By Zach Read
Paul Chelminski, MD, MPH, cultivates relationships with his patients; he doesn't allow guidelines to dictate his care. When he sees new patients, rather than dive head first into medical histories, he asks for extensive social histories – he wants to learn about his patients' families, their occupations, their education.
“If all you’re doing is reviewing a litany of guidelines, then what you’re offering people is not health care – you’re offering them a car inspection,” Chelminski says.
Last year, Chelminski’s brand of direct personal practice caught the attention of the Sanders Clinician Scholars Program, which seeks to strengthen doctor-patient interactions and teach young physicians about bedside manner. Today, with the generous support of the Program, funded by Charles A. Sanders, MD, former chair of the UNC Health Care Board of Directors, Chelminski’s approach to care is reaching residents.
For the past year, internal medicine residents have been learning to develop their own direct personal practice by joining Chelminski on home and nursing home visits, a patient-care approach Chelminski adopted years ago. The visits have become valuable experiences that shape how residents relate to patients and that show them how to provide personal care while navigating the financial and regulatory pressures, technological advances, and other significant changes that have impacted the health care environment.
Chelminski believes that because more physicians opt for narrower and more specialized training today – for stable niches in an unpredictable health care environment – they are shielded from the broad experience that can help them interact with patients as human beings.
“In order to negotiate with patients about improving their care and selecting the elements that are most important to them, we have to know who they are and what they value,” Chelminski says. “And they won’t listen to you unless they think you understand their background.”
Although home visits are excellent learning opportunities for young physicians, they don’t bring down all the barriers between doctor and patient. To connect with the patient, the physician must have a broad set of experiences to draw from. A staunch advocate for what he calls the “clinical humanities,” Chelminski, thanks to the Sanders award, is also exploring ways to bring the humanities into the medical curriculum early in the medical student’s education.
With an undergraduate focus in literature, and experiences ranging from blue-collar jobs as a teenager to the Peace Corps in West Africa, Chelminski has learned to view human lives as narratives - as individual stories. By harvesting the stories of his patients, by learning about the experiences that have shaped them, he gains access to better information, which leads to treatment plans preferred by patients.
Interest in the humanities provided Chelminski with the necessary tools to access his patients' narratives. A study recently published in Science and detailed last week in the New York Times contends that reading literary fiction enhances empathy, emotional intelligence, and social perception - all traits that can be beneficial in the clinical setting.
“The humanities prepare us for the challenges our patients confront us with when scenarios cannot be reduced to single causes or relatively tidy solutions or treatment," explains Chelminski. "I want us to consider a different form of narrative to prepare us for the challenge and privilege of patient care and lifelong learning.”
Chelminski isn’t alone in pushing for broadening medical education to include the humanities. Nortin Hadler, MD, professor of medicine and microbiology and immunology, sees a dramatic transition in how medicine is taught today, with training geared toward producing doctors with defined skill sets. Hadler contends that the doctor should instead be a participant in the care of the patient, helping the patient make decisions, a role that demands varied experiences.
“Being the navigator for the patient requires a level of humanism that can only be achieved with a broad basis in all that colors the experience of man from molecular biology to Kafka,” says Hadler. “I applaud the degree to which Paul Chelminski is pursuing this goal and the funding Charles Sanders provided to support the effort. Perhaps in the twenty-first century, no patient will ever again ask a doctor, ‘What would you do?’ rather than ‘What would you do if you were me?’”
Learning the craft of medicine
James Bryan II, MD, MPH, professor of medicine and social medicine, has been at the UNC School of Medicine for nearly five decades. Bryan has known Chelminski in various capacities dating back to Chelminski’s time as a medical student at Carolina. According to Bryan, Chelminski’s experiences and his diverse set of interests must be imparted to medical students and residents.
“The model for medical school is almost like a monastery,” says Bryan. “By necessity, students must withdraw from society because they’re working so hard at learning things like genomics. On the other hand, unless they’re sensitive to, participate in, and have contact with society at large, they’ll be inappropriate as they start practice.”
According to both Chelminksi and Bryan, teaching students to become competent in the science of medicine is not enough. Young physicians must learn the craft of medicine – how to customize and personalize care for the patient.
“There are a lot of commonalities among medical schools in that the nation expects you to be able to pass the measurements they’ve adopted to demonstrate competence,” says Bryan. “But at the same time, Paul’s point is that competence in terms of answering questions about congestive heart failure doesn’t equal competence in taking care of Mrs. Jones.”
Chelminski views the shift in medical education toward guidelines and formulas over human interaction as a move that not only has removed the doctor from the patient, but, in fact, elevated the doctor above the patient.
“What we’ve done to some degree is establish a scientific paternalism,” says Chelminski. “‘You need to get your cholesterol or your blood pressure to such and such a number,’ but instead of your doctor saying this, today we tell them what the guidelines are….While I agree with the goals, patients have to have a sense that they’re participating in these decisions rather than having these decisions made for them.”
Introducing ideas of personal practice medicine should not be tricky – according to Chelminski, the means to teach and acquire the skills for personalized care are not mysterious.
“I tell trainees and colleagues that we should converse with patients in a manner similar to how we initiate a sensitive and intelligent conversation with people we care about in other important life settings like weddings, funerals, bar mitzvahs, graduation ceremonies – or even the conversation we have in a bar with a close friend who finds himself undervalued at work and passed over,” Chelminski says.
The proper place of medicine
Chelminski typically exchanges 20 to 40 emails with patients each day. Recently he received this email from the daughter of a patient after a home visit at a local retirement community:
Dear Dr Chelminski
Thank you so much for your home visit with Dad. He felt so special. Still reluctant to use walker but will continue to work on this…
At the home visit, the patient had presented Chelminski with a copy of a book he had written on his World War II service in the Pacific.
“It is our privilege to serve people like this,” Chelminski says. “I should feel special for providing his care. After all, it was his service to our country that led to the GI Bill, which my father used to launch his career and pay for my education and opportunities in life.”
According to Chelminski, when medicine is practiced in such a way, the profession assumes its proper place in culture. “The arrogance of medicine is that it has thought of itself as coequal with – even bigger than – culture,” Chelminski says. “But it’s just a piece, and is subordinate. It serves society well only if it fortifies all the other elements of culture. I think about it this way: when we subordinate the importance of medicine, we can enhance its contribution to people.”