Monday, October 18, 2010

Guest post: The "art " of medicine and getting along with others

There is a reason why people often say “the art of medicine.”  It’s not just the fact that so much of what we do is based on culture and habit rather than science, but also the fact that there is a lot of finesse when it comes to relationships as a doctor.  Oh sure, we know all about patient-doctor relationships and its importance.  There are a lot of studies about it, and most medical schools spend time teaching students how to break bad news and so on.  But what about doctor-doctor relationships?  In the years since leaving residency, I feel like I have left a bubble and been deposited face-first onto a cold hard sidewalk, and have had to learn to pick myself up, dust off the grime and scrapes and keep walking.  I’ve had to learn the hard way how to get along with my colleagues.

I trained at a major academic institution, where residents would impress attendings and each other with detailed discussions about scientific studies and their merits and flaws.  Over a few years, we all become indoctrinated with the importance of evidence based medicine and more than that, the fact that it was the gold standard of practicing medicine.  There’s a sense that practicing according to evidence is the RIGHT way, and everything else is morally reprehensible.

Fast forward then to my first job out of residency.  I was in a small rural community in a group practice with a nurse practitioner whose husband was her supervising physician.  After a few months of working there, I started becoming really incensed at some of the practices she had, which to me, were questionable in some instances, and in others, outright harmful.  They were not supported by any kind of scientific evidence, and in some cases, even actively discouraged by the evidence.  I printed out guidelines and papers for this nurse practitioner to review, and in return, she gave me a book written by a layman which supported her practices.  Feeling helpless and outraged, I vented to other staff members and was ultimately confronted by her husband, who called me rigid and inflexible for not being able to accept that there were different ways to practice medicine.  They threatened to fire me, and “demoted” me to a separate office location in another part of the medical building.

 I did apologize to the nurse practitioner just to make peace, but have always maintained that her practices are wrong and detrimental to patients.  I have even contemplated reporting her to the board of nursing and him to the medical board, but have been afraid of repercussions (which is a separate discussion in and of itself).  I established my own patient base and kept my practice separate from hers.  With that separation, I was able to regain a sense of sanity.

After a period of time, I was finally able to move to a new job.  In this new job, I work with a couple of physicians who do some things that are not evidence based, although it’s nowhere to the degree that the prior nurse practitioner does.  I had a run in with one of the physicians who got very upset when we had a disagreement over a patient management issue.  Not wanting a repeat performance from my former job, I apologized to him for any hurt feelings, reiterated that we should have the freedom to practice the way we want, and stated that I wanted to have a separation in our patient population.  He was pacified, and the relationship was repaired.

At the end of the day, I realize that there really is an “art” to mastering relationships.  At the heart of being a physician is this fundamental conflict.  On one hand, we are supposed to tell patients what to do, because quitting smoking is the right thing to do, getting a flu shot is the right thing to do, going for the stress test is the right thing to do.  On the other hand, we are supposed to maintain an encouraging and positive relationship with patients when they don’t follow our recommendations, and we are supposed to respect their choices.  It can be hard to let go of the sense of what’s right and overlook that in treatment of the patient.

In the same way, when it’s been drummed into your head that practicing evidence based medicine is the right thing to do, it can be hard to accept other physicians disregarding that tenet.  It’s like what a young woman physician said to me about another physician, “I hate to tell him that he’s wrong, but… well, he is!”

Regardless of our position on evidence based medicine, we still need to be able to work together and get along.  We need to be able to depend on each other for backup and allow for differences in practice styles without getting too upset about other doctors not practicing according to guidelines or evidence.  After all, we’re not perfect ourselves and have to constantly strive to improve our own knowledge and habits.   

 Have you had conflicts with your colleagues about patient management issues?  How do you resolve it?  Do you think being a woman or being young has any impact on this?

- Kelly 

10 comments:

  1. It's never a good thing to be the new person in town who comes in and tries to tell everyone else what to do.... At the same time, it scares me that some people who clearly don't know what they're doing are practicing medicine. Glad you found your balance

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  2. My "mentor" at my academic institution frequently does things without the evidence. He uses anecdotes as guides which is infuriating and also forgets when things go wrong. That said he discusses his choices with his patients and they love the"individualized" care. We have agreed to disagree about his methods. Your status as a young woman only matters if you cannot discuss the issues calmly with your colleague. Then they will stigmatize your complaints...Be rational in your discussion and try not to get personal and you should be okay.

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  3. Just wondering how long you've been in clinical practice? I understand and appreciate evidence-based medicine, but I also know that with so many research studies supported by industry and/or eventually disproven, I like to query other physicians with more clinical experience at times.

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  4. As a pathologist, I learned some of the details I agonized over in training really don't mean much to the clinician and how they end up treating their patient. I agree with above - while evidence-based medicine is very important - you can easily go overboard and drive yourself batty trying to follow the latest trends. I like to read journals when I have time but prefer to let the important findings trickle down into practice - if they are important enough they invariably show up at the national meetings, in CME courses, or the clinicians - surgeons, oncologists, specialists - will bring them to our attention (or we theirs).

    When we have a difference of opinion over a case - we usually just get a third or fourth pair of eyes. If we can't agree within our group, which doesn't happen too often - we will send it out for expert consultation. Luckily I have a very democratic group and we all respect each other's opinions and are adult enough to disagree gracefully, in my experience so far.

    I think when you are first starting out, young or not, gender aside - it is appropriate to maintain a level of humbleness and deference without compromising your opinions and knowledge - there is a lot to be said for experience.

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  5. Would be really interested in knowing the treatment issues that doctors are currently divided on mainly by when they were trained. 30 years ago hot topics were: infant circumcision, mastectomy vs lumpectomy, appropriate length of hospital stay for absolutely everything, inpatient vs outpatient surgery, giving women estrogen for anything, abortion after the 20th week of pregnancy, appropriate use of antibiotics, etc.

    Evidence-based medicine differs based on what one is measuring. Old school doctors considered having to readmit a patient a sign that they had made an error in judgement. Modern doctors measure themselves more on the speed at which a patient can pass through the system.

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  6. Evidence based medicine is a statistical phenomenon. So, out of 100 patients, XX% will do best if treatment XYZ is given instead of treatment ABC. These are data that we all need to know. But, your individual patient is NOT guaranteed to be the statistical norm. So you need to treat, observe, look at mitigating factors, look at confounding factors, look at other concurrent disease. Otherwise we wouldn't need physicians. Any high school grad could apply the evidence based treatment.
    So - listen patiently, ask why your colleagues are straying from the computer protocol, have a sense of humor about stuff. I don't think young and female is the issue - young probably is.
    It takes a while to get used to the personalities in a community, defend your own principles without starting WWIII.
    The NP at your first practice is another issue - maybe deserves reporting - but as noted, this is a whole different discussion.

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  7. I tend to follow more guidelines rather than a knee-jerk reaction to the latest study.

    I think over the past few years the main thing is that I have become comfortable knowing what I'm comfortable with. I discuss the guidelines/evidence, and then give patients options.

    In terms of getting along with other physicians, I generally just try to leave them alone, as long as they leave me alone. If it's an error that I've made, I certainly welcome the instruction and feedback. I'm not above learning, because I certainly do not know a lot.

    Yesterday I talked with a patient who refused the flu shot and said that his daughter's (who has lupus) doctor told him not to get the flu shot because if he got it he couldn't be around her. I couldn't not say something about that. I told the patient that was simply not true, and maybe the other doctor meant the flu mist.

    There are some things we still know very little about, and of course guidelines and recommendations change over time, but if we don't at least try to follow the science and evidence we have currently, then we really have very little basis for our practices.

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  8. One of the truisms I took away from my neurosurgical residency is, "There are 10 ways to skin any cat." This is true both of patient management and of technical skills in the OR.

    As you gain experience, you realize that within basic boundaries, there are usually several paths one can take to arrive at a good outcome and "standard of care." Spine surgery is a good example; the same patient can be potentially treated with an anterior, lateral, or posterior surgical approach, and the outcome of all three approaches will be successful. Which you choose depends on a number of factors, including your personal technical capabilities. There is more than one "right" answer.

    Realize, too, that you may or may not know all the details about the situation you are judging. When reviewing another physician's treatment of his or her patient in hindsight, it is easy to miss something critical that would influence the decision making process. And remember, you didn't examine the patient at the time; they did.

    It distresses me to see how poorly we physicians often treat each other. Med school does not teach us how to communicate tactfully with our peers, most of whom have sensitive egos.

    What I dislike the most is when one physician tells a patient something derogatory about another physician, usually in the context of a second opinion. "Dr. X should have recognized that infection immediately!" or "Dr. Y should never have fused your spine!" This sort of unprofessional behavior incites lawsuits and discord among colleagues. I would strongly caution you to resist the (sometimes strong) temptation to do this.

    If you really think someone is committing malpractice or has made a genuine mistake, then certainly you should address the matter. Either talk to the person directly, face to face, in a tactful manner, or speak to the person's partner or supervisor and let that person handle it.

    Do understand, though, that no one is perfect, and try not to come across as an arrogant know-it-all. That won't accomplish anything positive. You might consider working with an appropriate committee at your hospital system to help improve compliance with standard of care instead of bouncing from one individual confrontation to another.

    I don't think being female has anything to do with this issue; it is all about maturity, tact, and professionalism.

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  9. http://healthland.time.com/2010/10/20/a-researchers-claim-90-of-medical-research-is-wrong/?hpt=T2

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