When the Doctor Goes Home: The Coming Indifference of American Medicine
It is the close to midnight and your mother is drifting in and out of consciousness. She is 77, not young but not old enough for fatalism. In her darkened hospital room you feel fear and the dread of uncertainty. And then, the doctor goes home.
In the New York Times, a recent article describes the migration of doctors from business ownership to shift workers. In increasing numbers physicians are no longer entering traditional "private practice" but exchanging autonomy (such that it is) for a role as employee of hospitals, large "corporate" physician groups, or universities. Most non-physicians seeing this change are reflexively sympathetic. After all, "doctors are just like us," need predictable days off, personal days, set vacations, and the duality of rewarding home life and well-paying and ego-fulfilling job.
All that makes sense, until severe illness visits. At that moment, in a hospital room at the end of the "second shift" or meeting the "hospitalist" whom you have never seen before, or when calling the primary care physician, who has no clue that anyone is in the hospital, you begin to understand the very different way we will be cared for at times of our greatest need. Most doctors do not want to advertise this nor will patients recognize it until the transition towards a gentle indifference is complete.
I have previously written that physicians must be vigilant and remain consistent with their unique moral responsibilities. Self-reflection and a steadfast commitment to the patient's welfare can right many wrongs. At the same time, however, public attitudes and polices must be able to sustain a culture that both understands and rewards these internal and most personal qualities. Unfortunately, at the very time when physicians themselves are least satisfied, society is forgetting that what you want from doctors when you are well is very different from what you need when you are sick.
Thirty years ago, the training and practice of medicine was deeply rooted in "inherited" values as much as craft. Physicians were in a noble discipline recast into paladins protecting society, even a bit of its soul, against an implacable adversary. Training was both arduous and flawed (inflated egos and autocratic mice that roared) but with a central purpose. When done well, doctors successfully confronted their most difficult internal challenges, fear of the power of illness and the willfulness to make important decisions when the consequence was uncertain. This "old" medical culture was best expressed by a single term: "My patient." It was as far from provider and client as you could possibly get. "My patient" conveyed both bond and responsibility.
We are about to burn the bridges to this tradition from both ends. Resident physician work rules mandate the numbers of hours and/or hours per night with severe penalties for even minor violations. Doctors care for fewer patients and surgeons operate less often. We have flipped from when doctors were mythologized for being strong to a system that all but advertises their fragility. A quick visit to the kitchens of Michelin-starred restaurants will show that the hard work that aspires to mastery over mere competence still remains a feature of that pride-filled profession.
Current fashion assumes that electronic records will be transforming, but data alone does not insure understanding. From a distance, medical diagnosis seems about answers, but is essentially about asking the correct and timely question. The right questions favor a diagnosis that comes both earlier and at a much lower price. Medicine is a numbers game and nothing trumps experience, though we are now imagining that the patient is protected the same way when care is distributed among a number of people and not centered in one.
Individual responsibility instills self-assurance and confidence leads to moral ownership. When this quality of care is lacking, physicians often find subtle ways to relegate without showing even a hint of shame. The physician that feels heroic, in the best sense of the word, is proactive in keeping the bar at a high level. When doctors are expected to just do their job, statistics more easily replace conviction.
There is thus a real distinction between systemic changes that predict for improvement or simply risk more empty scrutiny. Half a century ago, the perpetual criticism of individual medical performance was bedrock of training and practice. Work rounds with more senior residents, chief resident's rounds, attending rounds, chief of service rounds, formalized grand rounds, and clinical pathology correlations were ritual. Doctors knew when other doctors acted out of ignorance, anxiety, or fatigue, and in-house critiques were spoken in an effective language. If you did not get consultations or referrals, if your opinion was not followed, if you were never asked to teach others, you got the message far more directly than from a printout of outcome statistics.
There are still many teaching exchanges but they have veered from debate to compliance. It is perversely amusing to hear the deference to "evidence-based" medicine, as if clinical decisions made without resort to statistical analysis or prescribed "care paths" are doomed to personal whim or alchemy. Disease is a chameleon replete with deceptions, miscues, and very unpredictable rhythms. Critical thinking was and remains a better bet than slavish adherence to a formula. Without the doctor wanting to be Sherlock Holmes, you will guarantee that the cases for Inspector Lestrade will, more often, be left in the dark.
There was risk as well as reward in feeling personally responsible for others. Doctors accepted feelings of inadequacy when the diagnosis was wrong and an internal reprimand when a surgical technique was not done as well it should have been. Disease is a harsh taskmaster and there were few places to hide.
It was sufficiently hard that quiet shortcuts fit well when insurers anticipated that lower fees per individual would be met with higher volumes. The once-loyal patient followed the lower co-pay and doctors internalized the cynicism of the failed romantic.
We surely need to find a better balance point, but in ways that do not exchange frustration and even dented integrity for a less committed life. Unless we are careful and thoughtful, we will turn American medicine into a civil service wherein the only ambitions are to leave your shift on time or to get a bonus from complying with all the rules that mandate what you should be doing. It will only take a medical generation or two before no one remembers how glorious it was to be a physician in the United States.
Joel B. Levine, M.D. is Professor of Medicine, University of Connecticut Health Center.