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What’s Wrong With American Doctors?

It is February of 2005, and my grandpa is lying in an Intensive Care Unit bed at Beth Israel Deaconess Medical Center in Boston, critically ill from a renal artery rupture that planted him face-first in his parlor. As a functioning alcoholic who has already been in the hospital for a day, he is beginning to shake periodically, a sign of his withdrawals.

Still, it will take another twelve hours and exasperations from both my mother and grandmother (both nurses themselves) before the physicians get him the Ativan he needs to combat this symptom, which is small potatoes compared to his emergent reason for admission.

While he would eventually make a full recovery, in those few hours my grandpa had tremors he was also the unintended victim of “tunnel vision” exhibited by many physicians: they see the most prominent problem and address it, often losing grasp of a holistic view of the patient and neglecting his humanity in their attempt to treat him. In short, they see the medical problem as opposed to the entire person.

Of course, this doesn’t mean that doctors are heartless: the number one reason doctors choose the profession is to help people, and the grueling work it takes to become an MD is clear evidence of their devotion to their career. So how did we end up here, with doctors overlooking the humanistic nature of their work?

The answer: their education. The one system we trust to build our caretakers is also giving them the short end of the stick in the social aspect of their work. Physicians take a slew of scientific courses to prepare them, but few get valuable social education. Clinical experience doesn’t begin until the third year, whipping through short rotations and involving a “hidden curriculum” in which students learn to communicate with patients by watching their superiors. What results is a breadth of experience, but no depth in bedside manner.

According to a study published in the Social Problems journal, doctors feel they can learn more from the medical chart than from the actual patient. What’s more, their main motivation for speaking to a patient is to gather information for said chart. To top it off, doctors spend hours making rounds, discussing the patient publicly among colleagues but rarely addressing the patient directly.

One junior resident in the study summed it up perfectly: “If you don’t sit and talk with a patient for a half hour, in terms of your job description no one is going to be mad at you. But if you don’t know what the hemoglobin is on the patient, the chief of medicine is going to be very upset with you.”

Clearly, doctors are more concerned with getting the job done than having a personal touch with patients. This might be beneficial—the more people they can cure, the better, right? Not true. A study conducted at Stony Brook University shows that compassionate, attentive care results in better therapeutic impact for patients and lowered depression rates with elevated career meaning for physicians.  It creates a better reputation for a healthcare facility at no greater use of economic resources, too.

Appropriately educating our physicians to be socially competent might seem difficult to add to their quest for an encyclopedic level of scientific knowledge. However, some schools are already doing it. Harvard and NYU give medical students practice with patients from day one. Schools increase their diversity to give their students a wider perspective and more capacity for empathy. It is proven that we can teach people how to express compassion in the clinical setting, which alone could dramatically improve the way we provide care.

We should be implementing these strategies across the board, as opposed to hoping doctors inadvertently learn communication through fleeting clinical experiences.

In a world where quantity supersedes quality, we need to take back the reigns and create renaissance men of medicine, where the demands of education don’t erode the ethics of students and destroy their idealism for their careers. The welfare of patients, doctors and the entire healthcare system depend on it.

Brianna Graff is a nursing assistant in the Medical ICU at Brigham and Women’s Hospital and a pre-med student at Boston University.

 

 

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6 replies »

  1. I wonder – what if the year was 2078 and a robot was the “doctor” on duty for the day in the ICU. If the robot had ordered Ativan in a timely fashion, would that mean the robot had displayed its “humanistic nature?”
    This is not to try and imply that what happened was fine – it was not, it was inexcusable really – but what happened had very little to do with the personality or “humanistic nature” of the physician. What it really shows is that the system is flawed precisely because it depends upon the “humanistic nature” of the physician. There should be fewer and larger ICUs, and they should be staffed sufficiently that the information needed to prescribe the Ativan is immediately available to a physician who is likewise immediately available. There really is very little in common between acute and chronic care and the ICU is no place for the patient’s PCP to be on duty. Let them be the psychosocial consultant (and get paid for it) but acute intensive care needs a dedicated team.

  2. Thank you for your contribution. There is no excuse for such care. Only recruiting Mother Teresa’s at medical school admission will not help if they bow to the pressures of the system they created. In fact, the present model of education of physicians and hospital care should be scrapped. Power corrupts, so let’s change who is in power.

  3. I wonder if you can abet empathy and compassion by any education or training? Maybe it is 95% nature and 5% nurture? Maybe it would take medical schools to do the job you ask by screening out the applicants who didn’t have these qualities?

    The profession attracts people who have intellectual prowess because there is a heap of learning to accomplish. Maybe this will change with developments with AI. But academic success draws in those types of applicants; and those students who might be super humanitarians can feel distanced and intimidated by the pre-requisite and application process.

    We had engineers and chemists and bacteriologists in my class at med school….these types not noted for small talk.

    Another factor now is the way changing insurance directs the patient to its closed panels. Thus, to have the same doc for twenty years is distinctly unusual. This prevents the intimacy from time and experience.

  4. A completely focused physician “geek” would have started a regularly administered, low dose sedative at the time of admission to the ICU. The possible evolving occurrence of unstable delirium tremens (DTs) has a significant association with unexpected death. Early use of the sedative may not prevent a full-blown episode of DTs, but at least you have the advantage of managing a rapidly advancing situation before its unstable. When a medication does not have any real effect, most nurses also know that they would prefer to avoid a disaster by immediately calling the attending physician for a care plan adjustment. It only takes one episode of witnessing a full-blown DTs to know that one is enough for a life-time career, especially for the nurses involved.

    The ultimate balance between the scientific and humanitarian attributes that occur for an episode of health care represents either the presence of a gifted physician or a physician in the midst of a career long struggle to find a supportive working environment. Unfortunately, the gifted physicians are rarely recognized by an institution’s ability to offer supportive career development.

  5. Two things. First, don’t get rid of all of the geeks. You will always need some super smart, OCD types who might not be so great on warm and fuzzy, but you want them around when things are really bad.

    Second, patients may benefit directly with the compassion they may feel from a socially competent physician. However, I suspect patients will benefit at least as much from socially competent doctors who work well with other health care workers. Disruptive physicians, nurses and others also, really bring down the quality of care, and put patients at risk. Be nice if the medical schools taught you to work with each other and with other people in health care. (I make it a point to make sure to spend time with med students talking about how to communicate with nurses, techs, etc.and the value their patients will receive if they are good at it.)

    Steve

  6. I applaud your focus on bedside manner, as it’s a very important component to being a physician. I would argue that it’s less about the education and more about the constraints that the physician is working under. I don’t necessarily think that physicians are more concerned with “getting the job done” than with the patient-physician relationship, as a multitude of polls show that the patient-physician relationship is the primary driver of physician satisfaction in most fields (see Medscape surveys, as one example.)

    The problem is, physicians are under immense pressure to see patients as quickly as possible, and the documentation burden is only growing by the day. When you’re measured by your patient’s length of stay or how many patients you can squeeze into a day (20-30 patients for many PCPs), something has to give, and this unfortunately is often time talking with the patient. This deterioration of the patient-physician relationship is a main driver of physician burnout and patient dissatisfaction, but with decreasing reimbursements leading to a push for higher volume, it is only getting worse. Hopefully the patient-physician relationship will regain lost ground, but it’ll take a shift at the policy level rather than just teaching physicians better communication skills. Still, kudos for a well-written article, and I hope that you can continue to share your passion on such an important topic.

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