The Power of Knowledge
Life has changed and access to information is no longer the definition of value – we have seen these changes in the past as far back as 1494 when the printing press was introduced making books and knowledge more widely available:
And proceeds through newspapers, the steam engine, photography and the death of painting, the telegraph, movies and the death of theaters, the telephone, phonograph, radio, television, computers and the internet and if anything the speed of change is accelerating. So too in medicine have things changed with a shift away from paternalistic experts to wide knowledge access and cooperative systems of healthcare delivery.
The Sorry State of Medicine
But the physician is still a key part of healthcare delivery and for many in the profession, there is a sense of despondency and even despair with the profession and their ability to deliver the care they aspire to deliver each and every day. This recent piece in the Wall Street Journal Why Doctors Are Sick of Their Profession captured the spirit – only 6% of doctors surveyed describe their morale as positive and that’s not just bad for the doctors – it’s bad for patients too.
The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade
Running out of Time – Walking Gallery Jacket
Physician suicide remains high with doctors the most likely to commit suicide with a rate of 1.87 times that of the average population (the US alone loses ~400 physicians to suicide per year) and their “success” measured as a completion rate is far higher than the general population (x 1.4 – 5.5).
As this piece The Painful Truth: Physicians Are Not Invincible highlighted (South Med J. 2000;93(10) ):
Physicians fulfill a special role within our society. While they are given many privileges and rewards, they also carry serious responsibilities. Physicians are expected to be healers, available to others whenever a crisis occurs or a medical need arises. They are expected to have unfailing expertise and competence, to be compassionate and concerned, and to provide universally successful care in a cost-effective manner. Such idealized expectations emanate from patients, from families, from society (including payers and regulatory and accreditation agencies), and from within the profession of medicine itself. Self-imposed expectations inhere in the institutions of medicine — medical colleges, clinics, hospitals, professional associations, and collegial relationships — and are internalized by students of medicine as they are socialized to become practicing professionals. These expectations become a part of how physicians define themselves.
So when I came across a picture of this mug:
I posted it to my social media feed with a commentary
Great reminder for #RSNA15 of the value of clinicians in #healthcare pic.twitter.com/Mew9Rkg836
— Nick van Terheyden (@drnic1) November 30, 2015
I wanted to highlight that clinicians are still an essential part of the healthcare system and their contributions are valued. This mug captured a strength of feeling that caught me by surprise.
It is available for purchase from a British eBay store and has been subject to several posts including this one from ePatient Dave – here and here and plenty of likes, dislikes, tweets, and even some fairly hefty criticism including one comment about starting a holy war.
Doctors Under Siege
I know many of my colleagues feel besieged. The system has drained every last ounce of empathy and compassion out of many with overhead requirements that detract from direct patient care and turn highly qualified, talented and well-intentioned clinicians into data entry clerks and automatons. I have always believed and still do that every clinician gets up in the morning with all the best intentions to deliver high-quality, compassionate care. There may be a small percentage of individuals who do not but if they exist are a tiny minority.
We selected the career because we care. We selected the career because we want to offer support and compassion to our fellow human beings. We get our reward from these actions and there is no replacing the privilege of the trust that is placed in our hands in a personal and intimate relationship with our patients.
To get into medical school required an incredible climb up an academic mountain that was littered with others who did not make it. The experience tends to reinforce the sense of importance and verges on narcissism for some as the course and hurdles demand a level of self-confidence in our own skills and knowledge. It is little wonder that what emerges from the medical school sausage machine can appear devoid of compassion, over confidant and unwelcoming of other opinions. It is any wonder that there is any compassion left by the time a doctor emerges with his degree and board certification – and that’s before he steps into a the healthcare quagmire and finds himself unprepared for healthcare as it is delivered today.
But many patients and patient advocates perceived this negatively and as an affront to their place in participatory care. The perception from patients appeared negative and there were multiple reports of patients who had been blocked when bringing information to their doctor and Dave even cites the sad instance in the UK of the 19 year old girl who had fibrolamellar hepatocellular carcinoma (a rare cancer that with ~200 cases diagnosed worldwide annually) that was treated and then returned. Despite her pleadings to the contrary the Hospital and clinical team refused to believe her and told her to “stop googling”
There were even a few physicians who saw this mug negatively – as Bryan Vartabedian a pediatrician at Baylor said:
This mug reflects a dated mentality https://t.co/cUeELJOtUZ — Bryan Vartabedian (@Doctor_V) December 1, 2015
and he posted this piece “Doctors and the Google Threat“. I don’t disagree with him that information access brings huge value and makes healthcare more accessible to a wider population but the systems in place don’t support the time aspect that this new sometimes unfiltered and unscientific data brings to many of the clinicians I talk to. One of the main challenges with this was captured by one friend who said:
You came in to see me with 9 minutes of reading material but I only have 7 minutes of time to care for you
And James Legan said:
@jimmie_vanagon @drnic1 @tugger723 Web is a blessing & curse tons of info but w/o med training more noise than meaning — Jim Maughan (@tugger723) December 1, 2015
And the deluge of information that arrives on everyone’s phone is replete with snake oil and pseudo-science oftentimes amplified by celebrities who’s impact on their millions of followers can be incredibly damaging to individuals’ health.
Dave did take a constructive approach to the participation of patients
I personally am completely opposed to a patient going in and saying “I’ve decided I have condition X, and I want you to prescribe 42mg QID of medication Y.” I mean, have you ever seen the things medical students have to learn to get their license?? But I’m all in favor of a patient saying, “I have symptoms A and B, and from what I can tell from websites J and Q, that sounds like it could be M.” Explain your thinking, identify your source, and try to solve the diagnostic puzzle together: Collaborate.
While there are still doctors who see this as a challenge to the traditional model of care and the paternalistic distribution of knowledge and care, most do not. I leave it with these two tweets that for me captured the underlying spirit I felt when I posted the original image:
@drnic1@tugger723 I like to google with my patients at the point of care with #ProjectedEHR a great place to meet on common ground– — James Legan MD (@jimmie_vanagon) December 1, 2015
and this one
@harshybar @drnic1 you’re absolutely right and I love when my #patients are informed and ask questions #imaging3 — Geraldine McGinty (@DrGMcGinty) December 1, 2015
Everyone on the Same Side
Most physicians say the best part of their jobs is taking care of people – it’s the human moments, the taking care of people that make our jobs so satisfying. We are all on the same side – the structure of the system forces behavior that is not always ideal but despite this physicians do want participatory interactions – we love patients, especially ones that are engaged in their own health and care and we do not (and cannot) know everything.
You may well bring information to us that we are not aware of or have not read or heard about and we hope there will be enough time and opportunity to review this and help include scientific knowledge, no matter the source, in our review and guidance on the best course of treatment for you.
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