In my increasing experience of the world of medicine, I notice certain trends arising between patients and doctors. As I previously stated in my last article, communication is the cornerstone of fantastic patient care, but I would propose that this cornerstone is formed of a stronger material, perspective.
To describe what I mean by perspective I can refer to Webster's English dictionary, which gives many definitions of the word, but one stands out to me much greater than the rest:
'The capacity to view things in their true relations or relative importance'
Doctors are taught to recognise patterns to explain a change in a person's body, to understand it from a scientific perspective in order to correct it, and communicate it in an understandable form to reassure the patient. The definition of perspective in this case is not reflective of the previous definition, more reflecting 'observation and explanation' than 'observation and relating'.
For me, perspective in a medical sense, is viewing disease not as a collection of signs and symptoms, not in the way the change these symptoms creates changes a patient's life, but the ability to understand the effect of this change on the patient's mental view of the world and how a doctor's ability works to rectify this change.
To make a simply analogy, most pertinent to neurology but extraneously valid to most other systems, our view of the world is as if looking out of a window. Look out the window now, noting the detail of what you see, the way light shines off surfaces, how small movements cause shadows and how the structure of what you see conveys a message. Now imagine that the window has a crack, the image you see is now distorted, the message conveyed by what you see is distorted by the crack.
Disease, for me, is the crack in the window. From a scientific perspective, all we sense, that is to say hear, smell, see and feel, is seen through a screen which is our body. The tree you see is nothing more than the light your eyes can understand, change into a voltage and present to your brain. Neurological disease, for example a migraine, distorts this light and changes the tree and your reality. Disease changes the way we see the world.
So perspective is the capacity to view things in their true relations, ie that what we see is our brain's interpretation, limited by how efficient our body is at receiving information. The tree is light, interpreted through the lens in our eyes, through the retina, optic nerve, tract, radiation and nucleus. The second part of the definition is relative importance. The transient loss of vision experienced in migraines has changed the patient's view of the world, quite literally. By analogy, the pain and stiffness of early morning rheumatoid arthritis changes the button of a cardigan to a rubix cube and depression changes the simplest task into climbing a mountain.
Disease changes the way we relate to the world, which changes the importance or value we assign to it. Understanding that a patient does not come in just to understand their disease, or have it treated, but to understand the change it presents to their life and expectations and how they may have to adjust their world is a skill I believe that all doctors should possess.
A brain surgeon in Sheffield once told me that he never asks about symptoms straightaway, he asks what a patient can no longer do. As well as giving the surgeon a pattern or disease, ability to predict the area of damage and know how to fix the problem (if possible) it also gives him perspective of the effect of the disease on the patient's life. To the patient, it is the ability to remedy this change in their lives that is the reason to come to a doctor.
For me, and to all those I speak to, it is clear that the best form of care addresses a patient's expectations, not simply to restore their reality, but to help them understand their disease in the context of their world. Simply put, not to simply fix the crack in the window, but to understand what the new view means. In the consulting room this can be simplified to a simple question:
'What has changed in your life since all this began?'
Answering this question lets us know what exists beyond the cracked window, and helps us do our best to restore the patient's view.
All opinions expressed in this article are those of the author and may not represent those of Sheffield Medical School or the NHS.