Medical professionalism, or WE ARE YOUR GODS, BOW BEFORE US

One of our sciblings, Dr. Signout, is learning the ropes as she struggles (and presumably excels) through her medical residency. As her writing has picked back up, she has brought up some important questions about medical education and medical professionalism. I’m a little further along in my career than she, and I have some thoughts that may flesh out her experiences, and shed some light on the medical profession as a whole.

Her latest posts brought up two particularly important issues, one about how doctors are treated “without the white coat” and the other on what it means to put others’ needs before one’s own. These, it turns out, are connected.

Even when we shed the white coat, we’re still doctors. If we are out to dinner, and we see someone in distress, we respond. If a family member or friend has a problem, they call us up, day or night. Being a doctor is uniquely tied into personal identity. This makes certain situations particularly awkward—being a patient in your own hospital is discomfiting to say the least, and visiting a loved one is often no better.

Both situations are paradoxical—we never really take off the white coat, but at the same time, our role as physician is made secondary to other more immediate roles. It is nearly always the case that taking care of other doctors or their families is a challenge. In extreme cases, many of us have seen doctors reading through charts or writing orders on family members when they really should know better. But most situations are more subtle. A doctor seeing me as a patient may feel like any other patient, or may feel particularly helpless. A doctor taking care of a doctor may feel under special scrutiny. It can be uncomfortable for both, but more important, it can impede good care.

But lets push all that aside for a moment. Dr. Signout described a situation in which a friend was critically ill in her hospital, and she was treated no better than any other visitor.

Issue 1: are we, as doctors, any better than any other visitor? Of course we are. Or aren’t. Or maybe we’re worse. It’s hard to say. Ultimately, the patient’s nurse is often the best judge of what is best for the patient, and the patient’s doctor can place any visiting orders she wishes on the chart. But to be perfectly honest, in a profession where our ethics preclude any major gifts, tips, or monetary professional courtesy, one of the few perqs is to get a little “special goodness”, that is, a little extra help getting through the system. When a nurse shows up at the clinic during a break, there is a greater than 50% chance that she may end up being seen a bit quicker, if the conditions of other patients allow it. If a doctor calls me to get his mom in for an appointment, she isn’t going to wait two weeks. It’s a small thing we can do for each other. It happens. It becomes problematic when the boundaries blur and people expect “special goodness”, or we make decisions that endanger other (sicker) patients. Still, there is something fundamentally unfair about this, and crossing into unethical territory is a real danger. “Special goodness” must be dispensed with care.

Issue 2: whose needs are more important—mine, or my patients’? Both. And neither. We sometimes communicate this poorly to our trainees, as in Dr. Signout’s case:

That afternoon [the same day as her friend was critically ill] I was pulled aside by a superior and told that something I had said had caused a patient’s family member to raise an eyebrow. A few days prior, I had been post-call–awake for 30 hours–and on rounds, I had mumbled, “God, I’m so tired I can barely stand up.” This, he said, had been seen as unprofessional.

Fascinating. Let’s look at the message she took away from this:

I turned to face him and marveled at the strange blur before me. No eyes, no ears, no chin–just a building with a big, flapping mouth for a door and an inconvenient parking structure tacked awkwardly onto the back. Flap, flap, flap went that mouth.

Here is the message the hospital was giving to me: I am expected to maintain firm boundaries, refrain from complaining; and provide to patients’ families exactly what they want, whether it’s reasonable or not. However, I should not expect that when I am the loved one of a patient, I can demand any of the indulgences that families can demand of me–not kindness, not time for my own grief and anger, not a sensation of loss of control. I am a pillar of professionalism at all times, and even when I snap in two, both halves need to stand up straight.

The ethic of “placing the interests of patients above those of the physician” is often misunderstood. It doesn’t require us to ignore our basic needs.* OK, really it does. As residents, we are taught to live without sleep, without good nutritional habits, without satisfying our own emotional needs for hours or days on end. This ethic carries through into the rest of our careers. But should it?

When we talk to patients, they often miss what we think is important, and remember what we think is trivial. Being a good communicator/physician requires a lot of repetition, and attention to subtle cues. My patient may miss the fact that I just told them their blood pressure is high, but may focus on my yelling at someone on the phone in the next room. The message the patient takes away may be opposite of what I intended.

This is all a long-winded way of saying that Dr. S. was completely correct to take offense at her situation, but it was perhaps an unavoidable Catch-22. While patients sometimes like to see that we’re human, they really don’t want to believe it, and we feed that. By admitting weakness, she may have made the patient uncomfortable. But we, as medical educators, are the ones who made her feel weak and unsupported. Perhaps if she had been treated better, her needs attended to just a little, she would have been tired, but not dis-spirited.

Given that it is inappropriate to gain emotional strength from our patients, we must give it to each other. Sometimes this involves some “special goodness”, or sometimes just a recognition that my resident has had a really bad 40 hour stretch and needs a little support.


*It really is intended to guard us from conflicts of interest, that is putting our own financial and other interests ahead of the patient. For example, if I were to buy a CT scanner, and started getting lots of CT scans for mushy reasons, I would be violating this ethical principle. If I cancel my appointments for the day in order to get a little rest, this is pretty much OK.