The CNN nightly news talk host Glenn Beck wrote a blog about his over the holidays experience with medical care, surgery and the lack of compassion he experienced. Subsequent bloggers wrote about the source of blame for this lack of compassion. Many related their own experiences with non-communicative doctors; being treated like a number by health staff; disregard for his feelings and lack of patience with his questions; a system focused on the "bottom line."
There were some comments about physicians who spent an hour listening to the patient but never heard what the patient was saying. Other encounters with physicians were very brief, but the physician displayed empathy, answering questions appropriately, and demonstrated that he/she cared about what was happening to the patient. There was a lawyer who said that physicians are sued mostly because they fail to demonstrate concern for their patient as opposed to having done any specific malpractice.
I am old enough, and I have had experienced medical care long enough, first via the prolonged dying of my father from metastatic melenoma through to my career and now recent retirement, that I can see milestones that produced some of these changes in the caring by health care workers. These of course are my own observations and not a scientific study.
Before the 1960's, doctors by enlarge were members of the "good olde boy's club." Sons, and a few daughters of doctors went on to medical school to become doctors. In looking at my medical school's wall of graduating class pictures from 1871 onward, in the initial class, there were 11 students of whom one was a women, one was black, and the other nine were white males. Subsequent classes also had one or two women and one black. The number of students in each class grew slightly every several years until World War II. By the early 1950's, there were @ 45 students per class. The numbers in first year classes increased to 89 by 1971. In 100 years of the medical school, the class size increase by 8 fold. The make-up of the class changed to 11 women; this last year there were more women than men.
What has changed over the years has been the expectations of these medical students; namely, for the first 80 years, many more students were admitted in the first year than granduated. As the medical student progressed from anatomy and physiology to pathophysiology and specific organ dysfunction, grades in courses mattered most. Then in the clinical years, the last two year of medical school spent on the hospital wards and surgery suites, performance was assess on a very subjective basis and people flunked out because they were not percieved as being a very good doctor; ie, didn't fit the mold of what was perceived as being like the "good olde boys." Unlike today where students can complete their course work after 3 1/2 years, then they can leave the school, coming back to graduate in May some time, for the first 80 or so years of my medical school, medical students were required to be in school for the complete 4 years. Early students were expected to be in the hospital nearly all the time. They were given uniforms, meal tickets, and a place to sleep. The one year internship after medical school, was more of the same: 24/7. A doctor met one's wife, usually, a nurse who was going through a diploma issuing nursing school at arranged social functions of doctors and nurses within the hospital.
The doctors coming out of medical schools were pretty similar to their fathers (and some mothers). Physicians usually were located in small towns and as solo practitioners. Their prestige was mostly derived from them being the most educated person in the town, hence, consulted in many matters of importance. Pay for physicians was modest at best, frequently paid in barter. The banker or the lumber baron and/or equivalent were the wealthiest people in town. You can get an idea of a rural physician's life if you happen to see an old television series "Gun Smoke" and follow the character "Doc." Later gentrified TV doctors were "Dr. Welby M.D." and later still "Dr. Richard Chamberlin."
In the 1960's there were several events that changed medicine. Just prior to and during the Vietnam War the development of positive pressure ventilators and cardiopulmonary bypass apparatus allowing the insertion of technology for bedside watching a waiting that prevailed before. In 1964, Medicare, became the funding source for the previously medically neglected aged. Doctors were now paid regularly for their care and their total incomes skyrocketed. Our nation decided that there needed to be a diversity of physicians, hence the recruitment of women and African-Americans. At the same time as there was an increase in numbers and diversity of medical students, there were fewer students who had come via a traditional college curriculum of heavy math and science and light on the humanities. Indeed, beginning in the 1960's, college graduates recruited to medical school were just the opposite, heavy on humanities and light on the basic sciences. The newer students came with the expectations of " having a life of their own." Several problems became evident: there needed to be a standardized entrance examination; hence, MCAT; the focus needed to be upon retention of the admitted student instead of examination for exclusion through expulsion; and there needed to be more uniform testing along the medical school curriculum to be sure that students didn't graduate from medical school but couldn't pass the various state liscencing examinations taken at the end of the first year internship. There was the perception that four years of medical school and the subsequent internship was a hardship and dehumanizing process, this "awareness" resulted in more medical school "doctor-patient" humanizing learning instruction; the internship with its isolation in the hospital was deemed to beat the humanistic qualities out of the person who would become the Physician and Surgeon. What was perceived by many as a need to humanize the internship year, resulted in the extending of the training process. Since a physician's sinequanon training and skill was their ability to do surgery, and during their training they had to do so many supervise proceedures to be deemed competent, and since you were now off duty and out of the hospital, so you couldn't do the requisite number of procedures in one or two years to be minimally competent unsupervised and on your own. The training periods were extended. Now of course, the family doctor no longer delivers babies, does a gall bladder removal, enters the Intensive Care Unit, goes to the ER to see patients, sets the broken leg of that potential elite middle school athlete. All that care is done by someone who is specialized, and carries a very high medical liability premium.
With most people entering medical school now not having a living, breathing, in home role model physician dad/mom, the vast majority of new physicians are clueless as to what they are getting into, believing wrongly, that one can get involved with another human being who despirately needs them, and turn it all off at 5 pm, sign out, and head home for a meaningful experience with one's family. Soon the young doctor learns that the above scenario can't be done, then, they make being a doctor into a job, with defined responsibilities, hours, pay, time off, benefits, contracts with others, etc., etc., etc. Its hard to fit in "your patient's interests come first" when in fact they don't. Your interests come first.
So. With the advent of a diverse pool of potential doctors, lack of role models regarding the expectations of subserviance of one's personal wants that goes along with the caregiving for another person, the increase time it takes to become minimally competent with a particular technology, it is not surprising that many physicians are dissolutioned, focused upon themselves doing a good "job" when they are on duty, minimizing disturbances in their routines and come across as lacking compassion. It is hard to get involved with someone when at 5 PM you are leaving. The answer, don't get involved in the first place, and this attitude shows, shows very clearly.
After a number of years of turning off, one goes on to becoming "burned out." Medicine not longer is attractive and one starts to look elsewhere: golf, money, BMW, Carribbean Vacation destinations, etc.
What is missing of course, what the role models would have role modeled again and again and again, it is the patient-doctor interaction over time that is unique and nurishes the physician. Patients allow you to enter their world and space. It is about continuity, caring about how someone is doing, how they are grieving, coping, frightened, angry, loving, and for some, seeing life falling out of their hands like so many grains of sand. This window to another human being is the sustance of a physician's life. These are the rewards that give back to the physician many times more than they give to the patient/family. This is what the sacrifice is about. Without caring for someone else, it is hard to be cared for by someone else; its simply a two way street, compassion goes both ways. Those that give it, get it back.
