As much as contemporary conservatives would like to decry all change as the end of Medicine, it is highly unlikely that an institution with as much value as the medical profession will find itself completely disenfranchised at the expense of patients. As during the past few hundred years of American history, physicians in the U.S. will endure many difficulties during times of transition, but as must all survivors, physicians will have to adapt to short term changes (even if through staunch resistance) and evolve to match the needs of a growing society. (That is, if you believe in evolution. Those who don’t can complain all they want, sit on their thumbs, and wait to see what happens.) If we are worried that the general public will not find value in our services as compared to those of potential competitors (independent nurse practitioners, alternative medicine practitioners, etc.), then we must show the public the value in the services we offer. During the next few decades, there will have to be a system-wide change in the approach of physicians to patient care so that our service remains in its proper position: as leaders, coordinators, and decision makers in teams of health care workers, and as the final joint arbiter in care decisions with patients.
Fearful, Footloose, and Fancy-free
We live in a society that places great value in life and its preservation. This is one of America’s greatest assets: protection of the pursuit of life, liberty, and happiness. This is rarely protected nearly as effectively or vigorously elsewhere in the world (although the current presidential administration has weakened the perception and execution of these protections). However, this emphasis on life places the notion of death in an awkward spot: Americans don’t know how to die. We try to hold onto life until the very end, whether our lives, those of our family members, or those of our patients. Many have talked at length about how this attitude is costly with respect to health care finances: end-of-life care (intensive care or nursing home care) is very expensive and is sometimes reimbursed poorly by health insurance companies.
However, while there is much talk about how we conduct ourselves and make decisions at the end of our lives, there is less meaningful discussion about how we arrived at that point in the first place. The endemic fear of death not only affects our decisions in our final days, but it also affects how we manage our daily lives and lifestyle habits. As we gain more knowledge as to what might cause disease, we are inundated with this information and have difficulty processing and prioritizing each concern. Many people are so flustered and overwhelmed as to believe that “everything causes cancer,” and it is sometimes difficult for those of us who have a more precise, nuanced view to dispel that notion. This flood of information is numbing, and it makes people want to ignore everything: all of the “if you don’t stop this it’ll kill you” proclamations, and all of the small but significant measures that they could take to avoid pain, suffering, and premature death. People want to be live care-free, but they end up being careless.
Things to Change:
Instead of inundating our patients and our communities with more of the same type of mind-numbing information, we as physicians need to adjust our approach: we need to be concise and effective. While patient autonomy is paramount, patient care decisions are jointly made by the physician and the patient: there must be agreement, else the care provided is ineffective and the patient receives fewer benefits from the relationship. As such, the knowledge we provide can and should strongly influence the behaviors of our patients: problems of compliance should be related to forgetfulness, not disagreement, disbelief, or disgruntled feelings. There is much (conflicting) information out there: we need to help patients cut through the noise and find the correct path.
While being concise, we shouldn’t be too short in our explanations or too cynical about the intellectual abilities of our patients. Our society not only values life, but it also places a great value on intelligence: this is why physicians hold a professional and social status above other “health care providers”, as physicians have undergone many more years of training and learning, engaged in more complex activities, and held greater responsibility. Nonetheless, training does not necessarily equate with raw intelligence, and we as physicians should not lord over our patients or our team members (nurses, physician assistants, technicians, etc.) in a condescending manner. We should lead, but lead through skill and confidence as opposed to mandate (via degree).
Similarly, while our patients seek our knowledge and perspective, this does not mean that patients will not understand complex ideas. Instead of resorting to sensationalism, we should aim for effectiveness and clearness. For example, a physician might tell a patient: “If you keep smoking, you will die of lung cancer.” This may be true: lung cancer is the leading killer among cancers, and cancer is the #2 killer nationally and worldwide. However, a patient might then respond: “Well, I’m going to die of something anyways. It might as well be lung cancer.” This is not the message that patients should be getting. Instead, we need to help him/her develop more perspective: “About 25% of regular smokers die in their 40’s and 50’s, and it isn’t a ‘peaceful death in your sleep.’ Also, lung cancer and ‘dying’ isn’t the only problem. Almost 100% of cases of COPD are caused by smoking. Getting COPD means that you will gradually lose function in your lungs over time: you won’t be able to breathe and do all the physical activities you would like to do because of not being able to breathe. This isn’t a fun way to spend the last twenty or thirty years of your life.”
On a related note, why do kids know more about dinosaurs than their own bodies? Why are “health” classes in grade schools taught by gym teachers who have no teaching or health care qualifications?
Things to Change:
Knowledge is power, if you know how to use it. Too much knowledge can be a bad thing, or knowledge can be misinterpreted. We as physicians need to fight ignorance, not condone it. We need to be excellent debaters and effectively and efficiently convince our patients, not lecture to them. At the same time, we need to fight against misinformation from opponents of health care (those who stand to lose from better knowledge conveyance because their products are harmful to health), such as the tobacco industry.
King of the Hill
Physicians are at the top of the chain of health care providers. The term “health care providers” is an item of contention: some physicians say that it is a scheme to reduce the perception of the value of care provided by physicians while inflating the value of care provided by independent nurse practitioners, physician assistants, etc. While this may be the case, I think that there is much posturing that can be attenuated. Wherever physicians go, there are wanna-bes and don’t-wanna-bes: people who admire physicians and want to be as respected and influential, and people who hate the pomposity and arrogance of some physicians and want to show that they can be equally effective as health care providers. There is fault on all sides for this inane social and work environment, but I think that physicians, at their best, rise above this by openly praising and using the value provided by each of their team members while giving their teams reason to have confidence in their leadership and direction.
Things to Change:
Some skills are best provided by other health care team members. Procedures or machine operations might be better performed by technicians. Around-the-clock, personalized care is best provided by nurses. Physicians need to understand the value in all of these, and be thankful for them. Physicians have received the longest and most rigorous training, but that doesn’t meant that we can do everything effectively and efficiently alone. Physicians should be team leaders, not divas. Physicians, like good quarterbacks, pass the ball and make successful plays happen. The team cannot win without them, but they also don’t run every time.
A New Direction
Providing knowledge more effectively and being better team leaders may make a substantial difference in providing much better medical care to our patients while also developing stronger connections between physicians, health care team members, and patients. However, how will we accomplish these goals? Here are a few benchmarks to aim for:
1. Be comfortable with non-absolute knowledge.
And share this attitude with others. We practice medicine in an evidence-based manner, but at the same time, new evidence may refute old evidence with studies that are larger and better powered statistically. Instead of becoming cynical about knowledge acquisition, we should encourage in ourselves and others the drive to seek the truth: this is the science in medicine, what makes medicine better than charlatanry. In the meantime, we all need to work with what we know rather than be paralyzed without the confidence of definitiveness.
Attributed to General George S. Patton: “A good plan, violently executed now, is better than a perfect plan next week.”
2. Find balance in our approach.
We want to care for people and help them out of ruts, but at the same time not be so soft as to provide no firmness in our guidance. Instead of simply providing medical care, we should strive to lead people toward changing the way they approach their own health. Each person is individually responsible for his own health care, but he cannot do this without the guidance of a physician. Instead of just guaranteeing health care access, we need to also push our patients to seek health care in the right way at the right time rather than give up on the hope of a health care system better than the status quo.
Attributed to Confucius: “Give a hungry person a fish, he eats for a day. Teach a hungry person to fish, he eats for a lifetime.”