The Psychological Impact of Medical Training on Physicians

In the first chapter of his landmark work, Medical Ethics, Thomas Percival calls on physicians to ‘‘unite tenderness with steadiness’’ in their care of patients.

Percival wrote those words in 1803.  Today, they sum up what healthcare reform is asking of 21st century physicians: “Patient-centered medicine” requires that a doctor combine strength with compassion. A physician needs courage, fortitude—and great empathy. But, as I suggest in the post below, the hazing that turns medical education into an endurance test does not encourage tenderness.  Teaching through humiliation and intimidation only conditions doctors-in-training to develop a “tough hide” as they learn to take abuse without showing emotion.  

This is a process that trains young physicians to bury their feelings argue Jack Coulehan, M.D. and Peter C. Williams, Ph.D. in “Vanquishing Virtue,” a superb analysis of the “Impact of Medical Education” published in the journal, Academic Medicine, in 2001.  

 “The hot-house atmosphere is psychologically and spiritually brutal,” they write, and too often, “students receive little emotional support from faculty” or “role-model physicians.” Instead, students report feelings of paranoia: “I’m always being watched.”

Coulehan and Williams stress that some students survive, spiritually intact: “Certain personal characteristics of the student such as gender, belief system,” and age probably play roles, helping some students escape the most harmful effect of the conditioning. Medical schools that support “family medicine” and offer courses in “communication skills medical ethics, humanities, and social issues in medicine” can help.  

Nevertheless, in many instances, a poisonous, punitive culture saps the spirit of young doctors as they learn to “shut down” emotionally.

Little wonder that medical students who have endured this rite of passage resent the idea that nurse practitioners can do the work they do, and should receive equal pay and equal respect when providing the same services.  These physicians object, because they feel they have paid very high “dues” to earn the title “Doctor. “

Physicians have every right to believe that the social utility of their work demands respect, Coulehan and Williams acknowledge.

 “However, the duration, rigor, intensity, and abusiveness of today’s medical education also engenders a sense of entitlement to high income, prestige, and social power.” In essence many believe (rightly), that they paid a high price to earn that MD after their name—not just in the form of high tuition ,but in the form of  “long hours, deferred gratification, great responsibility–—which then warrant very high benefits in return, the cultural equivalent of ‘‘MD’’ license plates.

This leads to that sense of entitlement,” a belief “that physicians are due a special status in the world of healthcare not just because they have worked so hard, but because they have been so abused.”

While their grievance is justified, a sense of having been abused it is not a strong foundation for self-respect. Nor is it is a good reason to resent NPs. Rather, young physicians should resent a system designed to bully rather than to nurture, and vow not to repeat the ritual when they train doctors.

                                    The Explicit Curriculum vs. The Hidden Curriculum

 Coulehan and Williams explore the tension between the explicit curriculum of medical school, and a hidden curriculum, the unwritten code that shapes the values and behaviors of many physicians. “The explicit curriculum stresses empathy and associated listening and responding skills, the relief of suffering, the importance of trust and fidelity, and a primary focus on the patient’s best interest.”

By contrast, the implict curriculum, what they call “tacit learning,” stresses “detachment, wariness, and distrust of emotions, patients, insurance companies, administrators, and the state.” This is how residents learn to survive.

  Continue reading

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Unheard Hearts – A Metaphor, by Clifton K. Meador

Below, a guest-post by Dr. Clifton. Meador.

Many  HealthBeatt readers  know Meador as the author of a popular HealthBeat guest-post “The Art of Diagnosis,” drawn from his book True Medical Detective Stories  (“A Young Doctor and a Coal Miner’s Wife.”)

Long-term readers will recognize Meador both as one of the stars in  the film,, Money-Driven Medicine,  and as the author of well-known satirical writings on the excesses in our  medical system. They  include “The Art and Science of Nondisease (the New England Journal of Medicine, 1965) and  “The Last Well Person,” an essay he published as an “Occasional Note” in NEJM  in 1994. 

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Unheard Hearts – A Metaphor 

                                                      Clifton K. Meador, M.D

A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder Continue reading

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The Lost Arts of Listening, Touching, Seeing . . . The Depersonalization of Medicine

As Clifton Meador’s observes in “Unheard Hearts,” these days most doctors rarely listen to a patient’s heart.

 “Physicians do carry stethoscopes and it certainly is a badge that shows they are a physician, but the sad thing is a large percentage of them don’t know how to use it and use it improperly when they do,” says Michael Criley, professor emeritus of medicine and radiological sciences and the University of California, Los Angeles’ David Geffen School of Medicine.

In a recent interview with Cardiovascular Business, Criley explains: “When two-dimensional echocardiography became available in the mid-1970s it could have, and should have, provided a noninvasive way of seeing what the heart chambers and valves were doing when extra sounds or murmurs were created, but instead replaced bedside auscultation [listening to the heart].

Reading what Criley had to say, and thinking about Meador’s piece, it struck me that this is all part of what some call “the depersonalization of medicine.”

By and large, 21st century doctors do not lay hands on their patients. As psychiatry resident Christine Montross pointed out in a New York Times op-ed: a few years ago:  ”Today’s doctors rarely do thorough physical exams.” Instead, they rely on “diagnostic tests and imaging studies.”

Meanwhile, in medical schools, Montross  reveals, “virtual gross anatomy” lets students avoid the “messy” business of dissecting a real body. “This is a mistake,” says Montross.

                                    Listening to the Heart                        

Criley’s theory that the stethoscope has become little more than a badge of honor is based on a study of physicians’ cardiac examinations.. . Criley was the lead author on a study that investigated these exams, published in the the December 2010 issue of Clinical Cardiology. Continue reading

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The Electronic Medical Record and the Disappearance of Patients’ Stories

Below, a guest post by Christopher Johnson, a physician who has practiced pediatric critical care for more than three decades. For many years, Johnson served as the Director of the Pediatric Critical Care Service at the Mayo Clinic and Professor of Pediatrics at Mayo Medical School. Today, he devotes his time to practicing pediatric critical care as President of Pediatric Intensive Care Associates, P.C., i n St. Cloud, Minnesota, and as Medical Director of the PICU for CentraCare Health Systems.

In addition, Johnson writes about medicine for general readers, both on his blog  and in books such as HowYour Child Heals: An Inside Look at Common Childhood Ailments  and How to Talk To Your Child’s Doctor: A Handbook for Parents

Not a few doctors complain that, too often, electronic medical records seem designed to improve billing, rather than to improve care. Johnson suggests that today’s EMRs are trying to serve too many masters—not just doctors, but payers and lawyers who want to see information laid out in easy-to-read “templates.” 

With a single keystroke, one can “drag and drop” information from previous notes into these templates, Johnson observes. But when physicians use them to record their progress notes, something important is lost: the patient’s story. Traditionally, progress notes set out to “tell, from day to day, what physicians did to a patient and why,” Johnson explains. They are a narrative that fleshes out the patient’s history in a way that helps other doctors treating the same patient.

Johnson uses and appreciates the many ways that EMRS can help him. But when writing out his progress notes, he ignores those smart templates, and tells the story the old-fashioned way, typing out his progress notes, just the way he did when he used pen and paper. Not only does this help other doctors, but Johnson says, it gives him a chance to “think things through.”

Narrative connects the dots.

MM

The Electronic Medical Record and the Disappearance of Patients’ Stories   

By Chris Johnson, M.D.

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

Continue reading

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The Art of Diagnosis: “True Medical Detective Stories”

Below an excerpt from Dr. Clifton Meador’s newest book: True Medical Detective Stories, a collection of true tales about patients who presented with symptoms that mystified their doctors (June, 2012).  In each case, the doctor eventually cracks the mystery, but only by “listening–very carefully” to the patient. 

The book begins with a dedication to the late Berton Roueché, who popularized the medical-detective genre as a staff writer for the New Yorker.

Following the excerpt, I have added a Note on the author.

A Young Doctor and a Coal Miner’s Wife

                                        By Dr. Clifton Meador

A young doctor, Dr. Bill Hueston, and his wife had just moved to the mountains of eastern Kentucky, near the border of West Virginia. The small town was nestled among the coal mines of the region. Nearly all of his patients would be coal miners or family members of a miner. Bill would practice family medicine. His wife, a veterinarian, hoped to build a small-animal practice.

Liz McWherther, the forty-seven-year-old wife of a miner, came to see the young doctor. Over several weeks, she had developed a curious set of complaints. Each morning she woke with a dry mouth and slurred speech. She also noted blurred vision and difficulty urinating. Within a couple of hours of waking, she was completely free of any symptoms. These symptoms had been occurring each morning and going away by afternoon.

Liz had had a series of tests done by the previous physician, but none of these tests were abnormal. The physical examination by Dr. Hueston was entirely normal. She denied drinking alcoholic beverages or using illicit drugs. Hueston had briefly considered some unusual response to marijuana or other drugs that were prevalent in the area. Liz had not been down in the mines, nor did her husband bring back anything unusual into the house.

The complex of symptoms suggested multiple sclerosis or some diffuse neurological disease. However, the rapid disappearance of the symptoms was puzzling. The most perplexing feature was the improvement as the day went on. Nearly all neurological diseases get worse as the day progresses. In most cases after a night’s rest, the neurological circuits are improved, and patients are at their best on arising. Not so with Liz. She was at her worst on arising and rapidly improved within a few hours.

Dr. Hueston went through a long list of possible neurological conditions. None seemed to fit the findings or course of the symptoms. Hueston came to the conclusion that he needed a neurological consultation. The nearest neurologist was over fifty miles away, so he began filling out the request for consultation and other forms required by the miners’ insurance.

Hueston was chatting as he wrote. “My wife and I are new to the area. You know she is a veterinarian. She’s having a hard time dealing with the amount of skin disease in her patients. All of the cats and dogs are loaded with ticks and fleas. She didn’t have that problem in her city practice

Liz’s attention became alert. “Yeah, I had that with my cat. But I fixed it.”

“How’d you get it fixed?”

“I just dust her every week.”

Hueston stopped writing and paused. “You dust her. What do you mean ‘dust her’?”

“I just take my rose dust I use in my garden. Dust it on my cat. Then just rub it in.”

Hueston asked, “Rose dust? What’s that?”

 “I don’t know what all’s in it. It kills the insects on the roses and it sure kills ticks and fleas on my cat. My cat is free of ’em.”

Hueston, now in full alert, asked, “Where does the cat sleep?”

Liz smiled and answered, “Why, she sleeps right on my pillow with me.”

Hueston said, “I want you to go home and wash your cat. Don’t use the rose dust anymore, and don’t let the cat in your room at night. Let’s see what happens and maybe you won’t have to go all the way to Lexington.”

Liz came back a week later. Smiling widely, she told Dr. Hueston she had not had any more dry mouth, blurred vision, or slurred speech. Her urination was completely normal. The “disease” had gone away. She even brought a bag of the rose dust with her.

Dr. Hueston smiled back. He read the chemical contents on the rose dust bag and found what he suspected in the contents—organophosphates.

He went on to explain to Liz McWherther how organophosphates are nerve poisons. They cause some segments of the nervous system to fire continuously. The pupils constrict to pinpoint size. Salivation is inhibited. The urinary bladder does not function normally. If the exposure to organophosphates continues or the dose is large, death can occur.

Everyone wondered why the cat did not get sick. We will never know. Liz’s problems were symptoms that she noted and described.

Cats don’t talk.

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A note on the Author: Clifton Meador has been practicing and teaching medicine for more than 50 years and some of the patients he describes in these stories are his own.

Not only is Meador an engaging story-teller (he has been called the “Will Rogers of medicine”) he  has had a lasting impact both as a doctor, and as someone who has thought deeply about how medicine is practiced in the U.S. His well-known satirical writings on the excesses in our the medical system include “The Art and Science of Nondisease, (the New England Journal of Medicine, 1965) andThe Last Well Person,” an essay he published as an “Occasional Note” in NEJM Journal in 1994.

 “The Last Well Person” begins with this anecdote: “A supervising doctor asks a medical resident “What is a well person?” The resident  replies with some confidence: “A well person is a patient who has not been completely worked up.”

Meador then proceeds to tell a tale takes place in the not-too-distant future. The story’s only character is a 53-year-old professor of freshman algebra at a small college in the Midwest. Despite extensive medical evaluation, no doctor had been able to find anything wrong with the teacher. But he is the only remaining person for whom this is true. Doctors from all over the country flock to the Midwest to check him out.

At the time, Meador warned: “if the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick.” (Dr. Norton Hadler would later adopt the title for his book The Last Well Person: How to Stay Well Despite the Health-Care System, 2004)

 HealthBeat readers who have seen the film version of Money-Driven Medicine http://moneydrivenmedicine.org/ (produced by Alex Gibney, directed by Andy Fredericks) may remember Meador as the Nashville doctor who takes them on a tour of his town. Nashville is best known as the nation’s Country Music Capital, and Meador takes readers past “Music Row,” but as he r reveals, Nashville also is the headquarters for a “massive complex of healthcare corporations.”     

Their pristine headquarters are set high on a hill. In most cases, there are no corporate logos, no signs to identify who the companies are. (Perhaps they are trying to avoid surprise visits by Michael Moore.) But as he drives past, Meador identifies them:

“We have three mother corporations here:  HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, and Health Trust, which is a spin-off of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that’s headquartered here in Nashville.” In the background, we hear the song that Alex Gibney, the film’s producer, chose for this scene: “If you’ve got the money, honey, I’ve got the time.”

Over the years, Meador has watched Nashville’s medical industrial complex develop into one of the country’s biggest money-spinners, while, at the same time, health statistics in Tennessee have slid to the bottom of the national rankings

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The Pressure to Diagnose: Meador and Balint on The Physician’s Creed

The doctor who treated the Coal Miner’s Wife in the story above solved the mystery both because he listened to his patient–and because he didn’t rush to diagnose. 

As Dr. Jerome Groopman, author of How Doctors Think, has told us:   “Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what’s wrong.   And too often, we make what’s called an anchoring mistake — we fix on that snap judgment.”

Meador has taken that insight a step further: Sometimes doctors diagnose a “non-existent disease.”

Not long ago, Meador posted a comment on Health Affairs that sums up his doubts diagnosis: “The fact a patient is experiencing ‘symptoms’ does not necessarily mean that he are suffering from a disease. After 50 years in teaching and practice, I have come to see that not every symptom or set of symptoms has a medical diagnosis to fit. What I am sure about is that every symptom has a cause.”

 The symptoms are real. Meador does not assume that because he can’t crack the case, the patient must be a hypochondriac. Something is triggering the pain. It’s just not something that a doctor will find on a list of known maladies. For example, the coal-miner’s wife wasn’t suffering from a rare disease; she was “dusting” her cat. 

“Most patients in primary care have stressors causing their symptoms either from home or work,” Meador adds. “I agree with the old dictum that says ‘what the mind cannot absorb goes to the body.’’

Ultimately, he believes, “the insistence on a diagnosis” –i.e. the pressure to find a disease –“is at the heart of medical excesses and false diagnoses.”

Doctors Must Remain Open, Doubting Their Own Diagnoses

Groopman agrees that false assumptions lead to misdiagnosis: “Usually doctors are right,” he says, “but conservatively about 15 percent of all people are misdiagnosed. Some experts think it’s as high as 20 to 25 percent . . .

“The reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab,” he adds. “Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.”

The initial “snap judgment “could be based on the first thing the patient says,” he points out. “It could be based on something on their chart or in their file that somebody else has concluded in the past. It could be anything.” At that point, a doctor is likely to order tests that he believes will confirm his diagnosis. Often those tests do just that–or at least they seem to, in part because the physician expects that they will.

But Groopman warns, “each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.”

How can a doctor avoid misdiagnosis?

                  Not All Patients Fit On a “Decision Tree”

Groopman believes that when trying to assess complex cases, today’s physicians are too quick to trust “the preset algorithms and practice guidelines” that form so-called “decision trees.” 

 “The trunk of the clinical decision tree is a patient’s major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes,” he explains. “For example, a common symptom like ‘sore throat would begin the algorithm, followed by a series of branches with ‘yes’ or ‘no’ questions about associated symptoms. Is there a fever or not? Are swollen lymph nodes associated with the sore throat? Have other family members suffered from this symptom?

“Similarly, a laboratory test like a throat culture for bacteria would appear farther down the trunk of the tree, with branches based on ‘yes’ or ‘no answers to the results of the culture. Ultimately, following the branches to the end should lead to the correct diagnosis and therapy.”

He is quick to acknowledge that “clinical algorithms can be useful for run-of-the-mill diagnosis, distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact. In such cases — the kinds of cases where we most need a discerning doctor — algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.”

If the doctor attends to the patient in front of him, not just by listening to him, but by observing him–perhaps even laying hands on him– he may realize that the patient just doesn’t fit on the tree.

In the course of his clinical practice, this is just what Clifton Meador discovered.

Symptoms of Unknown Origin

Before writing True Medical Detective Stories, Meador published Symptoms of Unknown Origin: a Medical Odyssey (2005).  

The book describes Meador’s own Odyssey. “For years after graduating from medical school, Dr. Clifton K. Meador assumed that symptoms of the body, when obviously not imaginary, indicate a disease of the body–something to be treated with drugs, surgery, or other traditional means,” his publisher explains.

Experience would teach Meador that he was wrong. “Over several decades, as he saw patients with clear symptoms but no discernible disease, he concluded that his own assumptions about diagnosis were too narrow. In time he came to reject a strict adherence to the prevailing bio-molecular models of disease and its separation of mind and body.”

He studied other theories and approaches–for instance “George Engel’s biopsychosocial model of disease.” (Engel recognized the effect that our social environment has on our body/minds; he believed that physicians treating the body must also take notice of “psycho-social issues.)  

 “Meador also came to recognize Michael Balint’s studies of physicians,” his publisher reports. (Balint coined the term “patient-centered medicine” and stresses the importance of the doctor-patient relationship. In “The Doctor, His Patient and the Illness.” Balint concludes that once a doctor and a patient agreed on a diagnosis, the “non-disease” becomes incurable.) 

As a result, his publisher notes Meador came to recognize “the defense mechanisms that physicians use to cope when encountering their  patients’  distress” –and adjusted his practice accordingly to treat what he called ‘nondisease’.”  He had to “retool” his publisher reports, “learn new and more in-depth interviewing and listening techniques, and undergo what Balint termed a ‘slight but significant change in personality.’”

        Defense Mechanisms: the “Physicians’ Creed”

When a patient visits a doctor complaining of symptoms, he expects the doctor to diagnose what ails him. If he doesn’t, the patient is likely to view the visit a failure.

For his part, the physician presented with a patient in pain quite naturally wants to solve the problem. His medical training has taught him that the resident who names the disease wins the gold star. Thus, both patient and doctor conspire to “insist” on a diagnosis.

If the doctor cannot find a satisfactory answer, or the patient does not respond to treatment for the diagnosed disease, the physician may become testy–and ultimately blame the patient. In Symptoms of Unknown Origin, Meador quotes Michael Balint:

 “every doctor has a set of fairly firm beliefs as to which illnesses are acceptable and which are not; how much pain, suffering, fears and deprivations a patient should tolerate, and when he has a right to ask for help and relief: how much nuisance the patient is allowed to make of himself and to whom, etc., etc.

“These beliefs are hardly ever stated explicitly but are nevertheless very strong. They compel the doctor to do his best to convert all of his patients to accept his own standards and to be well or to get well according to them.”

This, of course, is the opposite of what Dr. Donald Berwick has famously described as “patient-centered” medicine.

Balint then goes on to describe a hypothetical “physician’s creed” based on a conventionally narrow biomolecular model of illness.  The creed reads: “I believe my job as a physician is to find and classify each disease of my patient, prescribe the proper medicine, or recommend the appropriate surgical procedure. The patient’s responsibility is to take the medicine I prescribe and follow my recommendations. I believe that man’s body and mind are separate and that disease occurs either in the mind or in the body. I see no relationship of the mind to the disease of the body.

“Medical disease (‘real,’or  ‘organic’ disease) is caused by a single physicochemical defect such as by invasion of the body by a foreign agent (virus, bacterium or toxin) or from some metabolic derangement  arising within the body. I see no patient who fails to have a medical disease.” (Hat Tip to “The Renaissance Allergist” for posting Balint’s comments on his blog

One wonders how many students graduate from medical school today believing some rough version of this doctrine. At least one reader commenting on Meador’s book suggests that the “Creed” remains part of our medical culture:

“Although the biomolecular model of Dr. Meador’s day has since been supplanted by the biopsychosocial model in academic circles, in actual clinical practice this transition has yet to occur. Instead of searching for root causes, we learn to blame our patients for their refractory illnesses by characterizing them as “problem patients”, “difficult”, or “noncompliant”. Those labels are often true, but they don’t encourage or help us to address the underlying problems. Dr. Meador’s book does.”

Or, as another reader puts it, “Meador not only pulls the rabbit out of the hat, he shows us where the rabbit was hiding.”

As we struggle to reduce that amount of overtreatment in our medical system, I hope that medical educators will begin to warn young doctors against the “insistence” on finding a single organic “defect.” Very often, behind human suffering, a wise physician and compassionate physician will find  multiple causes–biological, psychological and sociological–that cannot be easily separated.

 I recall a post I published on HealthBeat in May of 2011 quoting a doctor who mistook poverty for disease: “I diagnosed ‘abdominal pain’ when the real problem was hunger. . . .  My medical training had not prepared me for this ambush of social circumstance. Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.”  She was able to help her young patient only when she realized that he was going to bed with an empty stomach. 

 

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