Scene III, wherein we move on to more important things

What could be more important than a good old-fashioned flame war? I’ll get to that in a moment, so please stick with me.

The recent imbroglio between some of our doctor bloggers and non-physician scientists got me thinking (so it couldn’t be all bad).

As a quick summary, PhysioProf of the DrugMonkey blog used an incident of a doctor committing battery on a patient as a generalization regarding surgeons, all doctors, and medical education. Many of us who are actually doctors and physician educators took issue with that. PhysioProf apologized, but made it clear that s/he still feels that there is a valid point here, that doctors are bred to be arrogant, etc.

Let’s move on from the fray, and dig through the battlefield relics that may help illustrate larger issues.

In the “old days”, doctors were very much independent operators, and depended on the “wisdom of the greats”, meaning that medical knowledge flowed from the experiences of the best of us, passed to succeeding generations. Evidence-based medicine (EMB) has moderated this significantly, bringing the harsh but beneficial light of science into medical practice. EBM has done much to erode the paternalism inherent in the old system, and as such has done much for medical ethics, albeit peripherally. When my father was training in the 40’s, no one would think of questioning the attending physician—today, we count on it. My residents and students frequently challenge my decisions, bringing evidence to bear. Sometimes they are right, sometimes they are wrong, but the dialog encourages all of us to learn and become better doctors.

It may surprise some of you to learn that medical students receive some education in medical ethics, both formally and informally. Formally, medical students may have courses or lectures devoted to the topic; informally, they learn “applied” medical ethics as they take care of patients. Every case has potential ethical dilemmas, most of which are easily solved, but some seem insurmountable, and most hospitals have ethics committees to help with the difficult cases. In the same way that my residents question my medical decisions, they question the ethical ones. Since most medical-ethical conundrums do not have “correct” answers, it is useful to have at least a passing knowledge of medical ethics to bring to the table.

Medical ethics discussions generally invoke a few central principles: beneficence, non-maleficence, autonomy (to which I would add “paternalism”), and somewhat more recently, justice, dignity, and truthfulness (not to say that those are recently-added values, simply that they were not always an explicit part of the formal discussion). In particularly difficult cases, it helps to jot these down and write in some of the particulars of the case. Exploring ethical issues of cases, evaluating our own effectiveness, discussing patients’ perceptions of doctors—these are things we do every day.

All this is by way of illustrating that, to put it crudely, we aren’t a bunch of friggin’ idiots. When people speak of “doctors” as arrogant, unfeeling, etc., I’m sure there must be valid personal experience behind such assertions, but in the real world, doctors receive explicit instruction in these matters and are encouraged to be reflective.

Time to integrate: arrogance, an accusation frequently leveled at doctors, is a personality problem, but also a potential ethical problem. Too much arrogance can lead a doctor into problems with patient autonomy, and with judging what constitutes “beneficence”, among other things.

There isn’t a good way to measure “arrogance levels” in physicians. Many hospitals conduct surveys and polls to gauge patient satisfaction, including satisfaction with physicians, but this is only so useful. I’m sure there are people who study such things, but information on patients’ perceptions of physicians is not widely available.

So what of arrogance? Arrogance, as most of us are aware, can be a rather unpleasant personality trait. When does confidence become arrogance? I don’t know. What I do know is that it is impossible to practice medicine effectively without a certain level of confidence. An issue at the heart of the paternalism question is the issue of professionalism. Doctors are professionals who have knowledge not available to everyone—notice I did not say “not known by everyone” but “not available to everyone”. Anyone can buy medical texts, but not everyone can attain the knowledge and experience of a doctor, so we as patients are forced to trust our physicians. This gives doctors an awesome responsibility. We must constantly strive to not disappoint or abuse that trust. We must give the best advice available, and we must give the context to understand that advice.

By way of illustration, here is a conversation I’ve had with a patient (actually, with lots of patients):

Me: How are your blood sugars?

Patient: I check them sometimes.

Me: We’ve talked about this before—it’s very important to check them three times a day like we’ve discussed.

Patient: I feel OK.

Me: Look, are you interested in ending up on dialysis? Would you like to have strokes and end up in a nursing home?

Horrified Patient: Wha….?

Me: Because you are doing everything right if those are your goals.

Patient: No one ever told me that…

Me: (knowing that isn’t true, but not wishing to lose an ally) Well, now I’m telling you. We have to work harder to do this. Tell me what makes it hard to do these things and we’ll figure out how to do better.

This conversation, depending on how you heard the voices as you read, can give the impression that I am both arrogant and paternalistic, and perhaps a bit of an ass. But I know my patients, and I know how to communicate with them, and how to judge when I’m losing them in a conversation. Practicing medicine isn’t a matter of saying, “here are your options, now choose.” It is also about persuasion and coercion. That’s “necessary paternalism”. Do I ever get it wrong and become either too paternalistic, or perhaps not paternalistic enough? Yep. But I am explicitly thinking about these things, as are many doctors (how many I haven’t a clue).

So we doctors, as a group, may seem arrogant. That is a hazard in any profession. Changes in medicine over the last 2-3 decades have done much to level the ground between patients and doctors, but there will always be an asymmetry to the relationship. What we as physicians must do is recognize that asymmetry and make sure that when we exploit it, we do so properly, with the interests of the patient foremost.