However, we are sure that a fundamental requirement is honesty. The good doctor will not always be right. She will make mistakes, possibly serious ones, but she will come clean about what is happening even when it hurts. And, of course, the mutual trust that is essential to this relationship means that you must come clean with her, even when the truth doesn’t speak so well of you. You should say what you’re feeling, even when you think the doctor’s wrong or she displeases you. You may learn something important about the doctor from her reaction to criticism; if it’s anger, be wary.
Eventually, you just have to go with your feelings about the trust thing. And first reactions can be wrong. If something seems a bit off, give the relationship a little time. If you still can’t trust this doctor, you may want to look elsewhere.
Then there are the doctors to be wary of. A few examples are discussed in detail in the next section of the book. Others might include “Dr. Avatar,” the robotic doctor who practices medicine by rote and has difficulty connecting with real people. You’d do well to also keep an eye out for ones who might be aptly labelled something like Dr. Hype, Dr. Dolt, or Dr. Smarm. But you should also keep in mind that if you look hard enough you’ll find examples of most human personality types in the medical profession. After all, doctors are human beings, and if you expect them to be otherwise, you’re in for a real disappointment. So, carefully scrutinize candidates for your personal doctor and choose the partner who works best for you.
Once you’ve settled on a doctor, the two of you become health care partners, collaborators in the effort to make and keep you healthy. Tell your doctor who you are, every relevant detail. She needs to know as much as possible about you to do her best job. But keep a healthy emotional distance. If you start to feel inclined to push this relationship beyond appropriate professional boundaries, or if you sense that from your doctor, back off, put some space between you. This relationship may have its obligatory intimacies, but it is not a romance. The boundaries need to be clear and respected. Do not fall in love with your doctor is good medical and good emotional advice. This doesn’t need to be a friendship. You are professional partners, collaborators, and you need to keep the goal of this relationship—your health—in clear focus. While there must be confidence, respect, and trust on both sides, there also must be “spaces in your togetherness.”33
But if this is a partnership, then don’t both partners share responsibility for how it works or fails to work? Do you just have to take the list of doctors you are given by whatever health care system you are in at face value and then work your way through the available options until you find somebody who seems compatible?
Maybe not. Perhaps there is something you can do to improve your chances of developing the health care relationship you’re looking for. Perhaps you can help create the kind of doctor you are looking for. It might help you to do that if you had a better idea of how your doctor got to where she is and why she chose to do something that’s so difficult.
Jerome Groopman, How Doctors Think (New York: Houghton Mifflin Company, 2007).
Aaron Copland, “The Gifted Listener,” The Saturday Review, pp. 41-44, September 27, 1952.
Nassim Nicholas Taleb, The Black Swan: The Impact of the Highly Improbable (New York: Random House, 2007).
Christopher Chabris and Daniel Simons, The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us (New York: Harmony, 2010).
“Zebra (Medicine),” Wikipedia, https://en.wikipedia.org/wiki/Zebra_(medicine).
A.M. Harvey et al., Differential Diagnosis, 3rd ed. (Philadelphia: W. B. Saunders, 1979).
“Zebras with Different Stripes: One Patient’s Story,” SCOPE, July 17, 2012.
William Stauffer, MD, “Evolution of the Zebra: When You Hear Hoofbeats, You Need to Consider All Ungulates,” Minnesota Medicine, November 2008.
Louise Penny’s website, http://www.louisepenny.com/faqs.htm.
Richard Gunderman, “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics,” The Atlantic, October 30, 2013, http://www.theatlantic.com/health/archive/2013/10/when-physicians-careers-suffer-because-they-refuse-to-prescribe-narcotics/280995/.
Joshua J. Fenton, MD, MPH; Anthony F. Jerant, MD; Klea D. Bertakis, MD, MPH; and Peter Franks, MD, “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality,” Archives of Internal Medicine 172 (2012): 405-411.
William Sonnenberg, MD, “Patient Satisfaction Is Overrated,” Medscape, March 6, 2014.
Kahlil Gibran, The Prophet (Eastford: Martino Fine Books, 2011).
CHAPTER 4
Where Doctors Come From
Some knowledge of how your doctor got to where she is might help you to understand how best to connect with her. She spent four years in college, another four in medical school, and several years of on-the-job training (internships, residencies, and fellowships) after that. Those years aimed to accomplish two things: mastery of a large body of knowledge about how the human body is put together, how it works, what can go wrong with it, and what to do when things go awry; and mastery of a set of physical and mental skills that are necessary to translate that knowledge into caring for the health of real people. All that time was devoted to accomplishing those two goals. There was not a lot of room during those years to pursue other interests in any depth. Virtually all of aspiring doctors’ energies during their training are dedicated to climbing a very steep learning curve over a very long time.
If it’s that hard, why would a bright young person with many options for a productive, useful, and lucrative career that would require less preparation choose to enter medicine? The almost universal answer is because they want to do something tangible, hands-on, that benefits their fellow human beings. A concern for people and a desire to do something to help others may sound like a rehearsed answer to an interviewer’s question to a medical school applicant, but, trite as it sounds, that really is why most people choose a medical career.34 However, by the time they have clawed their way up the learning curve and are ready to start practicing medicine for real, a lot of them discover deficiencies in the unique interpersonal skills that they need to do their best, and also feel the pressures of a system that drives them in another direction. That combination—inadequate skills in the art of medicine and a system that values quantity over quality of care—can be a death knell for even the most well-intentioned doctor.
After spending all those years struggling up that daunting learning curve to the pinnacle and being granted the requisite credentials, how could a well-educated doctor, upon coming face to face with a flesh-and-blood patient, possibly feel ill-prepared for the job? Because most medical education, even now, gives pretty short shrift to the importance of dealing with that universal characteristic of flesh and blood human beings—ambiguity. There is so much other stuff to learn and such powerful history forcing medicine toward a solid footing in hard science, that the role of humanity generally takes a back seat. Many medical educators aren’t very enamored of equivocal answers, i.e. maybes. They feel pretty good about having done their job if they can teach their charges the yeses and noes.
Almost seven decades ago, social psychologist Else Frenkel-
Brunswik described aversion to ambiguity as a personality trait of people who are threatened by “novel, complex, or insoluble” situations. 35These people tend to play down or even deny ambiguity when faced with it. When confronting ambiguity that they cannot deny, these folks get seriously stressed. If there ever was a profession that requires dealing with “novel, complex, or insoluble” situations, it is clinical medicine. Medicine is rife with ambiguity and the last thing you want when you have to deal with it personally is a stressed out doctor. According to Johns Hopkins professor of medicine Gail G
eller, doctors with low tolerance for ambiguity order more tests, are less likely to follow evidence-based guidelines, cost more, are more frightened of malpractice litigation, practice more defensive medicine, and are uncomfortable with death and grief.36 That doesn’t sound like the person I need when I get sick!
But is it possible to teach people how to handle ambiguity? In other words, are doctors who deal constructively with uncertainty born, or can they be made? Is it that one comes into the world that way or not and that discomfort with uncertainty is an advantage when competing for a spot in medical school? Is it that more congenital “antiambiguists” enter the medical pipeline while the congenital “ambiguists” rejected by medical school (or discouraged from even applying), wind up doing social work or entering the ministry? Or could something be done in the process of choosing medical students and equipping them to practice medicine that would increase one’s chances of locating an ambiguity-tolerant doctor? Can the pool of this kind of doctor be expanded?
Well, it could be recognized that medical students with high or low tolerance for ambiguity differ from one another in some important ways.37 Some studies suggest that highly tolerant students are more likely to be leaders and are more willing to practice in underserved areas. Conversely, students who are ambiguity averse are said to be more afraid of making mistakes, to have more negative attitudes toward the socially disadvantaged, and to be less tolerant of alcohol abusers. So there are clues even early in their education that attitudes toward ambiguity might affect what kind of doctors these med students are likely to become, but, at least until recently, little attention has been paid to this personality trait in either the selection of students or in the medical curriculum. Instead medical education and the culture of medicine in general have usually rewarded certainty.
There are validated scales for measuring how well one deals with ambiguity, so this factor could be considered in selecting students for medical school.38 In recent years, a lot of thought has been directed at whether the traditional criteria for med school admission actually choose the people who are most likely to make the best doctors. Changes in premed course requirements and in the medical college admission test (MCAT) that emphasize more humanistic qualities have been proposed and, in some cases, implemented. Time will tell whether more admission committees will start selecting students who learn the facts, understand what they are doing and why, but are more likely to embrace the essential ambiguity of human beings and to be aware of the uncertainties.
One approach to creating doctors who are more intellectually flexible is to focus specifically on teaching empathy. Massachusetts General Hospital (MGH) psychiatrist Helen Riess claims that “Empathy training enhances relationships, increases job satisfaction and improves patient outcomes.”39 Dr. Reiss directs the MGH Empathy and Relational Science Program. She recognizes that doctors may not bring either innate or learned empathetic skills to their chosen profession, but she is convinced that adult professionals can be taught empathy. And she claims impressive results—improved outcomes with patients with diabetes, asthma, high blood pressure, obesity, and arthritis—and happier doctors.
Some medical school curricula now include teaching healthy attitudes toward uncertainty and ambiguity, but there is not much data on how effective those efforts are. There is some evidence, however, that time and experience can increase medical residents’ tolerance of ambiguity. It seems likely, as with most complex personality traits, that attitudes toward ambiguity are both innate and learned. Attempts to tilt the selection and the education processes in a direction that gives the best chance to generate more contemplative doctors are laudable. It will take time and more data to know for sure if these efforts are working.
So this stern-faced and slightly disheveled person in the white coat with a stethoscope slung rakishly about her neck who strides into the exam room, asks you a bunch of highly personal questions, and has you take off your clothes, didn’t just fall off the turnip truck. She’s paid some dues. She’s studied hard and long, seen a lot of human misery, developed a cadre of enviable technical skills, and dealt with her own life, perhaps even with personal illness. And she’s had maybe a course and a couple of tutoring sessions on various aspects of the art of medicine during her training. But she is hounded by a practice manager who’s not really into the soft stuff and constantly prods her to see more patients and spend less time at it. In spite of that, she continues to harbor a real love for her chosen profession. Still lurking in a warm, cozy, and passionately nurtured corner of her brain, lives the original reason she chose medicine. She really does love people and wants to do something tangible to help her patients to be healthy and happy.
Is there anything you can do to tap into that kernel of empathy, arouse that appreciation for the soft side of medicine? Can you help a doctor, struggling against the constraints of a largely dollar-driven health care system, emerge into the professional she originally dreamed of being?
But wait. Why should the doctor’s professional development be your responsibility? You’re paying for a service. Some would claim that you are buying health care, a product, that this is a retail transaction like buying food at the supermarket. It’s not your job to do the caring; that’s the doctor’s job!
That is just not true. You do not buy either health or treatment of your disease at the doctor’s office; if you think so, your care is not as good as it should be. Health care at its best is not a commodity; it is a partnership, a collaboration. There is an art to being a patient as well as to being a doctor, and if you don’t pay some attention to your responsibilities in this relationship, as is generally true of relationships, things won’t go as well as they could. The doctor may have the lion’s share of the responsibility here, but you, not the doctor, will be the one who suffers most if things don’t go well.
You are certainly bound by the courtesies common to relationships in general: keep appointments; show up on time; bring whatever information or medicines were asked for when you made the appointment; and have your insurance or other required information handy. And, while you should expect the doctor to spend as much time with you as is necessary to deal thoroughly with your problem, you do need to realize that there are other patients to be dealt with and that the doctor has an entire life that doesn’t involve you.
You should most definitely not take a cue from Daisy Brown (not her real name). Ms. Brown was a woman in her sixties with a chronic lung problem that wasn’t curable, but was well-controlled. At some point, she convinced the doctor who had cared for her for several years to take on the care of her son (in his thirties) who had asthma. At two o’clock one Monday morning, the doctor was notified that Ms. Brown’s son was in the emergency room with an acute asthma attack. As the doctor was getting dressed to drive to the ER, his phone rang again. When he answered the phone, he was greeted with Ms. Brown’s voice: “Doctor, since you’re going to the hospital now anyway and I have an appointment to see you tomorrow afternoon, can I just come in with my son so you can see me now and save me the trip tomorrow?” The doctor suggested to Ms. Brown, in as civil a tone as he could manage, that she should keep her appointment the next afternoon. Such total disregard for the doctor’s life will not do anything to enhance the quality of the medical care relationship. Even the most dedicated doctor may have had trouble resisting an inappropriate reaction to Ms. Brown’s unreasonable 2:00 a.m. request.
There are some other specific things you can do to help make this relationship as good as it can be.40 Be clear and precise about the reason for your visit (this may take some thought); if there are several reasons, do your best to prioritize them.41 Make notes to help you remember everything important to tell the doctor. Even if not asked, you need to tell the doctor not only what your physical complaint(s) is but also what concerns you most about it. Whether you are most frightened about possible surgery or worried about getting day care for your kids, or about transportation to the clinic, or any of co
untless other possible concerns, can make a lot of difference to how your physical complaint is best dealt with. And you need to be sure that you leave the visit with an accurate understanding of the information and instructions the doctor has shared with you; ask questions and tell the doctor when you don’t understand.
Then there is a basic responsibility to be totally honest with your doctor. That includes clearly saying what you feel about the experience, good or bad. There is a lot of evidence that doctors give the best care when they feel good about what they are doing, feel that they have done a good job. That is often more important than how much money they make. Your explicit appreciation for what feels like a job well done will pay off in the quality of your care. Conversely, if you don’t tell the doctor that you’re not happy with your care and why or that you disagree with the plan for whatever reasons, how will she know how to better meet her responsibility? Keep in mind that she is there, showing up every day to face needy people, because of that kernel of empathy that may be struggling against the constraints of the system, and that your heartfelt appreciation of her efforts could have a big effect on how good your health care is likely to be. This is a partnership.
In spite of your best efforts, it still might not work out. You may encounter a doctor whose potential for being the kind of doctor you need never existed in the first place (as we said earlier, that is a minority, but there are some); whose last kernel of empathy has succumbed to the burdens of a system that undervalues caring, uncertainty, and personal commitment; or whose noble motives have been overwhelmed by the money magnet. Aah, that devilish money magnet!
University of California, San Francisco physician Timothy Judson and University of Pennsylvania behavioral economist Kevin Volpp discuss the roles of extrinsic (read money) and intrinsic (read feeling good about one’s work) motivations in affecting how doctors behave.42 They call one of their four scenarios intrinsic motivation crowded out by extrinsic motivation. In the scenario a doctor is driven by a desire to care for patients with AIDS to pursue a specialty in infectious diseases. He develops a busy practice in that area and feels really satisfied with the good he is doing for his patients. He is making a difference in their lives, and that is why he chose a medical career. He practices this way for several satisfying years. Then he discovers that doctors with less training than he had, just completing a residency in Internal Medicine, start out making more money as hospitalists than he is making after several years practicing a subspecialty. And they work only in the hospital and have designated hours. The doctor gives up the practice he loves and takes a hospitalist job for the money. Sad story, but it happens. We’d bet he’s not as happy as he was.
The Good Doctor Page 4