Thursday, June 28, 2007

Minor deities?

An anonymous commenter below notes:

It's interesting; there is a repeated strong undercurrent of resentment of physicians in these comments and in a lot of healthcare blogs I read.

I had already been thinking about this topic. I am reminded in some ways about how people feel about legislators. "I love my legislator, but I hate Congress." I sometimes see a similar attitude about doctors. "I love my primary care doctor, but I hate doctors in general." What's going on here?

Joke #1: What does MD stand for? Answer: Minor deity.
Joke #2: Why can't a nun be a good nurse? Answer: Because she has been taught to serve only one God.

Jokes often reflect societal stereotypes, and doctor jokes are no exception. Why do so many doctor jokes make this kind of reference? Well, in part, it is because doctors make the kind of life and death decisions that are closely related to people's view of a divine power. Doctors can quite literally bring us back from death. We admire that, but unlike our attitude towards divinity in the theological context, we also resent it.

Joke #3: A man dies and goes to heaven and is patiently waiting in line at the Pearly Gates with other recent arrivals. A man in a white coat impatiently pushes his way through to the front of the line. "Who's that?" asks the new arrival of an angel standing by. The angel replies, "Oh, that's just God. He thinks he's a doctor."

People also believe that doctors often have poor interpersonal skills, don't want to be bothered with spending time with patients, and are arrogant and impatient. This belief is compounded when the insurance reimbursement environment puts pressure on doctors to deliver service in a rushed manner. The patients attribute the brusque behavior to the MDs themselves.

Joke #4: The first Jewish president is elected and is on the podium about to be sworn in. His mother nudges the person next to her and says, "You see the man up there with his hand raised? His brother is a doctor."

And yet, almost every parent would love to see a son or daughter become a doctor. It is as highly valued a career as one could imagine, and it brings great pride to the family.

All of this suggests a tremendous ambivalence about the profession and those in it. It's really not that surprising. It is inherent in any position of power and influence and prominence and perceived wealth. We admire our political, commercial, and sports heroes but also are quick to call them bums and crooks when they don't meet the standards we have set for them. We should expect some of that reaction in the highly personal field of medicine, especially since our interaction with a doctor is likely to occur when we are most vulnerable.

When I new to health care and was being interviewed to be Administrative Dean of Harvard Medical School in 1998, I asked Dean Joseph Martin a question that reflected my own ambivalence at that time, and the resentment noted by the anonymous commenter: "Do doctors still care?" He assured me that the new crop of medical students at HMS each year was as idealistic and caring as ever, and that the people I would meet at HMS and the hospitals in Boston were likewise extremely dedicated. I have absolutely found that to be the case.

No doubt we will continue to tell doctor jokes, but I hope we can also acknowledge that the men and women who have trained for this profession and who practice it are as well intentioned as we could ever want. Sure, there will be personality quirks and occasional bad behavior, as there will be in any group of people, but there is also a level of dedication and commitment that is extraordinary.

The anonymous commenter goes further, though, and says:

And yet when I read posts in Sermo (the physicians' only website), there is a strong undercurrent of discouragement and even despair with the profession they have chosen. No one is happy on any side.

I see this, too. Much of this stems from the reimbursement environment, in which doctors feel that their professional judgments are overridden by faceless bureaucrats in insurance companies and at Medicare, or by (ahem!) ignorant hospital administrators. They fear malpractice suits, too. So they practice defensive medicine, knowing certain tests and approaches are not warranted, but feeling pressured to inoculate themselves against patient complaints and lawsuits.

And truthfully, they (particularly the older ones) may have been trained in medical school and afterwards in ways that do not reflect the social, political, and financial environment in which they practice. They have been rewarded during their professional advancement for attributes that may not be helpful for coping with the current environment. And, finally, they face an ever more knowledgeable and (perhaps entitled) public that is not so willing to be forgiving of mistakes or tolerant of ambiguity in diagnoses and treatments.

I do not pretend to have an answer to this set of problems. I would like to think that society will value doctors commensurate with their dedication, skills, experience, ability, and commitment to our well being. But this will take movement and good intentions and also understanding, empathy, and forgiveness on both sides of the relationship.


Anonymous said...

I've had considerable experience as a patient over the last 10 years or so (CABG, DES, TURP and several other procedures). The doctors I've encountered were excellent, and I admire their skill and dedication. I'm alive today because of that skill and the wonders of modern medicine, including prescription drugs.

That all said, here is my wish list for both individual doctors and the profession generally:

1. Treat me as though I am a member of your own family (provide professional, competent and compassionate care) and as though you were paying the bill out of your own pocket (no unnecessary tests that are driven mainly by defensive medicine).

2. Embrace price and quality transparency so both you and I can more easily identify the most cost-effective specialists, hospitals, labs, imaging centers and drugs.

3. Accept competition when appropriate. The recent rhetoric from the AMA against retail clinics staffed by NP's or PA's, for example, is not helpful.

4. Admit mistakes and do a better job of weeding the comparatively few less skillful doctors, who account for a disproportionate share of malpractice, out of medicine.

I think the profession's historical resistance to #2, 3, and 4 may, at least in part, account for its arrogant image among much of the public.

Anonymous said...

I like what Barry has to say... very wise. I also couldn't agree more with Paul's assessment of physician sentiment: "doctors feel that their professional judgments are overridden by faceless bureaucrats in insurance companies and at Medicare..." That is so true. Nothing gets us angrier than having critical services denied to a patient in need by some gum- chewing third party via telephone -- who knows nothing of medicine, the details of the patient's case, or the critical importance of the test or service. If health plans and Medicare are going to play doctor, then why do we go to medical school?

Rob said...

As an IT guy, I have an immense respect for doctors as walking information systems. The amount of data they handle in an hour is astonishing. The ability to form quick diagnoses based on past experience, yet keep an open mind is a delicate balance act, requiring constant adjustment.

In short, they amaze me. I do respect the craft. As a diagnostician myself, I am suitably impressed.

I do not respect how health has become a big, market and advertising driven business, and I have to say that a class of doctor helped start that trend well before it leaked into the insurance biz.

I expect doctors to be very well compensated. I don't expect my body to be a product, or a consumer of services. That kind of thinking is trading in life and death, with market forces taking the place of a solemn oath as one of the few professions that pledges to help people, no matter what.

Doctors have to take some of the blame for that as much as big business. Just as I have to take the blame for my health problems as much as our society's placing a premium price on healthy, fresh food.

I understand the frustration, but they have the power. I don't. I'm just a lousy consumer, whose choice is "accept what we give you, or drop dead." I can't boycott critical care.

Physicians, heal thine own craft. I'll be happy to help, what with my computers and people skills, but it's up to you guys to save us from the idea that we shouldn't expect help unless we're economically worthy.

Anonymous said...

Bravo! Very thoughtful.

This is a rapidly evolving world. Therefore, the profession must change to continue being the same. If we fail to do so by ourselves, we will be forced to.

Anonymous said...

Barry gets a home run gold star from me.

The extraordinary wonderful doctors who've worked on me this year, and the other caregivers who are at the top of their craft, are absolutely great.

I encourage all those docs to tell the AMA to shut its fat mouth about political positions that hurt the profession's reputation. The AMA's real goal ought to be improving care as WE experience it - and if the AMA thinks we're not qualified to judge, then that kinda bolsters the Minor Deity perception, doesn't it?

Anonymous said...

I'm shocked by the news that the British have arrested at least three doctors in the attempted terrorist acts. I hope this will not create a backlash against foreign doctors here. We don't expect doctors to hurt people so it is especially shocking when they do.

Anonymous said...

This topic of doctor as terrorist has received some attention on other medically related blogs as well - see Kevin M.D. and Respectful Insolence, especially the latter. They raise some issues that may make Paul's title of "minor deities" seem ironic and scary.

Anonymous said...

Here is an interesting link that explains better than I ever could why both patients and doctors are unhappy:

Anonymous said...

The very best doctors are clear thinkers who employ the basic tenets of science -- and recognize patients as experts on the symptoms they present. The worst are among those who rely on trends for diagnosis and -- because they are expected to be all-knowing (everyone's fault) are afraid to say "I don't know" when appropriate -- or, similarly, suggest "this doesn't exist" when unable to provide an answer.

Doctors and patients -- who must also be held to standards of reasonability and disciplined self-help -- need to form equal partnerships in the process of factual discovery leading to optimal medical results.

Likewise, while everyone must understand the limitations of treatment, all parties in this alliance have to be politically aggressive in insuring that research dollars flow toward dead-end diagnoses: "nothing else we can do" is oftentimes the result of unimaginative, insurance-driven or even lazy approaches to disease. Doctors and patients need to bring energy to the plate, "apportion their beliefs to the evidence," and cooperate in maximizing health.