Book Review by Janina Levin
Drew Remignanti, The Healing Connection: A Partnership for Your Health (Something or Other Publishing, 2023. ISBN-13: 978-1954102156).
Analyses of healthcare of systems in the US (and the UK) have laid bare alarming asymmetries of power. Hypocrisy is the hidden message in medical education. Insurance companies and hospital administrators influence doctors’ decisions about standards of care. The most vulnerable populations often receive the worst care. But if we value professional expertise, we must also value those who put in the hard work to heal others. After all, patients have to trust someone. Dr. Drew Remignanti’s recent book, The Healing Connection: A Partnership for Your Health (2023), urges an alliance between primary care physicians and patients as a solution to the corporatization of medicine. Putting aside the imbalance of power and knowledge that sometimes makes communication between the two parties challenging, he asserts this relationship has been at the core of medical practice and ethics for centuries and we shouldn’t let that connection go. The book most successfully illustrates its patient/physician partnership thesis by emphasizing how vulnerable today’s doctors are in a medical system that exploits their altruism. Dr. Remignanti’s frankness creates empathy for doctors as competent and caring professionals caught in a broken system, an effect that should move us closer to the partnership he calls for.
Readers following current debates about the problems with US healthcare will be familiar with the criticisms in his book. Vivian Lee’s The Long Fix: Solving America’s Healthcare Crisis (2020) presents similar critiques—our current system favors payment for services rather than for results, providing little incentive for practicing preventative medicine. But an authentic wisdom and humor that is missing in Lee’s book enlivens The Healing Connection. Dr. Remignanti is a retired emergency physician with a Master’s in Public Health, and has himself battled multiple long-term health conditions. His storytelling captures the two essential sides of medical care—the doctor’s and the patient’s experience—contributing to medical humanities discussions about the history of the doctor/patient relationship and its effects on public health.
Physicians Aren’t Steering the Healthcare Ship
An early personal story Dr. Remignanti tells relates to the publication of this book. One editor told him that she receives so many manuscripts decrying the healthcare system that it would be better if doctors got together and tried to figure out how to make the changes that we so desperately need. He responded: “we physicians are no longer steering the healthcare ship, the helm … is currently in the hands of administrative and financial folks” (3). Early chapters take readers behind the scenes of trauma care but also reveal the “productivity” wheel emergency physicians submit to. Hospital administrators often admonished Dr. Remignanti to see more patients in less time, even threatening him with termination for not making the hospital’s quota. To put into perspective the volume of patients he has treated as an emergency physician, he tells readers to multiply 1,000 to 2,000 patients per year by forty years, explaining that each patient requires an average of twenty “decision points” (76). Given the pressure to cut corners, it’s not surprising that he has been sued two times for medical malpractice. In the first case, he agreed that he did indeed make a mistake, telling an unhappy lawyer to settle the case right away. In the second case, he was named in the suit despite never seeing the patient nor participating in her care in any way.
Example after example reveals that the problems he saw in the emergency room, where he had even less time than primary care doctors to make a proper diagnosis, amplify the breakdown of primary care. One memorable case is a thirty-seven year old man with hemophilia who had upper respiratory issues. With twenty minutes left in his shift, Dr. Remignanti felt pressured to see just one more patient that day. He was about prescribe him Tylenol with codeine and leave for the day when he saw a wheeled stool that reminded him of his dissatisfaction with a diagnosis of an acute respiratory tract infection, so he sat down to ask the man one more question, “What is the thing that is most worrying to you?” The patient answered “I’m worried that I’m bleeding in the head” (30). With two thoughts at war inside his mind—“Get out of here” and “good, we’ve got a test for that”—he decided to order the test. It turned out the patient was bleeding in the brain. Knowing he could easily have chosen to just “check that box,” Dr. Remignanti still thinks about how close he came to killing his patient.
Placebo Studies Spark Unexpected Hope
On the bright side, this book is as much the product of Dr. Remignanti’s curiosity about the doctor/patient relationship as it is a critique of the current problems in US healthcare. A chapter called “The Placebo Effect” develops his most original insights about why this relationship still matters.
Most of us think of placebos as the controls in scientific studies seeking to prove that a specific treatment actually works. Similar to p-values that measure chance effects we cannot reliably control, placebos show us the confounding human factors in healthcare studies. Yet Dr. Remignanti’s discussion of this concept leverages the research on these “human factors” to show not only that they contribute to healing, but that the doctor/patient relationship knots placebo effects to medical knowledge in ways that we still need. This relationship builds patients’ adherence to a course of treatment through the communication developed between doctor and patient over time, including doctors’ oath to heal, their medical knowledge, and their persuasive skills used for the good. We have been the beneficiaries of this complex of factors for centuries. Should we unravel the productive knot now? It might mean cheaper healthcare in the short term, but we would be giving up the one partnership that ensures truly competent and ethical medical care.
After suffering a stroke and taking time off to recover, Dr. Remignanti briefly felt as if he was offered a “get out of jail free” card (186), but he kept working in emergency medicine until 2020, believing that the root and the soul of medicine lies within the doctor/patient relationship. If the two parties could build a stronger alliance, then all the other forces currently in play—the hospital administrators, the insurance companies, and “more or less the entirety of society itself”—could be put in their proper places (187). Readers who might wonder if such an alliance is possible in the complex medical environment we inhabit will still be happy that doctors such as Drew Remignanti have been willing to pull their weight.
Janina Levin is BMJ’s Medical Humanities blog content editor, a trained medical editor, and a literary critic working in the areas of narrative empathy and men and masculinities. She also teaches writing at Saint Joseph’s University.