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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Diversity in the Physician Workforce is Essential; What Will Happen If the Supreme Court Overturns Affirmative Action?

In October, the Supreme Court heard Fisher v. University of Texas at Austin. You may have read about the case: the plaintiff, Abigail Fisher, applied for undergraduate admission to the University of Texas at Austin but was turned down. If she had graduated in the top 10% of her high school class, she would automatically have been admitted—but she did not.

When admitting students, the University of Texas first accepts all in-state students who place in the top 10%. This policy is race-neutral and fills about 80% of all spaces. The remaining seats are filled according to an evaluation process which considers six factors. Race is one of them.

Fisher is white and she claims that the explicit use of race as a factor in admission to the university violates the Equal Protection Clause of the 14th Amendment of the Constitution.

Within the next few months, the Supreme Court will announce its decision

            What the Case Means for Medical Schools—and Patients

Last week, the New England Journal of Medicine published an editorial warning that the decision will “chart the future of affirmative action in American higher education . . . including admission of students to our nation’s medical schools.”

The editorial’s authors underline the need for a physician workforce that is ethnically and racially diverse:

“To provide good care, physicians must understand the communities and cultures in which they work. An important way to ensure that physicians understand the lives of their patients and to reduce health disparities is to promote diversity.”

I agree, and would add a second argument: if Fisher wins, the Court’s decision will leave millions of Americans without the medical care they desperately need because they live in a place where few physicians want to practice.

In this two-part post, I will be asking four questions:

1) How do we attract more physicians to underserved communities?  Could we entice them with higher salaries?  (Probably not.  A doctor who doesn’t want to raise his kids in rural Alabama won’t set up shop there even if you double his income.)

2) Should we encourage medical schools to practice class-based rather than race-based affirmative action?  This is, at best, a partial solution. A large percentage of low-income Americans are white. If they were admitted to medical school, those who grew up in rural areas might well decide to practice in similar communities where physicians are needed.. But this would not solve a larger problem—the shortage of  Latino, African-American and Native-American primary care doctors available to work both in inner cities and in the many rural areas where minorities are rapidly becoming the majority.

Multiple studies show that outcomes, communication, and compliance improve when a patient is able to see a physician from his own racial or ethnic group. This is not to say that committed white physicians cannot overcome cultural barriers and build strong patient relationships in these communities. But  many fewer choose to work, and raise their families, in remote rural areas that are primarily Latino, Native American, Mexican-American, or African American.

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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.

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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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