Abstract
It was a sunny Monday morning and I just started medical school. Prof. Dr. med. Dr. med. h.c. Johannes W. Rohen, a German anatomist and former chair of the Department for Anatomy at the Friedrich–Alexander University Erlangen–Nürnberg, gave his famous lecture about how to become a doctor. Prof. Rohen, already 87 years of age, a tall man with an inspiring aura, told our class that medical school predominantly provides just one thing and one thing only: the acquisition of knowledge. I felt the initial confusion in the audience, although he elaborated on the next, more important steps to becoming a doctor: gaining experience, skills and knowledge, compassion, intuition, life experience, and finally love. The quote that struck me the most and has accompanied me ever since was the following: “I have seen many doctors in my career…also good ones!”
So what is a “good” doctor? The answer may be different depending on whom you ask.
The time went by and I became a geriatrician with a special interest in palliative care (PC). For me, both fields in medicine are wonderful examples of holistic and compassionate care. The essential component of PC is the multidisciplinary holistic management of terminal and other life-limiting illnesses to minimize and relieve the suffering associated with them. Among other things, it includes attention to the emotional needs of the patients as well as of the primary care givers during the patient's illness and subsequently to bereavement.
This issue of Journal of Palliative Medicine (JPM) includes a very intriguing review of the evidence-based nonpharmacological and pharmacological management of depression with patients in the terminal stages of life by Perusinghe et al. Not surprisingly, the existing evidence is sparse. I suspect that we will never see, for our patients, a systematic review and network meta-analysis such as the one from Cipriani et al. 1 published 2018 in Lancet assessing the comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder.
Still, the current review is interesting in a number of respects. The studies investigating the pharmacological methods showed that the use of antidepressants, such as SSRIs and mirtazapine, or stimulants such as methylphenidate are beneficial. Furthermore, the most studied nonpharmacological intervention was dignity therapy, which showed an improvement in depression that lasted post-intervention.
From a clinical point of view, several questions remain open: the authors did not find any studies that investigated the use of both pharmacological and nonpharmacological treatments. Therefore, no definitive statement is possible regarding the added benefit of combining pharmacological and nonpharmacological methods. In addition, most studies did not focus on the oldest old. Future research will need to establish the prevalence of symptoms, expand study inclusion criteria to include a broader range of patients more representative of geriatric population as a whole, and create new scales or modify existing ones validated in this population. 2
The report from Mr. Dolan et al. in this issue of JPM is also interesting. The authors conducted semistructured interviews with 15 patients with end-stage liver disease (ESLD) and 14 informal caregivers. For me, the results are striking: participants' knowledge about PC came primarily from their loved ones' experiences, with many conflating PC with end-of-life care. Importantly, transplant-listed patients expressed concern that a PC referral would negatively affect their likelihood of receiving a liver transplant. After hearing a brief description of PC, nearly all participants believed that patients with ESLD should learn about PC soon after diagnosis to help support their illness understanding and coping.
This study offers another perfect example why communication skills are so important: if we are not able to elucidate sources of patient or caregiver burden, how will we be able to comprehend the psychological/spiritual well-being and quality of life of our patients?
It is not for me to judge whether or not I am a good doctor…therefore, I truly believe that the words from Prof. Rohen will continue to walk with me into the future. We all strive toward the holistic practice of medicine that embraces the golden principle of maximizing quality of life by means of expert symptom management coupled with sensitive exploration, explanation, and management of patients' psychological and spiritual concerns. 3
From where I sit, the holistic and compassionate approach should not be the exclusive domain of PC. It should become the standard of health care. It is the only, the human way.