BY NINA UZOIGWE
Caregiving across continental borders is a multifaceted experience within global healthcare. Arthur Kleinman, a professor of medical anthropology and cross-cultural psychiatry at Harvard University, stated in his publication in the Lancet that caregiving is “a deeply interpersonal, relational practice that resonates with the most troubling preoccupations of both carer and sufferer”.¹ In this relational practice, “the laying [of] hands, empathic witnessing, listening to the illness narrative, and providing moral solidarity through sustained engagement and responsibility” embody the moral face of caregiving that physicians are to provide the sufferer in order to intrinsically acknowledge their patient’s personhood.¹ Impartation of presence plays a significant role in how a person internalizes their illness and progresses through treatment. When comparing the healthcare systems of the United States and Europe, one can articulate how this human touch is promoted throughout their patient care in relation to the impact of their respective cultures. Across this continental border, this presence is extremely beneficial to those in need of easement and reassurance, but the implementation and the extent to which this is hindered is heavily impacted by societal standards defined within their relative cultures.
Over the course of these past two summers, I had the opportunity to shadow and experience this difference firsthand in two clinical locations, the first being Ospedale Niguarda. Ospedale Niguarda is a leading Italian general hospital in Milan, Italy, a city often referenced as the Italian capital of health.² With over 4,400 employed medical personnel and servicing approximately 2 million outpatients, it hosts all medical disciplines and technologies from the stages of diagnosis to rehabilitation, integrating all disciplinaries to ensure that the best healthcare is delivered to all its patients.² The second hospital visited was Unidade Local de Saúde de Matosinhos. Known as the first local hospital unit located in Matosinhos, Portugal, it was established by the Decree-Law n° 207/99, a law implemented to improve the performance of Portugal’s primary health care system through the unification of health services, and serves as a reference model for other healthcare providers.³ By providing primary and continuous healthcare to the population located within this municipality, it embodies and exemplifies the effective integration of local hospitals and related health centers into one single provider entity, creating the foundation for the construction of five local health units that followed it.⁴ While comparing daily interactions between patients and doctors of these areas to those found within the healthcare system of the United States, the power of touch echoing throughout each case study’s respective patient experiences was captivating. As illustrated by the detailed experiences below, European healthcare systems prioritize human touch more than the US healthcare system, inherently improving the quality of care. This will be analyzed through the examples of Italy and Portugal, with the understanding that they are not representations of the entire European body, but rather distinct examples within this region.
To begin, when observing the value of human touch in U.S. hospitals, it is seen that it is extremely beneficial to those in need of ease and reassurance. In her 2018 New York Times article, “The Importance of Medical Touch,” patient Caitlin Kelly detailed the experience of receiving a breast biopsy where her left breast was exposed through a hole in a table.⁵ Kelly recounts that, “several hands reached for what’s normally a private and hidden body part and moved it with practiced ease” ⁵. Fearful of the procedure, she wept throughout the hour, but a nurse “gently patted [her] right shoulder and the male radiologist, seated to [her] left and working below [her], stroked [her] left wrist to comfort [her]”, actions that she was ultimately extremely grateful for since she knew that this was otherwise a routine procedure ⁵. Most important to Kelly was that her anxiety was never downplayed or disregarded by medical personnel, which she was highly appreciative of.
Likewise, this level of compassion was demonstrated in care within Northern Italy, specifically in Ospedale Niguarda. While shadowing an oncology resident in this general hospital, I witnessed how this was offered to a 68-year-old male patient suffering from Stage IV bile duct cancer by a resident, genuinely fueled by his mission to deliver the best treatment available to all of his patients. He wanted to give this patient documentation to sign, detailing the terms of compliance for experimental research. When walking into his patient’s room, this resident sat down on the hospital bed and pulled up a table. The patient was shocked when the resident lay the papers in front of him in an orderly fashion while engaging in cordial conversation. The patient gradually became exuberant upon reception of this level of care and concern, becoming more responsive to the details of the agreement as the resident reasoned through every clause. Each page was thoroughly explained with the patient’s concerns immediately addressed, and later that day, the demeanor of that patient was enlivened as he strolled up and down the halls in a pair of sunglasses, engaging in conversation with a huge smile on his face, despite his frail condition.
Finally, in Portugal, specifically in ULSM Matosinhos, this level of involvement was seen in its Emergency Department, where a 20-year-old female limped into the Day Surgery Room with a 10mm abscess behind her right knee. The area was blackened by inflammation and the slightest pressure applied to the site made her scream with tears rolling down her face. When the head surgeon of the department attempted to inject a local anesthetic to the abscess and drain the pus with a razor blade, the patient’s entire body trembled in anguish and sobs as she jolted away upon contact of the needle and blade with her leg. It wasn’t until another surgeon stroked and held her hand, turning her head away from the cause of her discomfort, that her wails became muffled and the procedure was executed. Although she later admitted that the pain was worse than giving birth to her child, she was able to endure her agony with the support of human touch.
However, although human touch has this universal uplifting effect in the doctor-patient relationship, it is also essential to note that the culture defines the boundaries of this said connection, especially in the division seen in U.S. hospitals. According to Atul Gawande in the New Yorker article, “Why Doctors Hate Their Computers”, more than ninety percent of American hospitals computerized in the past decade and adopted software in the hopes of utilizing a single platform to perform everything health professionals need to become greener, better, and faster.⁶ These actions include but are not limited to recording and communicating medical observations, sending prescriptions, ordering tests and scans, viewing results, scheduling appointments, and sending insurance bills, all through one medium.⁶ Physicians and nurses have become swamped with overcoming the learning curves for using these devices, cutting down one-on-one time with their patients. Abraham Verghese, a physician who works in a Stanford center that is focused on the human aspects of medical care, stated that this implementation has given rise to what he coins to be the “i-patient”, an icon represented in the computer, and the real patient, the patient on the hospital bed.⁷ With attention partly averted to computer screens, medical personnel have inherently created this division during patient contact, specifically during diagnosis and treatment.
Having these two separate entities places less emphasis on using the display of human compassion and presence as a means of providing the best care. The focus has shifted towards making sure that the patient in the online interface has all the appropriate fields and documentation filled out, rather than engaging in conversation with the patient who arrived to be seen. In Verghese’s TEDGlobal 2011 speech, he explained that the i-patient typically receives “wonderful care all across America” while the real patient is often left to wonder, “Where is everyone? When are they going to come by and explain things to me? Who’s in charge?”. ⁷ Although the utilization of online electronic health records has provided efficient means for addressing the current necessity of supplying extensive resources, this demonstrates that there is a disjunction between the carer and the sufferer in America due to the cultural drive to become economically better and faster, especially in a country that has a growing populace and is driven by financial incentives. According to a study completed by the Athenahealth, a private company that provides network-enabled services for healthcare in the United States, practices that “increased portal adoption rates by 20 [percent] or more over 12 months saw a median increase in patient pay yield of nearly five percent”, bettering overall clinical practice financial sustainability.⁸ Unfortunately, this creates a trade-off between doctor-patient contact and streamlined systems, building up walls of computers between these two entities at an alarming rate.
On the other hand, when referring to past experiences in European hospitals, the dynamic between the physician and patient was more centered on human touch, a defining aspect of both cultures. Within Ospedale Niguarda, the attending head physician in each of the eight departments I shadowed would often complete the department’s rounds with the head nurse, residents, and other doctors. They took the morning and early afternoon, after a short debrief, to meet and greet each patient and ask questions about the progression of their recovery, personally contributing to the quality of their care and taking notes on pieces of paper. It wasn’t until they were done with these rounds in the afternoon that each resident and doctor sat in a separate room full of computers to fill out medical observations and make official requests about treatments. Since 1991, Ospedale Niguarda developed and uses its own portal as an internal application that retrieves and gathers administrative patient specific data onto a centralized interface, “standardizing communication and process interaction between the different hospital units”. ⁹ But many of the doctors explained that the focus of attending patients at their hospital beds was to hold a conversation and use their hands to do their job, clearly drawing a boundary between logging in patient care and giving their patients the attention they need.
Likewise, when reflecting on the healthcare system presented in Matosinhos, Portugal, specifically USLM, it is seen that this value is highly treasured as well. Along the same lines of U.S. hospitals and Niguarda Ospedale, the SNS Portal (Portal de Saúde) forms the core of several projects developed by Portugal’s National Health Service, the Serviço Nacional de Saúde (SNS).¹⁰ However, this was created in hopes of “transforming the way information about health services and resources [is] shared” with Portugal’s people, centralizing the usage of the system for improving citizen oriented communication.¹⁰ By redirecting the purpose of having this system to bettering the lives of those involved in healthcare, it is clearly demonstrated that more focus is placed by administration on creating a clear line of communication for its people, preserving an attribute of human touch in technological advancements. This thereby makes human compassion a priority.
This is so much so that when observing how integrated human touch is in day to day care of USLM, there are extra steps taken to enforce precautionary measures. In fact, when traveling from one in-patient room to another in the Department of General Surgery of ULSM Matosinhos, one would find a series of large yellow and red signs that signal to the medical personnel within this department that a gown and mask should be utilized upon entry to these rooms or curtained off areas, an addition that was not seen in the in-patient rooms in Ospedale Niguarda. With Portugal being one of the most friendliest countries towards residents worldwide according to Expat Insider (one of the world’s largest and most comprehensive surveys on life abroad), the Portugese culture comes across as extremely warm hearted, where a kiss on each cheek is a social normality ¹¹. It would therefore be understandable that these signs would be utilized as an extra layer of precaution in an environment where a warm embrace is considered second nature. Thus, it is seen that in the midst of adopting computer systems into the medical environment, human touch still has a cherished place in the European day to day practice.
One may argue that medical efficiencies have more value than the human touch exhibited during time spent in hospital rooms and should be prioritized because it increases accuracy in diagnosis and allows for more medical issues to be addressed. According to Richard Harris in “As Artificial Intelligence Moves Into Medicine, The Human Touch Could Be A Casualty”, depending on how automation is employed, “it can help reduce medical errors and potentially reduce the cost of care”.¹² Even Verghese, in this same article, expresses hopefulness that artificial intelligence can help to sort through the clues gathered during medical treatment since “medicine is messy”.¹² However, being present in a patient’s recovery matters a great deal, especially to a woman with breast cancer who, after finding one of the world’s best cancer centers, decided to go back to her private oncologist in a small town in Texas. To her, although it had a “beautiful facility, giant atrium, valet parking, a piano that played itself, a concierge that took you around from here to there”, they did not touch her breasts.⁷ The doctors had no need since they scanned her inside out and understood the nature of her illness at a molecular level, but she yearned for her private oncologist who “everytime she went, examined both breasts including the axillary tail, examined her axilla carefully, examined her cervical region, her inguinal region, [and] did a thorough exam”.⁷ This level of attentiveness from her doctor was what she sought, as her concerns and her state of well-being were readily addressed with acknowledgement.⁷ Hence, even though a patient may long to be evaluated at the best level of care, doctors and nurses can’t merely be supplements to these machines. Although technological advancements make significant improvements in the competency of hospitals, these advancements cannot move forward and maintain their beneficence without recognizing that the impartation of presence by the caregiver is a psychological necessity for a working doctor-patient relationship to take root.
In closing, then, human touch plays a significant role in how a person internalizes their illness and progresses with treatment. As demonstrated by the told experiences found within the United States, Italy, and Portugal, human touch is extremely valued and beneficial to those in need of reassurance because this act of presence has the power to reanimate and make the pathway for recovery appear less intimidating. It is important to note that their respective cultures define the boundaries of implementation for this said relationship because their values impact what’s carried over amidst technological advancements. Although efficiency and professional competency are essential components for caregiving, quality of care has much to do with the presence of a doctor-patient relationship as it does with technological, pharmaceutical and financial facets of healthcare. It is only when advancements found within these fields account for this treasured interaction in patient care that the healthcare system across all borders can truly be elevated.
Nina Uzoigwe is a junior at Harvard College, concentrating in Bioengineering with a Secondary in Global Health and Health Policy. She can be contacted at firstname.lastname@example.org.
- Kleinman, A. (2012, November 03). Caregiving as Moral Experience. The Lancet 380(9853): 1550-1551.
- Niguarda General Hospital and Care Centers. (2019, August). Retrieved from https://www.ospedaleniguarda.it/0_LANGUAGES/downloads/Niguarda_hospital.pdf.
- Santana, S., Szczygiel, N., & Redondo, P. (2014). Integration of care systems in Portugal: anatomy of recent reforms. International journal of integrated care, 14, e014. doi:10.5334/ijic.989
- Missão, Atribuições e Legislação Categoria – Unidade Local de Saúde de Matosinhos. (2019). Retrieved from http://www.ulsm.min-saude.pt/category/institucional/missao/.
- Kelly, C. A. (2018, October 08). The Importance of Medical Touch. Retrieved from https://www.nytimes.com/2018/10/08/well/live/the-importance-of-medical-touch.html
- Gawande, A. (2018, November 28). Why Doctors Hate Their Computers. Retrieved December 10, 2018, from https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
- Verghese, A. (2011, July). A doctor’s touch [Video File]. Retrieved from https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch
- Irving, F. (2016, June 10). Why patient portals pay off. Retrieved from https://www.athenahealth.com/insight/patient-portals-pay-off.
- Locatelli P., Baj E., Origgi G. and Bragagia S. (2009). MEDICAL TUTORIAL: PORTING OF A CLINICAL PORTAL BETWEEN HEALTHCARE ORGANIZATIONS – Reuse of an Application in Health Informatics. Proceedings of the International Conference on Health Informatics – Volume 1: HEALTHINF, (BIOSTEC 2009) ISBN 978-989-8111-63-0, pages 375-380. DOI: 10.5220/0001780003750380
- SNS Portal transforms access to public healthcare in Portugal. (2017, October). Retrieved from https://joinup.ec.europa.eu/collection/ehealth/document/sns-portal-transforms-access-pub lic-healthcare-portugal.
- The Top 10 Most Welcoming Countries. (2019). Retrieved from https://www.internations.org/guide/global/the-top-10-most-welcoming-countries-39411.
- Harris, R. (2019, April 30). As Artificial Intelligence Moves Into Medicine, The Human Touch Could Be A Casualty. Retrieved from https://www.npr.org/sections/health-shots/2019/04/30/718413798/as-artificial-intelligenc e-moves-into-medicine-the-human-touch-could-be-a-casual