The Journal of the Arkansas Medical Society Issue 5 Volume 115

COMMENTARY The Power of Vulnerability Issam Makhoul, MD T he first encounter with a patient brings two strang- ers face to face to engage in a special relationship. It’s a balance of forces where either (1) the strongest dominates the scene or (2) a partnership develops based on mu- tual understanding, respect, and common goals. In the first type of relationship, the patient brings in her problems, expectations, and prejudices while the physician brings in her knowledge and author- ity, ever bolstered by the social power of the physi- cian’s white coat. After the usual icebreakers, the balance starts shifting toward the physician who sits in the inquisition seat, asking questions, dig- ging deeper and deeper into her personal story looking for the most intimate details. The balance shifts even further toward the physician during the physical exam that completes the undressing of the patient literally and figuratively. Standing naked in front of a stranger places the patient in a position of considerable vulnerability. Furthermore, in many medical encounters, this vulnerability gets worse by the way health care providers focus on the case and ignore the person and her perception of real- ity. For the patient, the symptoms and her personal perception of them are at the center of the visit, and the disease pattern does not exist. For the physi- cian, the disease pattern is the focal point, and the personal details are trivial. In this scenario, the phy- sician’s knowledge, authority, and power ultimately tip the balance away from the patient. How can we reconcile these two ways of looking at reality, and whose responsibility it is to steer the encounter toward the second type of re- lationship? And, since partnership implies equality between partners, can the physician truly be equal to the patient? Moving toward a partnership is the physician’s responsibility, and it can be accomplished by en- gaging on two axes at the same time: recognizing the disease pattern and its best treatments and discovering the unique story of the patient and al- ways integrating the patient’s perception into the story. Sharing elements of the physician’s personal life may be appropriate in some circumstances. I have occasionally done it, and most of the time I felt this was not the answer. The patients do not necessarily want to hear about us. Listening to their story and giving them control of the time with us is what they want. Showing vulnerability by giving them access to our hearts and touching them with our hands during the physical exam shows them that we care. In their struggle to restore their health, our patients need reassurance that we will do ev- erything we can to help them. They need to know that there is hope for regaining control of their lives and redefining the meaning of living now and here. “In the beginning is the hearing” ~ Nelle Morton Giving patients access to our heart and our time creates a balanced relationship. One of my colleagues once told me that she gave her patients her personal phone number. My first reaction was to be fearful that this would be a major intrusion into my personal life if I were to do it. She said, “Try it, they do not abuse it.” And I did. Indeed, I found out that 99% of the time, they use it with respect and consideration. On the other hand, doing so strengthened my relationship with them signifi- cantly and made them more compliant with their treatment plans. Occasionally, it was a life-saving means as I could direct the patients to the emer- gency room instead of them wondering in silence about what to do. It is a form of exchanging vulner- ability; surprisingly, being exposed to each other, being vulnerable, helps each party feel stronger and builds trust. Interestingly, the restorative effects of this type of relationship go beyond the positive impact on the patient’s life. Indeed, the healing effects are reciprocal and profound for the physician. As Em- ily Style says, “When we hear another out, glanc- ing through the window of their humanity, we can see our own image reflected in the glass of their window.” This type of relationship gives our life a meaning and restores to it a sense of purpose. At a time when our medical community is assailed by numerous unbearable pressures that are caus- ing burnout and sometimes physician suicide, it is time to jump with our patients into the boat of our shared humanity. This is a goal and a means for salvation for all of us. 100 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY David Wroten Executive Vice President Penny Henderson Executive Assistant Journal Advertising Nicole Richards Managing Editor Jeremy Henderson Art Director EDITORIAL BOARD Appathurai Balamurugan, MD, DrPH, MPH Family Medicine/Public Health Tim Paden, MD Family Medicine Sandra Johnson, MD Dermatology Issam Makhoul, MD Oncology Naveen Patil, MD, MHSA, MA, FIDSA Internal Medicine/Infectious Disease Benjamin Tharian, MD, MRCP, FACP, FRACP Gastroenterologist/Hepatologist Robert Zimmerman, MD Urology Tobias Vancil, MD Internal Medicine Darrell Over, MD Family Medicine EDITOR EMERITUS Alfred Kahn Jr., MD (1916-2013) ARKANSAS MEDICAL SOCIETY 2018-2019 OFFICERS Lee Archer, MD, Little Rock President Amy Cahill, MD, Pine Bluff Immediate Past President Dennis Yelvington, MD, Stuttgart President Elect Chad Rodgers, MD, Little Rock Vice President George Conner, MD, Forrest City Secretary Bradley Bibb, MD, Jonesboro Treasurer Eugene Shelby, MD, Hot Springs Speaker of the House of Delegates Jim Ingram, MD, Little Rock Vice Speaker of the House of Delegates Danny Wilkerson, MD, Little Rock Chairman of the Board of Trustees VOLUME 115

The Journal of the Arkansas Medical Society Issue 5 Volume 115 | Page 4