On Being a Patient

Since it began in Annals 5 years ago, “On Being a Doctor” has attracted enthusiastic interest and attention. Many readers tell us it is the first thing they read when their copy arrives. Authors send an average of about three manuscripts a week to this department (some 7% of our total submissions), and 73 of the best pieces have been collected into a widely read book. Our authors tell about the sobering, satisfying, anguishing, exhilarating experiences of doctoring; their stories are always deeply felt. And increasingly, they tell the story from the other side of the desk, the other end of the bed: the experience of being a patient. We have decided, therefore, that the patient's universe deserves its own place in our pages. Hence, this issue of Annals contains the first of a new series, “On Being a Patient,” a natural extension of and counterpart to the doctor's perspective. We intend to publish this feature from time to time as appropriate manuscripts appear.

As internists, we always try to maintain awareness of our patients' point of view, but the task isn't easy. We are, after all, carefully trained to put aside our “lay” personae as we go about doctoring; to bring to patient encounters our special, professional perspective, which is largely that of the biomedical model of disease, plus a variety of psychosocial constructs. These models are, after all, principally what we have to offer patients; they give us our unique leverage over distress and disability; they are the source, ultimately, of our rewards, both personal and financial. But patients bring with them to our encounters the experience of illness, a matter altogether different from the disease perspective. As we work together on problems, we try to get ahold of what patients are going through, and they try to grasp what we are grappling with. Often we meet in the middle; all too often, we don't.

Everything considered, we take patients' experiences, values, and choices considerably more seriously than we did even 30 years ago; every aspect of medicine, from clinical decision making and research on down to the concept of malpractice itself has been affected by this shift [1]. Despite the concerns of some, such reframing of points of view doesn't mean that we need abandon our models of disease or our responsibility for diagnostic and therapeutic decision making. On the contrary, this shift in the mix of patients' versus doctors' points of view can only enrich the practice of medicine—if we make good use of it. Robert Loeb, who taught generations of Columbia medical students and residents, used to say, “Listen to your patients; they are trying to tell you something.” What they are trying to tell us is important in at least two ways: first, hearing patients lies at the heart of our contact with them, the critical “connexional” dimension of the care we provide [2]; and, second, there is important diagnostic and management information to be found in patients' perceptions, descriptions, experiences, their attributions and models of illness [3, 4].

Maintaining “real time” awareness of both our own professional perceptions and, simultaneously, those of patients is thus a key professional responsibility. But maintaining that awareness is also an advanced and demanding skill, akin perhaps to musicians' highly developed ability to hear the music unfolding horizontally, so to speak, as individual voices, while at every moment also hearing it vertically, as a whole.

The experience of “listening with the third ear” to your own patients is a necessary but, unfortunately, not sufficient element in the refinement of this skill; reflection on what you've heard is equally important. Although it is difficult, if not impossible, to find opportunities for such introspection in the crush of daily practice, there are various ways to reflect in tranquility on the meaning of illness as perceived by patients, when the time presents itself: “decentering” ourselves, for example, into patients' worlds by writing down their accounts of illness in their voices [5]; absorbing the best of analytical writing on the meaning of illness [6]; and reading articulate, unvarnished descriptions of the experience of illness, whether disguised as fiction or frankly autobiographical, physicians' own accounts being a particularly rich source [7, 8]. “On Being a Patient” is Annals' contribution to the autobiographical genre.

We invite Annals readers to contribute manuscripts of the following kinds to “On Being a Patient”: first, physician-readers' accounts of their own experience of illness; second, accounts of illness written by their own patients; third, brief autobiographical writings on illness by published writers, physician or nonphysician, whether cast as fiction or explicitly autobiographical; and, finally, accounts of the experiences of patients' families. Patients and their families, like Corrie's in this issue of Annals [9], live through illness together; families' perspectives are therefore unique and important and also need to be heard.

Details concerning preparation of manuscripts for this department are to be found in Information for Authors published in each issue (see pp. I-11 to I-15 in the 1 January 1996 issue for the full version of Information for Authors). Although every contribution will be judged by its overall excellence, above all, manuscripts will be selected for publication because they tell about unique experience or tell about it uniquely well. We welcome comments from readers about individual contributions published in “On Being a Patient” and about this new feature in general.

• Copyright ©2004 by the American College of Physicians