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.

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A Doctor Confides, “My Primary Doc is a Nurse”

Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant”  who has been trained to deliver primary care.   He said it casually, dropping the fact into a long conversation.

Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program.  One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s  Medical  Director for Practice and Leadership. 

I’ll be writing more about Group Health Cooperative in a few days.

 In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians.  NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.     

By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.  

PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services.  They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been  paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.  

Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently.  In 33 states regulations vary. As this map  reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.

It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.                                               

                                              Why Physicians Object

Today, 14 states are debating whether NPs should be allowed to practice on their own.  Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner  attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.) 

Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse.  But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.   

Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath “  Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein.   Hoven insists that doctors are “not threatened” by NPs.  “At the end of the day what they want to do is deliver the best healthcare possible.”  

Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument.  As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.”  A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”

At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”                                    

When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:

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Health Wonk Review Posts Investigate

Nursing Homes, Nurse-Practitioners Developing More  Expertise, Efforts to Block Exchanges, How Patients Respond to Evidence that Some Tests are Unnecessary, and Whether Obamacare “Screws” Young Americans  . . . 

This  time around Peggy Salvatore hosts a Valentine’s Day Edition of  Health Wonk Review –over at Healthcare Talent Transformation . Her round-up of some of the best of recent HealthCare posts includes:

–  A piece on Health Affairs Blog by David Rothman investigating how Americans respond to “evidence that certain medical tests and screenings might be unnecessary, harmful, and not worth the money.”  How do they react to research showing that some drugs are harmful? To find out, you’ll have to read the post.  (You will find the link to this post, and all of the posts discussed below, here )

–  Good news from Louise at Colorado Health Insurance Insider:  A bill that would have repealed the 2011 law that created Colorado’s health insurance exchange/ marketplace, died in committee in a 9-2 vote. “Republicans and Democrats on the Committee on the committee rejected his portrayal of the Exchange– which has already made a lot of progress towards an opening date this fall.”

Louise adds: “Given the progress that Colorado has made over the past two years in creating the state’s marketplace and implementing various other healthcare reforms (both state-based, like maternity coverage and gender-neutral premiums, and ACA-related, including the recent push to expand Medicaid), I would say that Colorado is on track to greatly improve its overall healthcare outcomes.

She also includes a useful map showing the states that have defaulted on setting up Exchanges. As she notes “this doesn’t mean they will get a pass on Obamacare.”  By law, the federal government will set up Exchanges for them.

–  A post by Disease Management Care Blog’s Dr. Jaan Sidorov pointing out that non-physician professionals and lay-persons are managing to achieve a remarkable degree of medical expertise. This is, as Peggy notes, a controversial subject.

– A report that asks “do non-profit nursing homes really provide better care than their for-profit counterparts”?   Over at Healthcare Economist Jason Shafrin analyzes a study that suggests the answer is  “Yes.”   How do they arrive at that conclusion? Again, you’ll  have to read the post.

– A post that takes on “a recent infamous article on Buzzhead ”  claiming  that Obamacare “screws” young Americans.  Over at California Access Health’s Anthony Wright observes:  “there are some obvious and non-obvious reasons why Obamacare is a boon to young adults. “ The non-obvious reasons are worth thinking about.

These are just a few of the treats in this Valentine’s Day Edition.  I recommend that you read the entire Review here.

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