Tuesday, May 27, 2008

Medical Truths #1

I'm going to try to put out some opinions on how I see the medical field as it is and as it should be. These are truths in the sense of my own personal belief, not necessarily scientific axioms. I will try to keep the initial posts less tome-like, and hope to encourage dialog. With that said, # 1:

Medicine is a science.
The Practice of Medicine is an art.

I notice an increase in the cynicism of the public towards the health care field. I believe there are many political, social, and economic reasons for this. One reason, though, I believe is in the failure of our field to practice this simple truth. We are often blurring the lines of science, by not holding data up to an exacting standard. We are also poor artists. I think that many doctors have a presentation that suggests they are just throwing the drugs out there to see what sticks. Doctors do not often have (or take) the time to explain the science (how the stuff works), and even less time to explain the art (how did we come to this conclusion and plan).


Geoffrey Kruse-Safford said...

More than just explaining, I have too often encountered condescension from doctors. I have explained that I am educated and intelligent, and might want a bit more information than I am being given, and I get that parental smile that says, in essence, "Sure you are, Sonny." I'm not accusing you of this (because I have no idea what kind of bedside, or otherwise, manner you have), but it is a frequent experience of my own.

When I had my gall bladder out two years ago, I was told, simply, it would be a laperoscopic (sp?) procedure. I was told that three small incisions would be made, that it would take about an hour, etc. I was also told that if complications arose, they would have to cut, necessitating a hospital stay. I was given no more details; nor was I given information on pain management other than "Take these pills" (Vicodin, which I enjoyed far too much). I would have appreciated a bit more information, as well as some more details on how, exactly, the doctors would go about their procedure, what "complications" might mean, and what to do if, as I came close to doing, I got hooked on the drugs.

Doc said...

Close enough on the spelling, sonny! (It's laparoscopic, and I'm kidding, of course). It also sounds like you were not given a choice of pain meds. Ultram, for example, may have provided sufficient relief with less side effects and virtually no chance of addiction, as it is non-narcotic. Your experience is all too common. Most doctor groups will tell you that the answer to this is to give more money in reimbursements and thus give the docs more time to see patients. This is baloney in my opinion. For example, there seems to be an inverse correlation between the amount of money a doctor makes and the quality of the patient interaction. (I suppose this does reach a inverse curve threshold at some point) You saw a surgeon, who cut on you. That group tends to make the most money, and is frequently notorious as having the biggest egos--often manifested in not wanting to "bother with" other, non-surgical, aspects of medicine, such as, say, patients. I'm referring to a trend skewed by jerks on the extreme, but that is the gist, and sufficient example for the point that money is not the panacea here.
Lets look a bit at some of the potential causes of your observed condescension:
1. Condescension is a protective factor for many potential medical students. These are the "best and brightest," meaning they were what we used to call "gunners" in undergrad. You remember the type- comparing grades, trying to gain every advantage. I remember a classmate crying because I scored a higher score on an exam than he did.
2. Condescension is taught and reinforced in medical school. Grades are openly posted. Slogans like "AOA or no way" (honors society or you don't get to be a surgeon), a boot camp like machismo regarding call and work loads, general hazing-type abuse (collecting 24 hour urine samples) from misanthropic instructors, and the lot all encourage an already entitled (but perhaps insecure) student to develop a thicker skin. We call it alexithymia in the shrink biz, but it translates as an an inability to emotionally empathize.
3. Doctors have power, and power can corrupt. Life and death issues at work here. Me doctor, you patient kind of stuff. Alec Baldwin's "I am God." speech in malice. (I saw hat flick in medical school with the entire class-there were many cheers at that line; I hope they were sarcastic)
4. Current practices are set up to work on quantity over quality. Primary Care Physicians are often rewarded to not refer to specialists, and are to see themselves as the "gatekeepers" of the patient's overall health. (A term formed via HMOs). While it is good having one doc overseeing the whole of the patient's health. This is not easy to do when time allotted goes down, to make the bottom line. This does likely contribute to burn-out, poor communication, and condescension, for those doctors "stuck" in such a system.
Is there hope for docs?
Of course; there are great orthopedic surgeons, pediatricians, and everything in between. There are docs who understand that bedside manner and communication are key to healing--thus the "art" of medicine. (I have tried to locate, emulate, and utilize those docs with a similar demeanor.) You can find them by asking around. The really good ones have very loyal patients, rightfully so.
Medical schools are catching on. I am hopefully an example of this. I had a background in psychology (not the usual bio or chem) and was admitted. My friend was a philosophy major. Students are interacting with preceptors to teach bedside manner and patient interaction skills. I volunteer to moderate a class to the med students in ethics. Cool stuff, BTW, like discussing a baby born with ambiguous genitalia-- love seeing these kids wanting to know the "right" answer.
I still believe much more needs to be done.

Doc said...

BTW, if you would love a great insight to the residency process. read "House of God" by Samuel Shem. It's also rather inspirational.