MEDICAL IDEALISM AND REALITIES ARE AT ODDS

BY

PHILIP R. ALPER, M.D.

The intern who called me from Los Angeles to report on a relative’s progress in the hospital brought tears to my eyes because he was so bright, deft, understanding – and kind. In addition, he had been up almost the entire night before.

The young medical students who come to my office for preceptorship are the same way. They spend their summers in inner cities, emergency rooms, and medical outposts abroad, hoping to make a difference to the disadvantaged and the desperate. They are quite modest, but they have big dreams.

Weren’t we all like that at one time? And if that’s the way we were, what happened to us?

The difference between doctors in training and in practice is visible and audible all around us. I suppose we can call it the passage from youthful idealism to adult realism. But that’s just too pat. It’s a platitude that conceals more than it explains. Why, for example, did one study show women OB-GYN residents to have measurably more compassion than their male colleagues at the outset of their residencies, but no difference by the time they complete their training? Are the changes in all of us a process of maturation? Is it seeing things as they are rather than as we hope them to be? The effect of wider responsibilities? Or is it just getting worn down and becoming cynical?

The voice of physicians has grown strident. We gripe. We complain bitterly. We reach new highs of self-righteousness when commenting on insurers, government, the drug industry, and even patients. Docs have always done some of this. In fact, we recognize a MASH-like mentality as a way to vent frustrations and build morale. But as it was in the TV program, MASH, the mind-set was once good humored. Now, it isn’t. If this sounds overblown, say nothing and listen carefully the next time you are in the surgical lounge or the doctors’ lunchroom.

There’s a lot we overlook that, perhaps, we shouldn’t: Such things as the grossly inflated retail charges of the hospital and their impact on the uninsured. We’ve known about them for years, but said nothing. It’s also true in laboratories and pharmacies. But it’s likely to be true in our own offices too. The distorted economics of managed care let some patients get too much for their money, while we sock it to others while pretending not to know what’s happening. In fact, the plight of the poor, the uninsured, and the underinsured is something we’d prefer not to think about.

Some people believe doctors are uncaring or just in it for the money. They have lots of anecdotes plus a literary tradition from Shakespeare to Shaw to support their point of view. But haven’t we ourselves all seen (if not participated in) instances of debatable testing or surgery? And who hasn’t regretted how we spoke to a patient at some time? I know I have, and it was a patient who, long ago, was brave enough to make me confront my own behavior. He had an illness I couldn’t do much about, and I didn’t know how to deal with his feelings – or my own. So I said too little and hurried through the visits, convincing him that I didn’t care and making him wonder about my real motivation.

It is easy to rely excessively on our expertise to condescend to or even intimidate patients. We can readily take out our own frustrations on them by too literally doing what’s required of us, regardless of the impact of how we do it. I won’t forget the expression of horror on the face of a patient whose “informed consent” obliged him to absorb a mechanically delivered list of everything that could possibly go wrong during a contemplated operation and who then was coldly asked if there were any questions. Patients want to know that we care because it’s hard to trust us otherwise.

Yet it still isn’t that simple. I’ve put enough years into medicine to realize what paradoxical creatures we doctors are. A very tough-minded physician also takes care of lepers. The doctor who wonders what motivates colleagues to spend time teaching medical students contributes unpaid time in other ways without question. Those who volunteer at Samaritan House aren’t always the ones you’d expect to see there. So I’m convinced that what brought us into medicine is more likely to be partially submerged than to have entirely disappeared. That hard crust may conceal “the rest of the story.”

You may wonder what provoked this uncharacteristic recitation. It was my attendance at the World Health Care Congress in Washington, D.C., in January. I was probably one of the very few of the 800 attendees who came at his own expense. It was a stellar event. There were 45-minute in-person addresses by Bill Frist, Hillary Clinton, Tommy Thompson and even Milton Friedman, who was connected remotely by interactive satellite. CEOs, CFOs, and CIOs of dozens of health care corporations mingled and broke into small groups for presentations and discussions. In addition to the political and economic types, the medical directors of many health plans were also invited, something that we were told is highly unusual in such high-level gatherings. Lest it all go unnoticed, the Wall Street Journal acted as a sponsor of the meeting and furnished members of its editorial board who acted as both hosts and reporters.

I relate this to explain who was empowered in this symposium that was designed to facilitate the reshaping of medicine. Clinical guidelines, best practices, error prevention, pay for performance, and value for the dollars expended dominated the discussions. By the third day it became apparent that the perspective of the practicing physician was considered superfluous. Physicians had been studied and were “known.” That was enough to cover the subject. My comment that I did not hear a job described that I would want to take was greeted with surprise and bemusement.

To health policy “players,” doctors appear to resemble a herd of cattle, to be maneuvered, manipulated, and molded. The same powerful corporations that have their own crack Human Resources departments approach physicians as if we are inhuman resources. Bizarre as it sounds, the very people who dehumanize us desire humanity from us.

Doctors aren’t saints. We can’t legitimately blame all our shortcomings on others. No doubt we are also products of our times, influenced by their impermanence, impersonality, and selfishness. Still, we’re not ready to walk away from our patients despite the increasing stresses of practice. It helps that the spark that brought us into medicine continues to warm us from within, even if only a little.

Physicians will learn to incorporate systems improvements and new technology that makes the care we offer more fail-safe and effective. But at the same time, we need a health system that we can trust – just as patients need doctors they can trust.

Everyone gains by nurturing our highest aspirations.

Dr. Alper practices internal medicine and endocrinology in Burlingame. He is medical director of First DataBank Corporation, clinical professor of medicine at UCSF, and is currently the Robert Wesson Fellow in Scientific Philosophy and Public Policy at Stanford’s Hoover Institution.

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