For some time, I have taught communication and relational skills to medical students and physicians-in-training in an internal medicine residency program in the United States. What became apparent to me early on was that the humanistic, relationship-centred attitudes and behaviours being fostered in the classroom were not always finding their way into the clinic or onto the hospital floors. Sadly enough, this observation is supported by studies on patient–physician communication.1,2 In discussing this phenomenon with my students and colleagues, a common response emerged. They believe the relational behaviours taught in the classroom are not wholly credible in the “real world” of medical practice. Empathic attitudes and behaviours make little sense in terms of survival in residency training or success in practice. It seems as if these compassionate behaviours are being extinguished by a lack of incentive or reward in the system. Valued and rewarded instead are academic acumen, technical knowledge and skill, business savvy, and financial success.

To better understand this situation, I began to study the “real world” of medicine more intently. Based on this examination, it is my impression that the fundamental problem in the current healthcare system is a lack of meaning. For the purpose of this article, “meaning” will be defined as the underlying beliefs, guiding principles, and defining philosophies that make up the professional ethic of medicine. What follows are my observations and thoughts, as well as a brief outline of my recommendations.

Over the past century, there has been an insidious decline in attention to the philosophy of medicine. We have become less interested in or aware of the age-old values and ethical traditions of our healing profession. This claim is supported by the many studies demonstrating that medical training and professional socialisation, rather than developing and fostering humanistic attitudes and behaviours, actually erode them.3,4 As a result, the core meanings of medicine have been subsumed by the current, dominating societal paradigms of business,5 consumerism,6 the information age,7 technology,8 and the legal system. Clearly, these paradigms are integral and necessary to world culture and modern healthcare, but problems arise when they control the healthcare system, directing the way we care for patients and relate to clinicians.

Patient-care surveys reveal a steady decline in public satisfaction with medical care. Research studies repeatedly demonstrate a lack of communication, empathy, and trust in the doctor–patient relationship.9 Although a significant percentage of patients are satisfied with their individual physicians, they and their families are largely displeased with the overall healthcare experience.10 Escalating discontent and distrust are evidenced weekly in newspaper articles and best-selling books.11,12 This widespread public discontent with mainstream medical care is further evidenced by the large and growing movement to seek alternative avenues of medical treatment by turning, literally, to “alternative” practitioners.13

Dangling on the other end of the stethoscope, physicians and other clinicians increasingly find themselves frustrated and demoralised by a work environment devoid of respect and compassion for its employees.14 Morale within the healthcare work environment is at an all-time low.15 Physicians, emotionally exhausted and burned-out, are claiming disabilities and leaving the practice of medicine in unprecedented numbers.16 Loss of autonomy in medical decision-making, burdensome and time-consuming administrative hurdles, fear of malpractice litigation, and financial disincentives threaten physicians' livelihood and their sense of responsibility and professionalism.17 Clinicians, entering the profession with an expectation of providing humanistic medical care, quickly become disappointed and disillusioned.18

The present healthcare system, embedded in the principles of the marketplace, has become a caustic and dehumanising environment for patient and physician alike. Physicians are reduced to interchangeable “providers” and patients to generic “consumers". Clinicians, now treated like factory-line workers, are forced to process patients as if they were items on a conveyor belt. And so we find ourselves entangled in the paradox of modern healthcare19 — despite astounding scientific achievements and dazzling technological sophistication over the past few decades, societal satisfaction with the healthcare system is declining.20 The question we return to is why.

One of the greatest tragedies of the 20th century is that in developing the means we have forgotten the “meaning".21 Our society has forgotten that the practice of medicine is primarily a humanistic endeavour, not a scientific one.22 We have forgotten that medicine is a healing profession, not a technological one, and that the contribution of a doctor adds up to more than the sum of his or her knowledge and skill. We have forgotten that the patient, as a person, is far more important than the illness; that the illness is far more than the presence of a disease; and that when the cure of disease is not possible, as is so often the case, the humanistic care of patient and family fosters hope and healing. Our society has become myopic in its focus on technical treatment to the exclusion of how we might treat each other as sublime human beings.

The fundamental flaw in applying technological and mercantile approaches to healthcare is that they do not acknowledge or allow for a relational response to the inherent suffering in being a patient or a family member of a patient. Peering through the prisms of consumerism, informatics, science, and technology blinds us to the deeply personal relationships necessary for the transcendence of suffering and its transformation into a healing experience. Strategic plans, business ledgers, and diagnostic codes do not account for the unique and graceful relationships required in patient care. Yet, one of our primary responsibilities in medical practice involves this complex and time-consuming process of helping people cope with suffering.23 Suffering which extends from the physical, to the emotional, relational and spiritual domains.

The personal care that a doctor, nurse, social worker and every other healthcare professional offers to his or her patients on these multiple levels cannot be scripted, packaged, or coded. These intimate, sometimes gut-wrenching relationships are often “white knuckle journeys” in which patient, family and doctor hang on, literally, for dear life. It has been eloquently described by one patient as a journey in which the doctor “[enters] my condition . . . [mingles] his daemon with mine; . . . [and] we . . .wrestle with my fate together".24 Compassion and a sense of service to humanity are not commodities or provider services. Medical care, notwithstanding the current industry nomenclature, is an offering, not a provision.

Mindful, dignified and collaborative healthcare requires time — the time to listen, to touch, and to create meaningful relationships together. Research strongly suggests that, more than any other aspect of medical care, it is the empathic bond and trusting relationship between patient and physician that bring about measurable improvements in health outcomes.25 It is this humanistic and relational approach that the mechanistic paradigms of business, science, and technology cannot fathom. These intangible qualities are difficult to document in quarterly earnings reports or customer satisfaction surveys, or even in blinded, randomised, placebo-controlled trials.

The question remains — how to advocate for and re-create the practice of a humanistic healthcare philosophy in the modern era of medicine.

First, I believe it would be useful to begin on the individual level by re-evaluating our personal philosophies toward medicine and healing.26 A few examples of questions I have found myself asking are:

• How do I define “health” and “healing"?

• How do my behaviours and relationships reflect and represent those values?

• What values would I want my patients and colleagues to recognise in my behaviours?

• What might I do to increase the likelihood of those values being expressed?

• To aid in this exploration, seminars in medical history and philosophy should become a staple in medical schools, residency training programs, and postgraduate continuing medical education conferences. Even more importantly than formal educational programs, physicians should use each clinical and teaching encounter as an opportunity to develop and foster a meaningful philosophy of medicine for themselves, their patients, and their students.

Second, we need to be supported in caring for our families and ourselves. If we are physically, emotionally and spiritually exhausted, it is unlikely that we will be able to provide the type of medical care and healing that our patients want and need.27 We must advocate for a healthcare system that not only allows, but also encourages and even requires, the healing of its healers.28

Third, we need to create an ongoing public dialogue around the relational and ethical aspects of healthcare.29 This dialogue must include non-professional partners and extend outside of hospitals and healthcare centres into communities across the country. Given the pluralism of ethnicity and language in our society, it is essential that this dialogue be made available and accessible to people from a wide variety of cultural backgrounds and socioeconomic standings. Also of importance is the inclusion of patients' family members and non-professional caregivers as integral partners in this dialogue.

Fourth, what is required is a renewed focus on institutional or systemic ethics. The practical application of medical ethics has been, in large part, devoted to individual case analysis.30 What is sorely needed is an examination of the principles and behaviours of the larger system. We must examine the messages and beliefs underlying the verbiage, policies, and actions of healthcare organisations. And we must challenge them if we believe they are inconsistent with a healthful vision and mission.31,32 Examples of questions that demonstrate this initiative are:

• What healing values and principles does my healthcare organisation demonstrate in its daily functioning?

• How does my organisation support the development of its staff and encourage collaborative relationships?

• What healthful visions would I want to see implemented and integrated into the infrastructure?

• What might I do within this organisation to move it closer to that vision?

Fifth, we must take advantage of every opportunity to act and be perceived as agents of positive change within the system, rather than as protectors of the status quo. Needless to say, attaining and maintaining clinical and technical competence within any field of medicine requires a tremendous amount of time and effort. However, given the inter-relatedness and interdependence of medical practice, it is no longer sufficient for physicians to limit themselves to being individually competent practitioners in examination rooms, operating rooms or on hospital wards. What is required is not only clinical competence but also “systemic competence".

Finally, we must re-create the system so that it recognises, rewards, reinforces and reimburses humanistic standards of medical care.33 Accreditation and regulatory bodies should evaluate for the presence of these ethical and empathic attitudes and behaviours in individuals and within healthcare organisations. We must legislate these ideals so they become mandated and integral to the way our society provides healthcare, preserving the unique healing relationships between patients and clinicians. We must operationalise these ideals so they become active, functional components of our organisations — a dominant, leading presence within the system rather than a marginalised addendum.

Ultimately, it is our larger societal context that will determine how medical care is practised. It is the public who will choose which philosophies govern the healthcare system. The 20th century brought miraculous advances to medicine, but it also bled our healing profession of some of its vital meaning. Perhaps one of our chief professional responsibilities in the 21st century will be to repair the torn relational fabric of our healthcare system. Perhaps, as suggested here, our critical role as physicians at this particular moment in history is to reclaim the moral compass of our profession and to map out the lost meanings of medicine. It is my hope and belief that physicians will seize this opportunity and rise to meet the challenge of assisting our society to develop a more healing healthcare system — a system that combines the caring with the curing, the healing with the fixing, and the sacred with the science.