I
remember when I was a kid on the Southside of Chicago in the ‘60s visiting our
family doctor. He had his own office, a
solo practice, complete with his own nurses and the ever-present smell of
alcohol keeping it clean. His waiting
room looked like a large living room. He
did everything for our family, taking care of three generations of us: delivering my mother and me, doing surgery,
giving us vaccines, and coming out to our home when we were really “sick” with
things like the flu. He was very much a
part of our family. He also was one of
my idols growing up - I wanted to be a doctor just like him.
Those
days are long gone and family docs like that are rare, even in rural parts of
America. Doctors back then did learn the
science of medicine but spent a bulk of their time mentoring one-on-one with
another doctor in his/her practice, learning how to communicate with people,
developing relationship skills, and being involved in their local
community.
Nowadays, medical students will
learn communication skills by reading a book or in simulated labs with actors
playing the role of patients with various illnesses. =When medical students do
get to talk to real patients, it is mostly in a sterile hospital environment
during an illness crisis. Consequently,
it is very hard for those “docs in training” to gain much-needed experience in
developing patient relationships when the primary emotion in the room is fear –
their own and the patients’. The
patients are afraid of what might be wrong with them, as they sit in a
half-naked state with a gown that flaps open in the back. The students are afraid of doing something
wrong or not asking all of the dozens of closed-ended questions that they are
told to ask. Listening skills go to the
wayside in an environment like this.
Yet studies show that 80% of
diagnoses are based on the communication skills involved in getting the right
story, even with all the modern diagnostic equipment and specialists that we
have at our disposal. Extracting the
right story from the patient is the art of medicine that is being lost in our
increasingly technological world.
What
has led us down this path? I think two
main causal factors have (along with many secondary contributors): the massive growth of information and the
industrialization of medicine.
The amount of information
crammed into 4 years of medical school is daunting these days. I had been involved in trying to improve
medical education at a major university for a number of years, mainly by trying
to improve the amount of one-on-one mentoring young medical students would
receive. This type of medical education
is akin to the more humanity-focused training given to the family practitioners
of yore. But there is much resistance in
doing so. Other priorities and the
values placed on other types of information-laden experiences get in the way.
It seems there just is not any room left in their curriculum for “higher touch”
experiences like this.
Perhaps even more concerning,
however, is the industrialization of medicine – exemplified by the focus on
health business models which have more control over decisions of care than the
doctors themselves do. This factor
threatens the very fabric of our profession, both for medical students and
those of us actively practicing. As a
medical professional committed to serving patients, the industrialization of
medicine quickly gets personal. You are
frequently told by health insurers that you cannot prescribe this medication
nor get that test. System administrators
will only let you have 10-15 minutes per patient and get upset when you run
late. Additionally, it can feel like a
bevy of lawyers are on the look-out for any way to file suit and bring you to
court…even for conditions that are an expression of the forces of nature (like
birth defects) as opposed to actual human error.
As a consequence, much more time is
taken away from direct patient relationships in order for doctors to
defensively chart, fill out forms, and squeeze more people into a packed
day. Time and money are the value now,
not the relationship with the patient.
Nowhere
does this lost art of communication show up more than when patients get
seriously ill, especially when they may be in their last year of life. A number of studies have evaluated what is
important to Americans when they are dying along with the reality of how they
die. Some very concerning gaps
exist. Patients are focused on their
fears, on their future, on quality of their and their family’s life. Yet most doctors focus on using more and more
intensive treatments to fix things, even in hopeless situations. If doctors spent more time pulling up a chair
and talking about values and wishes, however, these gaps would disappear.
We as physicians need to step up,
learn how and when to put the science on the side, and instead to focus on the
human side of what it is to be a patient - no matter what the cost. We must get
to know the person and family in front of us and to help figure out how best to
travel the tough roads with them.
It can be done. Yes, it takes time,
it takes courage, but the results will always outshine all the technology we
can deliver.
Almost
all college students exploring the path to become a physician start out like I
did – with a very altruistic focus on helping people, being their confidante,
and serving as their lifelong family doctor.
Sadly, somewhere along the journey for most practitioners, this gets
lost. I encourage all young people
thinking of this career to spend as much time learning about the humanities –
the arts, theatre, social sciences, religion, volunteer activities – anything
that will help you focus on relating to others.
And keep this passion close to your heart throughout your future career.
It will not only make you a better
physician, but it will also help you to avoid burn out in an increasingly tough
business.
Dr. Michael Marschke graduated from the University of Notre Dame with the class of 1982. He currently works as the Director of Hospice and Palliative Medicine with Northshore University HealthSystems. Dr. Marschke can be reached at mmarschke@ameritech.net.
