Robert A. Raschke, MD
Banner Good Samaritan Medical Center
Editor's note: This is the first of a multi-part series on professionalism. The remaining parts will be posted over the next few weeks.
An important event in my career occurred about 20 years ago, late on a Friday afternoon. I was scheduled on call in the ICU for the entire 72-hour weekend, and even though I was just getting started, I was already tired and in a lousy mood. At 5 PM, I got a consult to see a patient in the neuro ICU. He was a 34-year-old man who had attempted suicide by drinking ethylene glycol antifreeze after an argument with his girlfriend. He had initially stabilized from a medical standpoint, but then developed delayed-onset cerebral edema. The team that was taking care of him had unsuccessfully pursued all treatment options. After 8 days of effort, he remained in a deep coma, near brain death. Now, with nothing left to try, and no hope left for a good outcome, they were dumping responsibility onto me just in time for the weekend.
I considered this unhappily as I began to page through his thick chart, trying to suppress my frustration so that I could concentrate, but I was interrupted by the patient's nurse – Terry - before I could get very far. She told me that the patient's mom had just stormed into the unit, and was demanding to talk with her son’s doctor - which as of the last 10 minutes was now me. She warned me that the patient’s mother was inpatient, accusatory and totally unrealistic about her son's prognosis, but despite all this, Terry acted somewhat relieved that I was there. The impression that she was somehow happy about the situation made me even more angry than I already was.
I had had enough. I really gave Terry an earful– outlining all my suspicions about the bad motivations of the referring team and concluding with my refusal to do their dirty work. Somehow, in my self-centeredness, I expected her to empathize with me. But she didn't. Instead, she appeared to be somewhat shocked and deflated. She listened silently to my rant, then turned and walked away without saying anything.
It took me a few minutes to realize that she had a higher opinion of me than I had of myself. She had thought I was a good doctor– strong enough to shoulder a tough situation– compassionate and empathic for a bereaved mother - ready to take on this challenge and make a bad situation a little better. I had proved her wrong.
I always thought of myself as a good doctor, but I realized then that I really wasn't all that good. I composed myself and tried to reset my thinking. I introduced myself to the patient’s mother briefly after explaining that I hadn't had time to review all the records– later, we would sit down and really talk. She actually wasn’t as unreasonable as I imagined she might be. It turned out I did have an important job to do in this case– to help a grieving mother come to terms with the death of her beloved son. The next day I apologized to Terry– this turned out to be a good long-term investment, since we continue to work together to this day.
This was an experience that got me thinking about how I could try to become a better doctor. Not by studying in order to get smarter, but by having the proper goals and attitude– the things this series is about. Recounting this story also gives me the opportunity to admit that I claim no special personal legitimacy to write a series for SWJPCC on professionalism. I am pretty lazy at times. I have a temper when I’m under pressure. I can sometimes be hurtful to nurses and residents. There are even a few people who would consider it the height of hypocrisy for me to come off like I know anything about being good. During the week in which I first began writing this section, I did a bunch of very unprofessional things– things I was ashamed of them even as I was proceeding forward with them:
- I got a page about a patient that was deteriorating just as I sat down to a very nice lunch. The patient was a young, otherwise– healthy alcoholic. I decided to relax and finish my lunch before heading up to see him. By time I finished dessert, he had deteriorated and was extremely unstable.
- I had misgivings about a patient’s DNR status. I thought the family might rescind the DNR order if they fully understood the clinical situation. But I didn’t want them to rescind DNR status, so I purposely avoided talking to them.
- I missed the essential (and not obscure) physical finding of abdominal pain in a patient with septic shock on steroids– a clinical mistake that I’ve repeatedly lectured others about during Mortality and Morbidity conference. This error delayed diagnosis of a life-threatening bowel perforation.
- I declined a personal invitation to attend the memorial service of a patient that I felt very close to– who had in fact asked me for a hug the last time I had seen her before she died. Instead, I sat at home and watched TV.
So no, I am not an expert at professionalism. But I do care about it. So I am not going to write about the doctor I am, but about the doctor I want to be. Please look at this series in that spirit and do not allow my personal shortcomings to undermine our consideration of this topic.
Why discuss professionalism in medicine? I've considered the possibility that the age of professionalism is over– that talking about it is like trying to get your kids interested in playing the board-game Monopoly. Technology is the thing nowadays. It’s incredibly satisfying to help save a patient’s life with ECMO in the ICU. Yet some technological advances increasingly distance us from our patients.
I have heard that when Laennec invented the stethoscope in 1816, there was widespread concern about the negative effect it might have on the doctor-patient relationship. Prior to the invention of the stethoscope, doctors placed their ear directly upon the patient's chest to listen to the heart and lungs. At this point in history, the stethoscope actually came between the doctor and patient– a barrier to the intimacy of the physical examination.
In a modern ICU, all patients are under "standard precautions" for infectious disease control– this means doctors and nurses are supposed to wear gloves when we shake their hand. Other infection control precautions require that masks, eye-shields and gowns be worn inside patient rooms. When we employ a proning bed, the patient is totally cocooned– it’s is difficult to even see a patient inside a prone bed, much less touch them.
Telemedicine is increasingly incorporated into patient care– this allows a physician anywhere in the world to take care of patients in our hospital remotely, utilizing video cameras. Mobile devices– almost like robots– with a face display video screen for a head, can be wheeled into a patient’s room to facilitate electronic interactions between doctors and patients.
The advent of the hospitalist has all but destroyed the traditional continuity of the doctor patient relationship. Patients who are sick enough to land in the hospital are rarely seen by their family doctor. Within the hospital, many doctors (including myself) work shifts– taking care of individual patients only within the time slots of their work schedule. Technically, my responsibility for my patients ends at "quitting time”.
More physicians are employed by healthcare systems than ever before. The choices that patients and doctors once made together are thereby increasingly influenced by non-physician administrators. Politicians have increasingly attempted to create financial incentives for doctors to behave as they think we should behave. The very semantics of related constructs such as the “physician report card” diminishes us as a profession, turning us back to a time before we could be trusted to know and do what was best for our patients.
I think it's fair to say that the risk that might lose our professionalism, our humanism, has never been greater than it is at this point in the history of medicine. So there has probably never been a better time to reconsider professionalism as an essential part of being a doctor.
Many of us were taught in medical school about how to “act professional” – maintaining a detached demeanor, not allowing yourself to get emotionally-involved, appearing confident in all situations, etc. That’s not the kind of professionalism I’m going to talk about. Sir William Osler once said “the secret to the care of the patient is in caring for the patient” I think that’s a much better place to start our consideration of professionalism.
In the next installment we will consider the Oath of Maimonides and how it applies to the practice of medicine in a modern ICU:
"The eternal providence has appointed me to watch over the life and health of Thy creatures.
May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.
Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."