challenges today. There is the challenge of short-term versus long-term benefits. Of listening versus communicating. Of leading versus following.
Take the looming problems of drug-resistant bacteria and opioid addiction. To fight these, clinicians need to talk with their patients about getting the right treatment, not the most treatment. With careful listening and open communication, we can devise the best answer for each patient and the best program for each community.
Humanism in medicine is enormously important. So is optimism about the future. Together, they give the health professions unique opportunities to bind together patients and clinicians, the public and its leaders, and communities, countries, and the world.
Bill Foege, one of my predecessors as CDC director, noted that we are at our best when we see — and help others see — the faces and lives behind the numbers. We can do that by making patients and communities VIPs. And that, in turn, will help us build a better, healthier, and more rational future for everyone.
Thomas R. Frieden, MD, MPH, is the director of the Centers for Disease Control and Prevention. This article is adapted from a talk he gave while accepting the Gold Foundation Award for Humanism in Medicine.