I attended medical school from 1996 to 2000. At that time HMOs were on the rise, Google was being born and a strong emphasis was placed on patient autonomy. Although no one recognized it at the time, we would become the next generation of physicians. We had already been advised by old wise doctors to choose another profession. That we would never make any money. That MDs were no longer respected by society, and everyone (insurance companies, litigators) were out to get them.
We enrolled in med school anyway. We would become the physicians that knew nothing other than evidence based medicine, that would trade in our pharmacopias for epocrates, and see a work hours revolution change how patients are cared for in the hospital.
As an impressionable first year medical student I had a wonderful course called Medical Humanities. In a series of lectures we explored the philosophy of doctoring, and received our assignment. To preserve our humanism despite the rigors of training. To see each patient as an individual. To ask open ended questions. To respect cultural and racial diversity. To evolve beyond the paternalistic model and embrace the world where the patient is a partner.
I took this assignment on as a mission, reminding myself as years went by that smart and skilled was only part of the equation. That acting patient and compassionate was ultimately important. Years later I find myself in a field caring for extraordinarily ill patients, where astronomical efforts are made to save a life. Where more often than not this falls short and the best we can offer is a good death.
Over time I sense something that is just not right. It began with overwhelming frustration as a patient arrived with a ream of "medical information" downloaded from the Internet. Later it turned to disbelief as I found that my patient who cannot afford their rent is buying $100 per month of vitamins and supplements. As I find myself explaining why their information and supplements are bunk I find myself tip toeing in order not to offend and alienate. With so many new sources of medical information I think perhaps the grumpy old physician was on to something, the role of the physician has changed. Not necessarily a lack of respect toward doctors, but certainly a fair dose of skepticism that perhaps is deserved.
In my opinion the partnership model became derailed as the physician embraced the evidence and at the same time grew fearful of litigation. Informed consent then became central to the patient- physician relationship, a legal document. The conversation turned to odds of this and that, alternatives A and B, and finally the decision is up to you. The physician no longer answers the age old question, "If I were your mother/ child/ spouse what would you tell me to do?" Instead the doctor deflects a personal stake in the matter and ensures that in case of a bad outcome it will all be supported by the evidence, guidelines and paperwork.
Emerging from my medical training I began to feel an alienation at the bedside of my sick and dying patients. Witnessing their struggle with fear and uncertainty I felt like the care was falling short. The paces of a typical hospitalization includes selection of the proper evaluation, declaration of the correct diagnosis, and the discussion of treatment (with risks and benefits)- by the book. All of this done with the physician as the advisor and patient as a partner. When tackling the toughest issues- for instance at the end of life this series of discussions and decisions became just too much.
Grandma is too ill to speak for herself and there is a 80% chance that she will die. Would you like for us to do? Continue to try to save her? Should we treat the renal failure/ pneumonia/ UTI? Place a feeding tube? Continue lab work? Continue IV fluids? Turn off the ventilator?
My attempts to impartially advise and educate about all options grew in conflict with an urge to protect. To comfort. To spare whatever suffering could be spared for the patient and their family. But to step in and dictate what should/ could be done would be adopting the age old Paternalism we were raised to leave behind.
Perhaps there is a better way. May I be bold and call it "Maternalism". A way to provide compassionate care and resume part of the burden that we were taught to deflect. Partnering not as an equal but as a nurturer and comforter. For dying Grandma, first to help the family understand the situation, then to articulate what Grandma would have wanted. If that is go down fighting, they get a fight. But prevent the fight gone awry where Grandma suffers years as a vegetable with a feeding tube. If Grandma wanted to die naturally, then we allow nature to take its course. But spare the family from the agonizing series of discussions, where the family feels that at each step they are actively bringing the death of their loved one.
I find myself in a struggle to practice with excellence but also to sleep at night. Perhaps what we need is a sound clinical trial- or perhaps a meta-analysis to investigate the most effective role of the physician- in the post-Paternalistic era?