Thursday, June 21, 2012

Paging Dr. Einstein

About a year ago, I was having lunch with a friend when the subject of finding a good doctor came up.  What makes a good doctor?  What qualities are most valued?  My friend leaned forward and asserted, “I really don’t care if my doctor is nice and all that stuff, I just want the freakin’ smartest doctor I can find.”  I pressed my lips into a half-smile.  I didn’t agree with her at the time, but I found my ability to counter lodged somewhere between my heart and my throat.  The truth is, when I started medical school, I felt much the same way.  Who cares if a doc pats you on the shoulder and comforts you?  Who cares if she smiles and asks you about your wife, kids, and pet zebrafish?  To me, all this was much like the toy that comes with your kid’s meal—a delightful bonus, but not the real substance of medicine.  I just wanted someone to do the right tests, give me the right meds, and send me on my way—fixed up and ready to go.  But even in the first few months of my training, I could see that my initial impression of good medicine was rather short-sighted.  It seemed odd that on one hand, I was a proud member of a fraternity that prides itself on stratospheric test scores and intellectual acrobatics.  Yet on the other hand, I was beginning to see that brute intellect plays only a small supporting role in medicine’s celebrated script.  For many of us, this comes as a hard pill to swallow.  But the truth is it doesn’t take a genius to be a great doctor.
Part of the problem for both patients and providers alike is that we often view illness as a technical difficulty. If our computer crashes, we expect the whiz at Apple to uncover the problem and provide the restorative reboot.  If our car crashes, find us a skilled mechanic who can dive under the hood and give it new life.  Hell, if the economy crashes, we believe the officials we elect to office should have the power to tweak a few policies, rejigger the interest rate, and get our GDP rocketing skyward again.  And why not?  We are of a bold generation that has always viewed even the most complex problems as a giant brain away from happy resolution.  But what if a loved one gets sick?  And what if it’s my child—not my computer—who’s crashing?  Often, our initial intuition is the same.   Employ the smartest doctor in the hospital to swap a few meds, execute some elaborate surgery, and restore everything back to normal.  A doctor’s job is to fix our cracks and mend our leaks so we can get on with our lives.  And presumably, the smartest ones are also the best fixers.  But of course, matters of life—and death—are never quite so simple.
Despite whatever value we assign to our beloved gadgets, laptops don’t think, and cars don’t feel.  They also don’t dream, aspire, believe, defy, invent, or imagine.  It’s the fingers that touch a keyboard that possess the ability to translate the ideas and emotions of a brazen mind.  Cars carry passengers, but it’s the passengers who carry a lifetime of joys and sorrows.  And when an economy crashes, it’s the people who suffer, not the GDP.  So while flawed devices and failed policies can be restored and renewed, they can also be discarded.  Human beings—well, not so much.  This is the real grit of medicine.  We can preserve health, but not indefinitely.  We can treat pain, but we don’t cure misery.  Despite all our medical advances, more often than not, our job is not to fix, but to advise, to advocate, and to comfort when suffering has already established a foothold.  The brilliant engineer must decipher when old parts should be abandoned and outdated systems replaced.  The great physician—she must walk with the worn, and sit with the broken.  And it’s not that we should disregard the breadth of her knowledge.  It’s just that there is truly no replacement for the depth of her compassion.
For those of us who still view illness as technical blip, it’s likely because we have never been truly sick or cared for the gravely ill.  Yes, we’ve probably taken antibiotics for a throat infection or received x-rays for a broken bone.  Maybe even gone through surgery and rehab for certain injuries.  But the most common and costly diseases afflicting Americans are the unsexy, life-sapping diagnoses that prompt years, even decades, of suffering.  Diabetes, depression, heart disease, cancer—all chronic diseases without cure.  If you spend enough time around doctors, you will hear them refer to treatment as “medical management.”  Because in cases of long-standing illness, it isn’t about coming up with dazzling answers or pondering over a mysterious case until reaching that single “aha!” moment.  You work with patients to juggle a dozen prescription pill bottles.  You remind patients why they can’t eat their favorite foods—the ones they’ve grown up enjoying.  You even prepare patients for how chemotherapy will cause them to lose their hair, their hearing, their sex drive, and much of their independence.  And you help them understand why once your health leaves you, it doesn’t often come back.   Because for patients whose lives are marred by poor health, medicine becomes more about dedicated support, compassionate care, and constant education.  It turns out the ability to perform high-flying mental acrobatics is really just a bonus.  Like that toy that comes with your kiddy meal.  When you are truly famished, your focus shouldn’t be on the toy.
The truth is that for many patients, they come to a doctor sick, and leave sick.  And for 365 days a year, they are the ones taking care of themselves.  Physicians don’t get to play miracle healer as often as they’d like.  Instead, the challenge is how to better empower patients to choose for themselves the lives they want to live, even when illness has become a part of everyday reality.  I know if someone I really cared about got sick, there are some people in my class I would trust without hesitation.  Not because they are brilliant, though most of them are.  But because they are the type of people that you can trust to carefully guide you while understanding that your diagnosis is not your defining characteristic.  For those who are truly ill, there are often many tough decisions with few good outcomes.  And the “right” decision is different for each individual.  Because after all, we aren’t just a collection of moving parts, all mass-produced from the same mold.  We harbor unique thoughts, values, and aspirations.  And all of these things play into excellent care.  Clearly, amputating a pinky finger might mean one thing to me, and something very different to a concert pianist.  Simply put, there are “good” answers, and then there is true guidance.  The latter is what distinguishes the outstanding physician.  It may not require the gift of pure genius, but it demands a level of human compassion that is perhaps every bit as rare.

4 comments:

  1. After a friend gave me some extremely thoughtful feedback about this post, I realized that I perhaps did not address what I meant by compassion and how it plays out in meaningful ways when caring for a patient. First, I must say I definitely don't want a dope for a doctor. But at the same time, I think there is a "Dr. House" mentality among our generation that believes there is sexy particle-physics-like stuff going on in the OR and physician meeting rooms. It's simply not true. Two things I think people don't consider:

    1. The majority of mistakes and shortcomings that occur in medicine are not due to gaps in knowledge. If a patient came in with a list of 12 medications, most doctors should be able to identify which ones have potentially disastrous interactions. The problem is either the doctor wasn't conscientious enough to go through the meds, or much more commonly, the patient has an incomplete list of the meds she is taking and doesn't know the name of these other blue pills she is taking. They are diamond shaped, you know? Now here is the dilemma. You can either say "hey, it's not my problem," and go by the list the patient has and make some convenient assumptions. Or you can spend time calling the patient's primary care doctor, filling out forms to release old records, wait by the fax machine for the pile of records to come in, and sort through why she is on each of the medications and ensure everything is appropriate. In almost all cases, you don't get paid for the latter. If you spend a day in the hospital, you will quickly realize there are interns, residents, and physicians who go this extra mile without fail. And then there is perhaps the majority who say "it's not my problem." This isn't a lapse in intellect. We work in a very broken health care system, and you can drown going the extra mile for patients. But this is the reality. Some do, and some don't, and it has very little to do with your IQ.

    2. You have to remember that if you are reading this blog, you likely have the benefit of a top notch education and are probably in the top 1% when it comes to understanding and taking ownership of your health. I don't say this to flatter any of you. But the reality is, a lot of patients will have a hard time understanding why they need a control inhaler and a separate emergency inhaler after being diagnosed with asthma. And some will struggle to understand what asthma is altogether. Why can't I just use my emergency inhaler 5 times a day, I don't mind and I'd rather not have to take two separate meds. I think my child has asthma because she got an infection from her cousin, and she needs antibiotics, not an inhaler every day. This asthma all started after I went swimming in a cold pool as a teenager, and your meds won't help that. Again, if you knew how often these situations occur, you'd probably be a bit appalled. The problem here again isn't that the physician had some gap in understanding. It's the skill and effort required to translate that knowledge to a patient who sees the world differently than you.

    My point goes back to the fact that compassion isn't really just about being someone's friend and saying nice things. Having worked with all kinds of doctors, I've seen how something drives a few to stay late, answer the "annoying" questions, and work patiently to come to compromise with patients who see things differently. I am calling this "compassion" even though it entails perhaps many different elements. But this speaks again to my point that all this has little to do with intelligence. Of course, you need a baseline level of intelligence and it is my feeling that most of those who get into med school are at this baseline. What then sets you apart as an amazing physician is your ability to care for people when it is impossibly annoying and inconvenient. But then again, great clinicians wouldn't view it as that.

    ReplyDelete
  2. I think it's accurate that most people have a "Dr. House" mentality, myself included oftentimes. That's a really good way of putting it. Instant gratification is our preference as patients, and we want you to give it to us even if the right answer is long-term medical management. I definitely wish (and sometimes try) to treat my body like a logical machine that can be repaired on demand. I think that almost all of my doctors have been conscientious. Only recently do I feel that I've encountered one who really doesn't treat me well, but he is the only bad one out of many. I think it's true about most jobs - conscientiousness outweighs intelligence. Tough question: At what point is it unreasonable to expect the doctor to go the extra mile? Some of the accountability has to be shouldered by the patient. I suppose that has to be determined for each time and place, case by case.

    ReplyDelete
  3. You hit the nail on the head Adam. That's the big question... where does the Doctor's responsibility end and the patient's begin? I think you can come up with many different answers depending on how you view it, whether you are asking from a medical-legal perspective, a societal perspective, or an ethical one. But personally, I think even if you could draw a clear line to delineate where the responsibility lies, you would still have those physicians willing to give the extra effort and go beyond their professional duties. This is the case in pretty much any job. Whether you're a mailman, a doctor, a detective, or a soldier, you could come up with all kinds of examples regarding shouldering the extra load when it's inconvenient. And when the stakes are high, there is no doubt the type of person you want in your corner.

    I don't think there is a clear-cut answer to how responsibility can be divided, but surely part of your duty as a physician to understand a patient's unique situation and transfer your expertise so that patients can understand and own their health. And this presents a limitless variety of challenges on a case by case basis as you alluded to. If the patient only speaks Spanish, is it your responsibility to learn the language? To provide a proficient translator? What if 80% of the population you serve is Hispanic? Similar questions of responsibility can be asked if 80% of your population is Hindu, or high school drop-outs, or professional athletes. I think it is definitely your responsibility as a doctor to engage the specific community you serve, but how well you do that depends on your effort and character.

    ReplyDelete
  4. what an insightful post, really enjoyed reading it! i think our generation is, in many ways, accustomed to a degree of instant gratification...we expect the best from everything and everyone, and that includes doctors. that said, we're also a very young generation, and most of us haven't had to utilize the healthcare system all that much. we may have had quite a bit of experience in the clinic or hospital by proxy (i.e. when a family member is ill and we are at the bedside), but most of us haven't been hospitalized for extended periods of time. thus, we tend to view healthcare as another consumer service industry: just as we expect a chef at a restaurant to cook a good meal or a car mechanic to do a good job on the oil change and tune up, we expect doctors to fix our somatic problems quickly.

    i think for those who have personally been through the healthcare system through and through, they see the value of an empathetic physician. they realize that their own bodies aren't a laptop that can be repaired at the Apple Genius Bar, they are complex sentient beings. a good physician knows his/her medicine. an excellent physician is the one who has both medical and empathetic knowledge.

    ReplyDelete

The content of this site is owned and copyrighted by its author Jay Zhu, including all comments & messages ©2012