Dharmaraj Karthikesan’s BlogMy life as a doctor and the way I see it…
I met a young doctor who used to work with me recently. I had just completed my night rounds in the hospital and I was leaving for home.
And then I saw him. He was unkempt, exhausted and appeared famished. Worst of all, he looked like a man who has totally given up on being a doctor. He appeared hesitant when I asked him what was wrong, but I could not just leave him there.
After much persuasion and insistence on my part he agreed to join me for a late supper. While he ravaged through his first proper meal of the day, he finally opened up. He has started working for the past week in a new speciality. Though the hours are longer, it was not an issue. He was well aware of the sacrifices he was expected to make.
However, the degradation, humiliation and constant harassment have finally taken their toll. He was literally chased out of the ward just minutes before he met me because he could not remember the details of a patient he clerked. He was not allowed to refer to his notes and had to recite the lab results by heart like a trained poodle. The words were abusive, hurtful and condescending. And worst of all, it was said right in front of the patient.
He finished his meal and stood up to leave. And as he left he said this “Please don’t worry about me. I will be fine”. I was not convinced. The shame of being publicly humiliated is not a stain that washes easily.
The doctor-patient relationship often takes centre stage, but the epitome of good clinical practice depends on how the doctors treat each other. The medical profession is filled with fragile and vulnerable egos that often have trouble working with each other in a genuine collaboration of trust and mutual respect.
We complain, argue, fight and obsess for the sake of our patients, but do we dare reflect for even an iota of moment our actions and attitude towards our fellow caregivers?
So what went wrong in the noblest of professions and how do we fix it?
Stop the stereotyping of doctors
“The surgeon knows nothing and does everything. The physician knows everything and does nothing. The psychiatrist knows nothing and does nothing. The pathologist knows everything, but always a week too late”.
“Surgeons are egomaniacs, anaesthesiologists are lazy, orthopaedic surgeons are meatheads, obstetricians are mean and brain surgeons think they are God”
There isn’t a single medical speciality that has not been ripped apart and ridiculed.
As I continue to mature and evolve in clinical practice I have encountered a variety of doctors. And most of them share a common trait. They live under a grand delusion that their speciality is the only one that matters and worth doing. They have strong negative feelings about doctors who have chosen a different career path and have a deep seated urge to insult them at every opportunity they get.
This has to stop. Every facet of medicine is equally important.
As a clinical cardiologist I depend on the primary care physicians to detect and refer their patients to me early for cardiac interventions. It would be near impossible for me to screen all the patients with coronary artery disease in the population. I lean heavily on the cardiac surgeons for cases not amenable to minimally invasive interventions. The endocrinologists help us manage the difficult diabetics who need expert fine tuning of their insulin regimes. The emergency physicians are crucial front liners in diagnosing acute cases and stabilizing them prior to sending them to the cardiac care unit. The intensive care specialists help us manage the ventilated patients and are crucial to the running of our cardiology services.
Every single doctor provides an important aspect of patient care which complements the work of the other. We work like a grand complex machine where every part is imperative to the running of sound and safe clinical practice. We are all equally important. And that is the often forgotten ‘stereotype’.
You don’t need to criticize or challenge other doctors to earn respect
I read an article recently where a rival oncologist told the parents of a young patient with incurable cancer that he could have saved her life had she been brought to him earlier. He completely disregarded the considered opinion made by the oncologist who actually managed the patient from the beginning. His actions were borne without actually consulting the managing oncologist and in that one frivolous statement completely shattered the foundation of trust the parents had on the treating team. This unnecessary disagreement between doctors often compromises the best interest of the patient.
Rival doctors often spread malicious lies about their colleagues. I have a friend who works in an established private centre and a rival cardiologist once told one of his patients that “he was a far more brilliant cardiologist” and that my friend was less experienced than he was.
Another surgeon told personal details about another doctor to his patients including mistakes he made as an intern and his unfortunate marital problems.
Just recently I overheard a junior doctor thrashing his ward colleague in front of the nurse’s station. He knew I was within earshot and yet continued to speak ill of his colleague who happens to be a trustworthy, humble and talented doctor.
This leads to lack of trust between doctors and dents one’s reputation. A patient is unlikely to respect a doctor who openly criticizes another and may feel threatened you would do the same to them.
Bullying is not a necessary evil for training doctors
One of my mentors told me prior to my training as a physician that one of the most important attribute I was expected to develop was a thick skin to criticism and condescension.
Each doctor invariably undergoes a different form of bullying throughout a long career. It can be as subtle as denying one the privilege of referring to a patient’s chart while presenting a case just seen barely fifteen minutes ago amid a flurry of admission. Or it can be downright humiliating like being called ‘stupid’ and ‘incompetent’ during morning rounds for an incorrect answer.
I have seen senior surgeons screaming at their residents and interns during surgery for seemingly simple or negligible errors. Every small mistake during surgery is magnified out of proportion and a running commentary will follow suit on how the doctor ‘does not have what it takes to be a good surgeon’.
Physicians are often in a foul mood early in the morning if the lab results are not available on time although the interns would have personally delivered the blood samples to the lab technicians. The interns will face the brunt of their anger knowing full well they did nothing wrong.
Radiologist are often condescending when interns request for an emergency CT scan as they are an easier target compared to the senior consultant whose orders the interns are carrying out.
Family physicians and general practitioners are often the object of irate registrars and consultants who feel they contribute nothing to proper patient care not realizing the crucial role these primary care physicians play in screening patients prior to sending them to tertiary care.
A paediatrician may swear at a doctor for missing an intravenous cannulation on a preterm neonate and then adopt a serene demeanour when facing the parents of the child.
We often excuse doctors who are bullies because they are ‘great with patients’ and are ‘brilliant clinicians’ or ‘gifted surgeons’. This hurts the profession more than you can imagine.
Doctors trained in this hostile environment will foster deep resentment towards their peers. It becomes ingrained in their psyche. Once they get better and more confident they will develop the same impatience that was shown to them towards their junior doctors. And they will in turn become the very bullies they once despised.
This never ending vicious cycle will continue and the interns will mature into senior doctors thinking that bullying and condescension is a necessary tool for training doctors.
Bullies are cowards. Period. There is no way we can justify the actions of those who continuously seek ways to make the lives of others miserable. Since bullies only respond to strength, the medical hierarchy should start becoming much stronger. Cultures that shun the bullies making them look weak instead of the recipient should be fostered. This is easier said than done as the bullies often sit at the top of the food chain but cultures change because people are committed and steadfast in changing them.
Good and honest communication saves lives
Newly minted doctors need proper training to become competent and safe. They should be encouraged to ask questions and any uncertainty regarding a patient’s management will be cleared during the rounds. The young doctors learn by observing the intricate process of decision making that goes into managing a patient and in time they will become better clinicians.
Suppose a senior registrar or a consultant barks at every question as it is a ‘waste of his precious time’ or that ‘you are supposed to know this’. The junior doctors will hold back their questions or doubts for they are preoccupied with fear of appearing incompetent or lazy. They fall into the trap of placing emphasis on trying to save face and look like they know what they are doing at all times rather than admitting ignorance.
The interns will dread the clinical rounds and will only perform the most basic of duties such as tracing the lab results, writing the discharge summary and updating the progress notes. They will immerse themselves in paperwork and avoid spending time preparing for clinical rounds.
Since the interns and junior doctors are often the ones manning the wards after clinical rounds while the consultants and registrars are engaged in the busy clinics, subtle deterioration in a patient’s clinical condition can go unnoticed. The interns who lack proper clinical training to detect such dangers or even the ones who may suspect something wrong but hold back in apprehension out of creating a false alarm, may not alert the senior doctors until its too late.
The patient’s care is severely compromised and the interns will retreat further into their shell as they will be blamed for this unfortunate event. If the interns try to defend themselves and argue back, they will be blackballed throughout their career in medical practice and labelled for insubordination.
And shame does not encourage improvement. The culture of blame and punishment fosters more mistakes and fatalities. Doctors do not report their errors for fear of retribution.
And our mistakes will work its way down to affect the patient’s lives.
The doctor-patient relationship paradigm depends closely on the doctor-doctor relationship. Bad and damaging cultures foster a hostile atmosphere that erodes trust, tarnishes good communication and promotes disrespect within the medical community. The role doctors play in harming each other ubiquitously affects the patient’s care, however unintentionally.
If we work in an environment where we are kind, tolerant and respectful of each other, we will in turn be more humane to our patients. Young doctors will be nurtured in a system that is steeped in kindness and compassion and they in turn will become sound clinicians who resonate the same values.
It is, as Plato once said “Be kind, for everyone you meet is fighting a harder battle”.