Wednesday, November 10, 2004

The Ideal Doctor

Found this great NY Times article by way of Medrants.

In my idealistic zeal (okay, what little I have left), my first thought after reading this tale of two interns was that I would rather be like the caring but overworked intern than the efficient but emotionally detached one. In fact, that has been my practice style for the past few years, with the typical results: my self-respect intact but my life an eternal Sisyphean struggle.

As I thought about this more, I realized that these are not the only two choices. Couldn't it be possible to take the best from both practice styles and meld them into one? An efficient, unoverworked, caring and careful doctor who still has time for family, friends, patients, self and sleep? Who not only feels valued and respected, but is also able to generate a reasonable income that is sufficient to pay off school loans, raise a family and live comfortably too? A good doctor who is also a happy doctor? Am I dreaming?

And then I got to thinking, what would be an ideal doctor anyways? It depends on who you ask.

Patients want a doctor who listens, is compassionate, and treats them with respect. Some people have specific criteria or a checklists of things they want to see in an ideal doctor. But many of these things, such as having a courteous staff, or not being rushed because of an overbooked, may be out of a doctor's control. So when people say they want an ideal doctor, they really mean an ideal health care system.

And even though people want a patient and caring doctor, they also expect a doctor to be knowledgeable and clinically competent. Makes sense. Various medical organizations expect an ideal doctor to meet certain endpoints as a surrogate for knowledge and competency.

Many people's ideal doctor is someone like Marcus Welby, M.D. But you know what? Robert Young, the actor who identified closely with the role he played, suffered from depression and had an alcohol problem. If that is what happens to a fictional ideal doctor, imagine how hard it must be to be a real one.

Other television shows have inspired others as to what an ideal doctor should be like. When the British Medical Journal was conducting a survey of the best doctors of all time, real or not, Medpundit wrote:
My vote would be for Dr. McCoy. Despite living in a high-tech world where diagnoses could be made with the pass of a scanner, he never lost sight of the essential requirement for a good doctor: keeping the humanity of his patients at the forefront. He treated enemies and crew members with the same dignity and respect and competence. He was a hands-on doctor, and compassionate. Unlike later Star Trek doctors who spent more time beside their computers than at the sides of their patients, he was always at the bedside, keeping an eye on his critically ill patients. In many an episode he pulled all-nighters to come up with a cure for the latest alien malady to strike the crew. He never hestitated to stand up to his captain if his orders were contrary to his medical ethics. And, I suspect, he was the inspiration of many a child from my generation to go into medicine. (Although you won't find it admitted on any medical school application essays.)

And what about doctors themselves? Most doctors and doctors-to-be recognize the importance of emotional and financial self-preservation.

Patch Adams, MD had this to say about what he values as a physician:
My God, its friendship. Remember, I make my patients my friends. I can't distinguish between them. I don't want a patient that isn't my friend. I want to be intimate with every person that dares be intimate with me. I'm very confused about my boundaries. I literally want to fall in love with every person I'm with. I want that kind of relationship because I love friendship. It's just such a magnificent creation.

And I am curious about people. It doesn't matter where people come from for me. I just want to be with people and enjoy it. The magic of being a physician is that they will let you into their lives. If they perceive you care, they will let you into their lives in ways you cannot dream. People spend their lifetime with a friend trying to get what I can get on the first encounter with a patient. It's pretty breathtaking.

Okay, I'm not going to be best friends with all of my patients, but he's got a point. It's not about being an ideal doctor, isolated in a vacuum. Doctors can only be doctors if there are patients. So it's the relationship that we want to be ideal. All doctors have patients who love them and others who hate them. It's about the right personality match.

It's not about being a perfect doctor, because no one can be perfect. Personally, I think malpractice lawyers (intentionally or unintentionally) continue to foster the myth of a perfect doctor so that they can continue to blame doctors when they prove to be only human.

Patch Adams again:
Also, malpractice is wrong. Malpractice insurance set up an adversarial relationship with your patients. You get afraid if the patient is your adversary. The doctor says, "God, I made house calls, but then my hunch said don't get an X-ray, so I didn't get an X-ray, and they sued me to the wall". We do not carry malpractice insurance. We will not practice in fear and mistrust. In addition, the whole malpractice thing inadvertently reinforces the doctor-as-God concept. If we can't make mistakes, we must be perfect. It also implies that the doctor is responsible for the cure and the patient is the passive recipient of it.

Perfect is the enemy of good. As long as we expect perfection, nothing will ever be good enough. As long as people continue to die or have imperfect outcomes or are unhappy because they feel disrespected, there will be malpractice lawsuits. Which result in higher judgements because of injury inflation. Which means higher malpractice insurance costs. Which means doctors have to see more patients to pay for their premiums, and have to order more tests to protect themselves. Which means higher health care costs for everyone. Which means people expect even more for their hard earned money. Like perfection. Which keeps the cycle going.

For me, I think being an ideal doctor is about being trying to be a decent human being, treating trying to treat others as you would like to be treated, and balancing these with accepting that I can't do everything for everybody and that it's okay to say, "No". All while sharing an experience called life together. Let's see if it works.