Map of life expectancy at birth from Global Education Project.

Monday, October 27, 2008

The People Speak

Okay, let me try to sum up some of the comments on what makes for the kind of doc people appreciate, and throw in some thoughts or two of my own.

Number one, honesty is the best policy. I think that has more than one dimension. It includes being up front about the bad news, not being afraid to say you don't know something, and admitting mistakes.

In the old days here, and still to a considerable extent in Latin America, it was the norm not to tell people when their condition was likely to be fatal, the archetypal example being incurable cancer. We certainly have a different ethical norm now, but a lot of doctors still feel that there is something cruel about depriving people of hope. Of course we're all mortal so "hope" is really a matter of degree. How long might each of us expect to have and in what state of comfort and cognition? Answering that question, even for the most technically competent physician, is as much art as science and people do sometimes beat even the most definite prognoses. But doctors should certainly accurately report their best judgment and the true degree of uncertainty.

The second point can be harder for some doctors. The culture imbues them with God-like powers and some of them enjoy that role.

Which makes admitting mistakes even harder, especially with the fear of malpractice suits hovering behind the scene. But the evidence shows that the likelihood of being sued for malpractice has little to do with whether physicians were in fact negligent or incompetent, and more to do with how people feel they were treated. An admission of error and an apology can actually reduce the chance of being sued, and turn away wrath. The fact of the matter is that doctors are human and they all, every one of them, make mistakes. We need to accept that, as long as they are really trying, are not negligent, and are not incompetent. All of which is not the same as being infallible.

Next there's the issue of talking down to people about technical matters, presuming you're just too dumb to understand, or not being bothered to explain. What really frosts my pumpkin is when doctors think they're doing us a favor by explaining things in terms of weird metaphors, like viruses being "intelligent" and able to "outsmart" the medications. It's more difficult to explain biomedical issues accurately to people who don't have a lot of biological education, but it's your job. It can be done, you need to figure out how. Which means not talking down to people, giving them the chance to ask questions and not acting all intellectually superior when they do. Then take the time to think through how to make scientifically accurate, if necessarily somewhat simplified, explanations.

Xine notes that there is a difference between what we expect of specialists and primary care physicians. Indeed, although I'd say it can get a little bit tricky operationalizing this. When people have chronic diseases, or serious diseases that have a relatively long course of treatment, the relationship with the specialist can become primary. In fact, in the case of chronic disease, often the specialist in fact becomes the primary care doctor. It's one thing to see a surgeon for a one time procedure after we've already been diagnosed and gotten the basic 4-1-1 from our primary care doc; but the relationship between someone with cancer and an oncologist is much more intimate. So I'd say this is more of a continuum than a dichotomy.

Roger puts technical skill foremost, and I expect most people would if they were asked. Our problem is that we usually can't really tell how skilled the doctor is. Like Roger, I do know that my doctor is good a freezing warts, which certainly wins him some cred because I know that some of them aren't. He's willing to go right after the earwax and he gave me excellent advise about how to work out a stiff shoulder. So we can pick up on that stuff. But most of it is far from obvious. That's why we go to them, after all -- they're the expert. If they are out to lunch, we really don't know until it's too late.

As Kathy notes, however, doctors have certain performative roles (little technical term their from sociolinguistics) as well as biomedical roles. We need them to sign certifications and excuses and so on. They might think all that is beneath them or a minor part of their responsibility, but people depend on them for it. This is a form of social power that doctors have been known to abuse, as well. Maybe I'll talk about that at greater length at some point.

So people tend to judge their doctors' competency impressionistically. I'd like to know more about how they do it.

Now, as for the compassion/empathy thing versus professional reserve. It's a difficult balance, not just insofar as how it affects patients' feelings and likelihood to follow medical advice, but also insofar as it affects the physician's emotional well being. Remember that it's the biggest thing in the world when one of us has a serious health problem, but doctors see it many times, every day, and sometimes their patients really suffer and sometimes they die tragically, no matter what they do. Doctors have to figure out how to truly care about all those people without lying awake all night and turning to the bottle. That is not easy, and becoming callous or overinvolved are both occupational hazards -- or perhaps swinging between the extremes with different patients, depending on whether they rub you the wrong way or you are attracted to them.

So we need to cut them some slack, while recognizing that meeting these challenges is indeed a big part of their job and ought to be one reason they make the big bucks, as much as their biomedical knowledge and technical skills. That's what I'm trying to help them to do.

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