I was clearing out old files not long ago and came across a copy of “The Doctor,” a painting by Samuel Luke Fildes that hangs in the Tate museum in London. As a moment caught in time, the painting depicts a physician at a child’s bedside during a house call near the end of the 1800s. With the child in crisis, the parents look at the doctor as he studies the child.
During my years as a pediatrician, this painting has crossed my desk and screen numerous times. It is often used in lectures and presentations to elicit feelings of nostalgia in the face of a changing health care landscape. In other circumstances it has been held up as evidence of the physician paternalism that defined the doctor-patient relationship through the 20th century.
Whenever I saw an image of the painting, I didn’t pay it much attention to it. I didn’t find it remarkable or telling. Just old.
This time, though, I couldn’t escape the painting’s draw, though I couldn’t put my finger on what I found so compelling about the image this time around.
Then it hit me. It was the intensity of the doctor’s gaze and his posture. What caught me this time was his presence. This doctor was all in.
Presence is the mindfulness that one individual brings to an encounter with another. It’s a defining element of human connection. In medicine, it’s what happens when a clinician’s connection is untrammeled by a screen or other competing inputs. It’s the focus of mind, spirit, and intent around a moment in time that’s about another person and his or her most pressing problem. Presence, be it in a clinic exam room or with a friend over coffee, is a uniquely human gift.
The scarcity of presence
Maybe “The Doctor” caught my eye this time because presence is increasingly scarce in health care encounters.
Perhaps this representation of a patient encounter caught my attention because medical care is increasingly mediated by tools and instruments. Advancements like the electronic health record have come to define the interaction between those providing care and those receiving it. And much of what was once done with clinicians’ eyes, ears, and hands can now be done more efficiently by machine. Increasingly, the opportunity for physical connection with patients is turned over to surrogates. The cost for this technological presence is disconnection from patients and a progressive dehumanization of their encounters with doctors, nurses, and other health care professionals.
Beyond technology are the economic forces conspiring to diminish human presence. Among them is the industrialization of health care. This trend is concerned with the movement of patients through clinical spaces with attention to efficiency and profit margins. Industrialization has reduced clinician-patient interactions to transactional units valued by volume. Individualized forms of human-to-human engagement are discouraged in favor of algorithmic checklists and scripted visits intended to drive survey metrics around the new cottage industry of patient satisfaction.
At the same time, medicine has become remarkably precise. Instead of looking at patients on the broader level like the doctor in Fildes’s painting, health professionals are instead trained to see collections of genes, markers, and proteins. In reducing the body to its most basic elements, we see diseases and their variants instead of people.
It has been suggested that “The Doctor” was created in response to concerns over the growing presence of science in late 19th century medicine. The painting’s absence of medical instrumentation common to the era was perhaps a subtle commentary on the creeping technological divide between doctor and patient. There is nothing here to interrupt the intense connection between this doctor and the patient under his care. I can only assume this was the artist’s point.
A new generation of superhuman clinicians
But times are changing. And most health care professionals are not prepared for what the next generation of patients will need from them.
In his book “Deep Medicine,” physician Eric Topol suggests that as artificial intelligence begins to complement physicians’ daily work, one of their most valuable skills will be emotional intelligence.
That make sense to me. As machines develop the ability to do things humans once did, medical professionals will be left to master the things only humans can do. This new clinical role will call for the ability to translate and contextualize complex information in a collaborative way with patients. Presence and other basic elements of human connection will emerge as defining features of a new generation of healers.
This reality will reshape the clinician-patient relationship and, in turn, redefine the role of health care professionals.
And in a stroke of irony, the technology that once separated health care professionals from patients in the early 21st century may force a new, unexpected role for us. Our inability to compete with machines may be the very thing that defines us.
Driven by the clinical complexity that only one human can explain to another, the future work of medical professionals will center on intensive presence. And as technology continues its exponential march, expect a renaissance of human connection as depicted in “The Doctor.” I anticipate a resetting of human perspective where clinicians are left to consider their purpose and mission as healers. In a type of reprioritization, health professionals will move closer to understanding where technology sits between us and our patients. As a consequence, all of those charged with caring for patients will learn to value, cultivate, and focus on the very things that only they can do.
When human connection becomes scarce, the capacity and willingness to connect becomes precious and noticeable — in paintings or in real life.
Bryan Vartabedian is an attending physician at Texas Children’s Hospital in Houston. He writes about medicine, technology, and society in the 33charts newsletter.
Yes in the current rushed, high tech, assembly line culture of medicine, where productivity looms important, the compassionate presence of the caring physician takes on added and emphasized importance.
I cannot look at this painting without recalling that it was a primary image in the AMA’s battle against Medicare, meant to evoke what would be lost when government financing started. Seems the corporatization of medicine stole so much more of medicine’s soul and spirit.
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