Archives for posts with tag: professionalism

bmjtorture

Matthew DeCamp, Leonard Rubenstein and I published a piece in the British Medical Journal about how normal clinical care was perverted in the torture milieu by the CIA and its physicians. Very topical given the latest State of the Union, and Trump’s love for Guantanamo.

A recent research article in the Journal of General Internal Medicine, and the gap between its findings and the real world, helps point up the usefulness and limitations of research. The article, by Susan H. McDaniel, PhD, and coauthors, set out to determine how often doctors speak about their colleagues in supportive or critical ways.

Their method is one widely used in the field: simulated patients, actors, were prepared with lifelike stories about their feigned cases of advanced lung cancer complete with manufactured charts describing what previous doctors had done. The conversations they had with physicians (some oncologists, others family medicine practitioners) were recorded, transcribed, and analyzed; each statement by a physician about the care provided by other doctors was categorized as Supportive, Critical, or Neutral.

The results were not altogether surprising, but I’ll let their abstract’s summary speak for itself (I edited it slightly):

 Twelve of 42 comments (29 %) were Supportive, twenty-eight (67 %) as Critical, and two (4 %) as Neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians.

As far as I can figure out, however, the article did not discuss what doctors should do in a very common circumstance: when their patients did receive treatment from another physician that they, the doctors, feel was incorrect. Last week, for example, I saw a patient who had been treated by some oncologists (they weren’t from Hopkins – which doesn’t mean this story couldn’t have applied to them). They had given her treatment without discussing with her the risks or benefits. She came to me bewildered and frustrated.

So what should I have done in that case? Made polite noises? Reflected the patient’s feelings? I did those as well. At some point, though, the patient’s intuitions should be verified and the truth called out: no, it is not okay to leave the patient’s wishes and preferences out of the equation, and all the more so when they are vulnerable, as cancer can make anyone.

Sure, tactfulness is key, and collegial relations with other providers can be maintained in such a circumstance, but identification of systematic missteps in care (such as leaving the patient out of a treatment discussion) is no vice. In fact, such honest talk is in the very service of professionalism.

How do you talk about your other doctors with your primary care provider?

Cross-posted to the blog at Talking To Your Doctor.

A recent article in the academic journal Annals of Internal Medicine has given rise to a lively exchange of letters. The article, entitled The Racist Patient, touches on some issues many would prefer to ignore. Here’s the start of the piece by Sachin H. Jain, MD, curently at the Boston Veterans Affairs Medical Center in West Roxbury, Massachusetts:

In my final months of residency, I was summoned to see an angry patient. Mr. R. was furious that our pharmacy did not stock his brand of insulin. He wanted to issue a complaint.

“You guys always mess up my insulin whenever I am here. I told the other doctor, and now I’m telling you. You guys just can’t get it right.”

“I’m sorry,” I told him. “If you prefer, your family can bring your insulin from home and our nurses can administer it. Would that be an acceptable solution?”

“You people are so incompetent.”

Uncertain of how I might best diffuse the situation, I looked uncomfortably in the direction of my patient’s son, who was seated at the bedside.

“You look at me when I talk to you,” Mr. R. commanded. “Don’t you look at him.”

“I’m sorry. Why don’t I come back later?”

As I uncomfortably walked out of the room, he launched a grenade.

“Why don’t you go back to India!”

On pure instinct, I responded, “Why don’t you leave our [expletive] hospital?” To underscore my point, I repeated myself.

I exited the room in a cold sweat.

In a later issue of the Annals, letter-writers shared various ideas about how one might best react in that situation. “[In a similar situation], my personal feelings were immaterial [to the proper treatment of the patient],” said a Dr. Galishoff of Alabama, who had experienced anti-Semitism. Dr. Sahai, of Houston, Texas, who identifies himself as a physician of Indian descent who has faced similar remarks, says, “I have never lost my cool in the presence of the patient.”

Even Dr. Jain himself wrote a letter of response to “clarify misconceptions.” He protests, “I am in no way proud of how I reacted to [the patient’s] incendiary comments.”

This is where I depart from the opinions already expressed, though I should take pains to point out that I would never, I hope, make a remark like Dr. Jain’s even if faced with such an obnoxious patient.

My point is this: sometimes professionalism is too weak a vessel to contain our very real human feelings and emotions in stressful situations. I am not sure how Dr. Jain should otherwise best have expressed his displeasure in a way that conveyed the extent of his hurt. I agree that a strongly worded letter, composed later with due deliberation, would be an ideal response in tune with the spirit of professionalism. But this does not change the fact of emotions: when we are angry, we get angry, and we respond.

What better way – as a human being, not just as a physician – to express how horrified we are at naked racism than to call out the person who launched, as the author put it, that grenade? Curses are a powerful expression of injury, and were Dr. Jain to have confined himself to a letter, or the pallid adjective “appropriate,” the patient might not have learned anything at all.

Cursing at patients is not part and parcel of professionalism, and I hope I would never do so. But – then again – I hope I would never be the target of such a racist remark. Sometimes, our human feelings burn through the veneer of professionalism and we are left as insulted as anyone.

Have you ever had a sensitive or offensive exchange with a doctor or patient? How did you react?

A friend wrote me after a reading:

“[W]hat I took from it is that there are indeed two MEDICINEs: the science one (read lab animals) and the humanistic one in the best tradition of Hipoocrates forward.”

The reference to “two medicines” puts me in mind of the famous essay by C.P. Snow about two cultures: the sciences and the humanities. If you read far enough down in the Wikipedia article about the concept, you see – as with so many concepts – how it becomes complicated and quibbled with out of all recognition.

Sometimes, though, quibbling misses the main point. There are those who are blind to the sciences, and those who are exclusively centered on the virtues of the humanities. Not to say that there isn’t overlap, but there should be more.

The same can be said of medicine. To be excellent professionals, doctors and nurses require both technical facility and appreciation of emotional complexity. And by “excellent” here I mean something like “virtuous,” in the sense of striving towards perfection of the whole individual.

So, when we are talking about the two medicines, perhaps we should mean that the best of the scientific/biomedical view of the patient, and the humanitarian/narrative/irreducibly complex view should both be united in the provider. If that were the case, whatever action a provider took would be in a deep sense uncategorizable. 

Patient-centered care often brings the grandest flights of fancy rudely down to earth. Whether this applies to the idea of “two medicines in one provider” is difficult to say. I do think that most people are looking for a provider who combines multiple virtues: a full person, not a scientific machine nor a device to convert suffering into publishable narrative.

How to cultivate such inner diversity, true balance, without sacrificing depth and accomplishment…?

I neglected to jot down some notes at the time about Matthew Wynia’s plenary speech at the International Conference on Communication in Healthcare. I think I was too nervous about getting out of the auditorium after the speech in time to overspend at the American Girl store and the Lego outlet. Wynia has a multifarious research portfolio. He has researched the ethical nightmares of medicine during the Holocaust with attention to its implications for today’s practitioners (on which see here). He is also head of ethics at the AMA (the existence of which post, given the AMA’s position until recently on improving access to care for America’s uninsured, gives one some pause).

His talk was a restatement of the aims of professionalism. Starting with the School of Hippocrates, Wynia traced the ethical foundations of medicine – with communication with the patient at its core – to the present day. (I summarized some of his references on my Twitter feed.) While professionalism means different things to different people, Wynia pointed out the etymologic (and to his mind, the true) meaning. To profess means to promise; members of a profession aim to promise something to society; and, thus, professionalism is the means by which a profession ensures that those promises are kept. 

Since the mission of medicine is ethical, professionalism must include ethical standards. The obvious question is how these profession-wide standards are meant to reinforce the relationships that develop in the context of the patient-doctor dyad. Wynia did not address these questions, but he did – in the final part of his talk – emphasize the importance of an institutional culture in making communication (as part of professionalism) possible. I left with many thoughts about how to do this, and – specific to my interests – how best to make autonomy part of initiatives in quality improvement. More to come, I hope, on this effort.