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What they don't teach in medical schools: The art of care-giving
By Arthur Kleinman |
June 2, 2009, Tuesday
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CARE-GIVING is understood by economists as a "burden," by clinical psychologists as a "coping process," by health-services researchers in terms of health-care costs, and by physicians as a matter of clinical competency.
But, for many people, care-giving is a foundational component of moral experience. It is a practice of acknowledgement, empathic imagination, witnessing, responsibility, solidarity, and the most concrete forms of assistance.
It is this moral aspect that makes care-givers, and at times even care-receivers, feel more "present" - and thus more fully human.
But, aside from skilled nursing, rehabilitation efforts by occupational and physical therapists, and the practical assistance of social workers and home health aides, care-giving, especially for victims of health catastrophes and end-stage conditions, has relatively little to do with the contemporary practice of medicine.
A personal story
To illustrate this point, I draw on my personal experience as the care-giver for my wife, who suffers from a severe neurodegenerative disorder that has impaired her memory and motor functions, restricting her independence.
I wake her up in the morning, assist her in toileting, bathing, and dressing, make us breakfast, and help her feed herself.
I assist her in walking, placing her in a chair, and getting into our car.
I am with her nearly all the time to protect her from injuring herself, because she can neither see nor navigate safely on the street or in our own home.
It is disturbing to witness the deterioration of a once elegant, intellectually lively, and highly independent companion of more than four decades.
But our emotional reactions, from frustration and anger to sadness, have been cushioned and sublimated by our work, the long rhythm of our days together, and, above all, by the support of family and close friends.
That concern and responsibility for us is as much a part of care-giving as all the mundane practices I have listed, and amounts to moral solidarity with our struggle.
I give you this personal sketch because it is the best I can do to illustrate what care-giving entails, and why it is so crucial to everyone's life - and to the human condition more generally.
Care-giving, as illustrated by our case, includes what happens when hope and consolation are abandoned and when all there is to do is to be present with the sufferer, sharing his or her suffering by simply - and usually silently - being there.
In medical schools, however, the curriculum in both the basic science and clinical apprenticeship years places the greatest emphasis on understanding the biology of disease processes and high-technology treatments.
The illness experience gets less and less pedagogic attention as the student progresses from classroom to inpatient ward and clinic.
In the broader system of healthcare, students can readily discern that medicine largely leaves the practical and emotional tasks of care-giving to nurses, social workers, and the patient and his or her network of support.
The structure of service delivery and the funding of health services work to discourage professionals from the art of care-giving, and can, in fact, undermine the practitioner's efforts.
The result is moral impoverishment of the practice of medicine.
To prepare for a career of care-giving, medical students and young doctors clearly require something besides scientific and technological training.
A care-giver
Indeed, current professional education can even be seen as enabling the physician as a technical expert, while disabling him or her as a care-giver.
To overcome this trend, we must incorporate the humanities into medical training as a means of rekindling and deepening those human experiences of imagination and commitment that are essential for care-giving, and resisting the bureaucratization of values and emotional responses that causes failure in the physician's art.
(The author is professor of medical anthropology, Harvard University. Copyright: Project Syndicate, 2009. www.project-syndicate.org.)
But, for many people, care-giving is a foundational component of moral experience. It is a practice of acknowledgement, empathic imagination, witnessing, responsibility, solidarity, and the most concrete forms of assistance.
It is this moral aspect that makes care-givers, and at times even care-receivers, feel more "present" - and thus more fully human.
But, aside from skilled nursing, rehabilitation efforts by occupational and physical therapists, and the practical assistance of social workers and home health aides, care-giving, especially for victims of health catastrophes and end-stage conditions, has relatively little to do with the contemporary practice of medicine.
A personal story
To illustrate this point, I draw on my personal experience as the care-giver for my wife, who suffers from a severe neurodegenerative disorder that has impaired her memory and motor functions, restricting her independence.
I wake her up in the morning, assist her in toileting, bathing, and dressing, make us breakfast, and help her feed herself.
I assist her in walking, placing her in a chair, and getting into our car.
I am with her nearly all the time to protect her from injuring herself, because she can neither see nor navigate safely on the street or in our own home.
It is disturbing to witness the deterioration of a once elegant, intellectually lively, and highly independent companion of more than four decades.
But our emotional reactions, from frustration and anger to sadness, have been cushioned and sublimated by our work, the long rhythm of our days together, and, above all, by the support of family and close friends.
That concern and responsibility for us is as much a part of care-giving as all the mundane practices I have listed, and amounts to moral solidarity with our struggle.
I give you this personal sketch because it is the best I can do to illustrate what care-giving entails, and why it is so crucial to everyone's life - and to the human condition more generally.
Care-giving, as illustrated by our case, includes what happens when hope and consolation are abandoned and when all there is to do is to be present with the sufferer, sharing his or her suffering by simply - and usually silently - being there.
In medical schools, however, the curriculum in both the basic science and clinical apprenticeship years places the greatest emphasis on understanding the biology of disease processes and high-technology treatments.
The illness experience gets less and less pedagogic attention as the student progresses from classroom to inpatient ward and clinic.
In the broader system of healthcare, students can readily discern that medicine largely leaves the practical and emotional tasks of care-giving to nurses, social workers, and the patient and his or her network of support.
The structure of service delivery and the funding of health services work to discourage professionals from the art of care-giving, and can, in fact, undermine the practitioner's efforts.
The result is moral impoverishment of the practice of medicine.
To prepare for a career of care-giving, medical students and young doctors clearly require something besides scientific and technological training.
A care-giver
Indeed, current professional education can even be seen as enabling the physician as a technical expert, while disabling him or her as a care-giver.
To overcome this trend, we must incorporate the humanities into medical training as a means of rekindling and deepening those human experiences of imagination and commitment that are essential for care-giving, and resisting the bureaucratization of values and emotional responses that causes failure in the physician's art.
(The author is professor of medical anthropology, Harvard University. Copyright: Project Syndicate, 2009. www.project-syndicate.org.)
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