Monday, October 25, 2010

Maternalism

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?

10 comments:

  1. Even though as a pathologist I am not directly involved in patient care (so don't get to personally go through your struggles) this strikes me as an excellent platform.

    Patients do need a guide through the muck of the internet and we didn't spend spend 8-14/15 (I spent 10) years after college in higher education and amassing large quantities of debt for no good reason.

    My dad has been practicing neonatology since the mid-seventies. As I read this, I was reminded of listening to him tell stories about guiding families, based on his knowledge and experience, in making decisions about ending their newborn's life. I realized, growing up and listening to him, that nurturing and comforting the families is as important as treating his patient. He has definitely got the "maternalism" aspect of medicine down.

    Excellent post, JC.

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  2. What an excellent post. First of all, concerning the Internet, I won't give patients my e-mail address, and although they can contact me for non emergency stuff through the office website, there is the on-line warning of "do not send any attachments". For the insistent patient, I tell them I charge by the hour while they sit in the office and give me the junk to review. No one has taken me up yet on this offer.
    Having been out of med school from long before the HMO horrors, I tend to fall into the "grumpy old physician" mode. But I definitely make my opinions known to the patient, and the beauty of private practice, they can take it or leave it and go elsewhere. Obviously, this philosophy is couched in more sympathetic words, but that's the gist of it. I don't have time for nonsense relayed by everyone's next door neighbor's grandmother's cousin. When I am told the outside source demanding a certain treatment is a physician, I usually say, fine, let him/her write the prescription.
    Makes my practice quite pleasant and the patients I get tend to self select for the value of a medical opinion - whether help with end of life decisions or something as simple as the best medication for them.
    While not objecting to the principle of "evidence based" medicine, we have to remember that the evidence is for a statistical norm. It doesn't mean that every patient fits the profile.

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  3. Excellent post - I find that "maternalism" is an excellent term for what many of us are trying to do in practice now. Balancing the evidence with comfort.

    As a rural physician, we are allowed more of this as many times we know/are friends with the patient. We talk about this often with medical students - sometimes, the evidence doesn't justify but the comfort of the patient does - interesting.

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  4. I guess I am I the sandwich generation of docs. Trained by grumpy old docs and having medicine transform on our watch. I agree that I do practice a lot of "maternalism"--a balance of the evidence with the patient's individual characteristics. Mainly, less hot air and more just listening. But as you know that is not what pays in medicine. And I doubt "reform" is going to make that better.

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  5. Hi, From my position (I work as a part-time family doctor in the UK) this post hits so many familiar notes.While the ethos of medical practice here is slightly less polarised than you suggest, the sentiments are similar. As family doctors we are often in the position of sifting through evidence-based recommendations to select options which are individually tailored for the patient's needs. After all, the evidence base only applies to the population on which it is researched; the elderly, frail and anyone with multiple conditions are excluded from participation, and usually no qualitative elements are included.
    'Maternalism' ? I like it.

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  6. I don't think evidence based medicine is at odds with a "maternalistic" approach. We can still be very patient centered while practicing evidence based medicine.

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  7. What a great post. I love the idea of "maternalism" as a new, more balanced approach to counseling patients and families. I also deal with a lot of end of life care and life changing illnesses. I have so many issues with how this is handled that I'll probably come up with a followup post at some point. It's one of the most critical issues in medicine today. Kudos for bringing it up!

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  8. I agree that I do practice a lot of "maternalism"--a balance of the evidence with the patient's individual characteristics.I love the idea of "maternalism" as a new, more balanced approach to counseling patients and families.

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  9. Also love "maternalism." That is just genius, I hope it catches on.

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  10. Maternalism. What a wonderful, eloquent post. Sounds like something I want to spend the next ten years studying- Thanks for this contribution.

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