Wednesday, July 20, 2011

Doctors Behaving Badly

Obviously, there is more to medicine than prescribing this pill for that disease, and then allowing it to work its magic.

Human beings are not lab rats, so the effectiveness of medical procedures has something to do with the physician’s ability to relate to the patient. Studies have shown that when a physician can connect to the patient, by treating him with courtesy, respect, and civility... treatment will be more effective.

And, by the way, a physician who respects his patients sufficiently to apologize for his errors is far less likely to be sued for malpractice.

This is more important when patients are being treated for mental health problems. Therapists have discovered that the most effective treatment for emotional issues is a human connection.

You will not be able to make a human connection with your therapist if he or she is systematically rude and offensive.

If the therapist pretends to be a blank screen,  a disengaged and detached interpreter, he is insulting the patient and thus is not going to be producing therapeutic benefits.

And nothing is more boorish and rude than giving the patient the silent treatment. Classically trained analysts used to be taught to do this; it is rude even if the analyst is perfectly respectable.  

Actually, if the analyst looks to be respectable, the silent treatment is even worse. It’s one thing to be treated rudely by a strange character; his views then represent only his views. But if your analyst represents bourgeois respectability, his views presumably represent the views of the community at large.

So, if you looking for the worst form of boorish behavior, don’t look to the strange psychoanalysts who behaved bizarrely in session. Look to the respectable types who give their patients the silent treatment.

If couch-side manner is most important in psychotherapy, it must be least important in the operating room. If the patient is anesthetized on the operating table, a good beside manner would be, dare I say, superfluous.

Surgery and therapy exist at two extremes of the medical spectrum. Ironically,  in psychoanalytically-oriented therapy the patient is laid out on the couch, in a posture that was supposed, from the time when Freud discovered it, to be a slightly more conscious version of the hypnotic trance.

I find it peculiar that Time Magazine, in printing an article on the importance of physicians’ bedside manners, chooses to highlight the way surgeons behave in the operating room. That is... the one time where they don’t really involve doctor/patient communication.

Obviously, manners matter in the operating room. Courtesy matters, as does politeness. They matter on baseball teams, military  units, and company units, too.

Yet, when we think about beside manners, we are within our rights to see the issue in relation to a scene where a physician is tending to a patient at the patient’s bedside, and where the two individuals can actually interact.

It might be too much to ask, but a little intellectual coherence would go a long way, even in Time Magazine.

If we are talking about doctors behaving badly, the research makes an important point, namely: “... when doctors were more courteous to operating room staff, their patients were more likely to survive and avoid complications than the patients of docs who were O.R. boors.”

Time offers another salient example that also has nothing to do with bedside manners. It involves the way physicians interact with hospital pharmacists and nurses: “In studies of medication orders at hospital pharmacies, the researchers found that 75% of pharmacists and nurses prefer not to confront difficult physicians to ask about potential medication interactions or errors in the prescription.”

Apparently, physicians do not know how to work with others. Time seems to believe that since surgeons are captains of the operating room, they seem especially prone to abuse their power and authority. You remember Lord Acton’s famous phrase: All power corrupts; absolute power corrupts absolutely.

Given that surgeons often do not even know the people who are working with them, they are more likely to be more rude, more insulting, more offensive, and more obnoxious.

It is also fair to say that surgeons are often overwhelmed with the amount of work they have to do and with the cost of making mistakes. Surely, they work under very high stress conditions.

Then again, they might be stressed about the state of modern medicine. The evidence I have is only anecdotal, but I know surgeons who are stressed out by the lower compensation rates that they have been force to accept, the higher malpractice costs, and the generally lower standard of living and social prestige that they have been suffering.

If a surgeon is not only being paid 20% of what he used to earn for performing an operation, and if he is being assisted by a nurse instead of another physician-- because either Medicare or an insurance will not pay for a second physician-- then he is going to be stressed.

Different people have different ways of dealing with stress. Some people meditate; some people exercise; some people listen to Bach; some people blow off steam.

As it happens, the first three are effective ways of lowering your stress. The last one is not.

Yet, letting off steam, letting it all hang out, getting it off your chest, expressing your anger openly (lest it become bottled up and give you cancer)... . all of these represent the therapy culture’s dubious contributions to stress management.

It’s terribly bad advice. If a surgeon in the operating room, in a very high stress situation, decides to follow what has traditionally been the best advice offered by the psychiatric profession, he might well be led to believe that he can deal with his stress by releasing his pent-up emotions, the better to maintain his lowered stress level.

He might even notice an immediate feeling of reduced stress after he blows up at the intern or the nurse.

And yet,  this tactic leads him into a vicious circle. As soon as he becomes aware of how bad he has just made himself look in front of his team, he will become more stressed, and, if he is following the therapy culture program, he will deal with it with more outbursts.


David Foster said...

A couple of decades ago, it was recognized that multiple aircraft accidents had occurred because of bad communications among the crew members, and especially that there were cases where a copilot or other individual was reluctant to bring a situation to the attention of the Captain because of the disparity in authority. IIRC, there was actually a case with a foreign airline (Korean, I think) in which the copilot watched a low-fuel situation getting worse but failed to bring it to the attention of the Captain because "he has such a bad temper." Formal training programs, called Cockpit Resource Management or Crew Resource Management, were established to deal with this problem...I know there have been some attempts to mimic these in the medical field, but it would seem there is much more to be done.

Sam L. said...

My Physics prof once told be that in his experience, If you demonstrate your intelligence to a doc, he'll say things like "The Heart Is Like A Pump." If you act otherwise, the doc uses the most complex language he can.

Some docs think they are gods. Some have learned humility.