Opinion | Treatment Is a Two-Way Street

I was reading about the relationship between the pioneering psychologist Erik Erikson and the iconic painter Norman Rockwell. Erikson, who gained fame for explicating eight crucial stages of psychosocial development across the lifespan, was Rockwell’s psychotherapist.

Both men lived in the idyllic Massachusetts town of Stockbridge, where Rockwell painted one of his most recognized pieces — “Stockbridge Main Street at Christmas” — depicting picturesque Main Street during the holiday season. Stockbridge Main Street was also home to the famous Austen Riggs Center, a bastion of psychoanalytic practice and long inpatient stays. Rockwell’s wife was hospitalized at Austen Riggs for treatment of depression and alcohol use disorder. Rockwell, himself, fell into a deep depression, which led to a serendipitous encounter with Erikson and subsequent outpatient treatment with him.

Rockwell was fussy about his paintings — a perfectionist at heart. In a depressed state, his obsessiveness was insufferable, overthinking his technique and questioning the quality of his artwork. Erikson pulled Rockwell out of depression and helped impart the social milieu of the 1950s into Rockwell’s paintings. In audio recordings, one can hear Rockwell tell his son Tom how Erikson helped him revitalize his painting, even dispensing advice to Rockwell about how he should begin the lineage of Rockwell’s celebrated “Family Tree.“

One wonders whether the relationship between the two men held any meaning for Erikson. Erikson was born in Germany and emigrated to the U.S. at age 31. He never knew his biological father — in fact, he was initially deceived about his paternity. As Erikson wrestled with his identity, he changed his name several times, finally arriving at “Erik Erikson” and subsequently coining the term “identity crisis.” According to Jane Tillman, PhD, director of the Erikson Institute, Rockwell’s paintings helped suffuse Erikson’s identity by enabling him to reflect on art that was quintessentially American.

Tillman’s account leads me to believe that the doctor-patient relationship is, at its best, a bidirectional affair — a two-way street. Although high-functioning doctor-patient relationships are not the same in magnitude as the one between Erikson and Rockwell, who ended up good friends, they have a special give-and-take quality. My premise is that while the physician is the ostensible healer, the patient helps heal the physician, usually through subtle means uncovered after the physician reflects on a patient’s visit or upon termination of the relationship.

The idea first dawned on me as a psychiatry resident. I evaluated a young woman for a relationship problem. I thought the initial session went quite well. I asked her if she would return to discuss some issues in more depth. “I’m not seeing you again,” she replied. Puzzled, I asked why. “Look at your plants,” she said angrily. “They’re half-dead. If you can’t give your plants a little TLC, how do you expect to take care of me?”

I was shocked. I had no answer. Admittedly, I never had much of a green thumb, but the patient rightly pointed out that my inaction — not watering my plants — was inexcusable. It had a profound effect on me and led to my subsequent interest in horticulture, perhaps over-compensating for a perceived failure.

As a physician, I find it much easier to give advice than receive it, which is not a surprise. If I have to see a doctor for personal reasons, the conversation starts off stilted until I tell them I am also a physician. Upon informing the doctor I am a psychiatrist, there is often an enthusiastic exchange of stories about difficult or unusual patients. Bruce Springsteen would say that physicians’ collective stories are “The Ties That Bind.”

I recently moved to Charlotte, North Carolina, and I had my initial visit with a primary care physician (PCP) who went to medical school and trained in my hometown of Philadelphia. He told me his wife trained in emergency medicine at the same institution where I attended medical school and did my residency. We shared a good laugh when discussing the sundry characters known to visit emergency departments who are not really in crisis, and how difficult it was to decide whether to prioritize their medical needs or mental health needs.

The conversation quickly turned serious. The PCP informed me that at least half his patients had concomitant mental health problems that went unaddressed mainly due to time constraints (he was allotted only 15 minutes per visit). He also confessed that he didn’t feel comfortable playing the role of quasi-therapist. I told him that back in the day, I was a consultation-liaison psychiatrist, and I was routinely called to assess med-surg patients. I informed the PCP he could easily brush up on psychiatry, and I recommended a couple of primers he could read, including The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, considered a classic.

Research confirms that physicians who can emotionally engage with patients have better outcomes and higher patient satisfaction scores. When a patient perceives that their physician cares and listens to their concerns, they are more likely to comply with medical recommendations and return for follow-up visits. But there is very little research indicating that paying credence to our patients’ advice and musings makes us better doctors. Can patients stimulate our personal growth, as Rockwell did for Erikson in his search for identity?

The short answer is that physicians can become better doctors by being patients. When doctors exchange the white coat for a hospital gown, they learn the importance of empathy and language and gain an appreciation for the trauma of illness and trauma of treatment. The well-known author and speaker Danielle Ofri, MD, PhD, echoed the same sentiment; she devoted an entire book to lessons she learned from her patients. One of the most important, she believes, is learning what it feels like to actually be a patient — in her case, the humiliation and helplessness she felt both during and after giving birth.

In addition to assuming the patient role, listening carefully to our patients, especially the poor and others who are disadvantaged, helps physicians grow, because learning how to overcome barriers to high-quality treatment — barriers such as poverty, poor access to care, time limits on interactions, bureaucratic red tape, and general mistrust of healthcare systems — enables physicians to adopt more personalized approaches to healthcare. Clearly, if we accept our patients as teachers, they will infuse elements of humanism in our training and practice. Patients have been known to “define our work, instantiate our values, and shape our identities,” much like Rockwell aided Erikson. It is not unreasonable to expect that doctors who are exposed to diverse communities will develop strong clinical skills, become patient advocates, and contribute to a vibrant physician workforce.

It’s been said that medicine is an art whose magic and creative ability reside in the interpersonal aspects of physician-patient relationships. Too often, however, medical practice has become stymied by tasks that need completing and patients that need complex services. Grinding through our day, we lose sight of what a special role we can play in patients’ lives. It is only when we rediscover our passion for the practice of medicine and embrace our mission — to serve the suffering — that we realize we have the power to transform patients, and in doing so, transform ourselves.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.