Education and Compassion: Week Two

                  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.