Dr. Pauline Chen on medical care.
A physician friend known for her conscientious work recently disclosed that a year ago she was named in a malpractice lawsuit. The revelation rattled me not only because there were no discernible errors in the care she provided, but also because I couldn’t believe who had provoked the patient to hire a lawyer.
It was another doctor.
“I’m shocked that nothing was done sooner,” the other doctor had said when the patient went for a second opinion. “You could have died.”
The patient later decided to sue.
Like many who heard the story, I was quick to criticize the other physician. Throughout training and regularly at work, we are reminded of the importance of professionalism and respect. Shifting blame, doctors are taught, demoralizes other clinicians, undermines patient trust andcompromises patient outcomes.
Surely, I thought, the doctor who had trashed our colleague was out of line, his comments aberrant. But it didn’t take long for me to recall instances when friends and I had been equally critical about other doctors’ work. And while I wanted to remember those indiscretions as private, limited to a few colleagues at most, I wasn’t entirely sure.
I had to wonder: are we all capable of talking like that in front of patients?
The answer, according to a recent study in The Journal of General Internal Medicine, is an unqualified and disturbing, “Yes.”
Over the last decade, few issues have garnered as much interest among health care experts as disrespectful behavior among doctors. While sociologists have devoted careers to researching the topic, it wasn’t until the 1990s that the medical profession itself began to take serious note.
Spurred on by the increasing complexity of medicine, concerns about safety and patient satisfaction and an ever-growing urgency to contain costs, the Institute of Medicine convened a national panel of health care experts to discuss “the chasm” between what could be and what was actually being done for patients. In 2002, they published an ambitious report that called for a “sweeping redesign of the entire health system.” Realizing that vision, said the panel, would require, among other changes, better collaboration and cooperation among physicians and the creation of a “culture of respect.”
Medical schools, regulatory agencies, professional organizations and entire health care systems responded to this cri de coeur. Official definitions of professionalism were rewritten to incorporate the concepts of teamwork and shared responsibility. Schools added mandatory coursework on thewhys and hows of working in a team. And licensing and accreditation boards began asking for evidence that doctors could not only lead, but that they also knew how to work as part of a team.
But this new study reveals that old habits and responses die hard.
Researchers trained three actors to portray “standardized patients” with advanced lung cancer who had recently moved to town after being treated by another doctor and who remained unsure about their diagnosis or prognosis. The actors, carrying medical records written to reflect only universally accepted guidelines of care, made a total of nearly three dozen office visits to various family physicians and cancer specialists working in the community.
The actors were not told to elicit the doctors’ opinions about their previous care; but after analyzing transcripts from each office visit, the researchers found that in 40 percent of the consultations, doctors went ahead and spontaneously offered their opinion anyway. A tiny percentage of these comments were neutral; a third were supportive. The vast majority, however, were unabashedly critical, with the doctors’ comments ranging from “Hell, you don’t want to trust doctors,” to “This guy’s an idiot!”
“Doctors will throw each other under the bus,” said Susan H. McDaniel, lead author of the study and a professor of psychiatry and family medicine at the University of Rochester Medical Center. “I don’t think they even realize the extent to which they do that or how it can affect patients.”
Probably, added Dr. McDaniel, most of the comments were unintentional. Faced with a constant pressure to cut costs, increase productivity and keep patients happy, plus the additional difficulty in this case of discussing prognosis with a terminal cancer patient, many of the doctors no doubt experienced significant levels of stress. In the moment, criticizing another physician to a patient might have felt like an effective way to fortify their own credentials and build up the patient’s trust.
“There is probably something reassuring in saying, ‘Boy, your doctor didn’t do a good job and now I’m going to take care of you,’” Dr. McDaniel noted. “But those kinds of comments are bad for the patient.”
To help remedy this problem, Dr. McDaniel began a physician coaching program at the University of Rochester Medical Center a year and a half ago. So far, she and her team have managed to work with approximately 150 doctors, observing them with patients and with colleagues, then offering feedback and support. Eventually they hope to expand the program. “When you really think about it, it’s hard for people to regulate themselves when they get frustrated,” Dr. McDaniel said. “And physicians get frustrated a lot.”
She added: “There’s a lot of attention focused on the patient experience, but I think we need to work on improving the clinician experience as well.”