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Two's Company, Three Hundred Million's a Crowd: Balancing Clinical Integrity and Population Consciousness in Medical Education

Kontos, Nicholas MD; Querques, John MD; Freudenreich, Oliver MD

doi: 10.1097/ACM.0b013e3182308cea
Response to the 2011 Question of the Year

Dr. Kontos is assistant professor of psychiatry, Harvard Medical School, and director of transplantation psychiatry, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Querques is assistant professor of psychiatry, Harvard Medical School, and associate director, Psychosomatic Medicine/Consultation Psychiatry Fellowship Program, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Freudenreich is associate professor of psychiatry, Harvard Medical School, and director, First Episode and Early Psychosis Program, Massachusetts General Hospital, Boston, Massachusetts.

Correspondence should be addressed to Dr. Kontos, Massachusetts General Hospital, 55 Fruit Street–Warren 605, Boston, MA 02114; telephone: (617) 643-6830; fax: (617) 726-5946; e-mail:

A core challenge of 20th-century medical education was reconciling the clinical care of patients with a scientific approach to medicine. Educators using proposals as diverse as the Flexner Report and patient-centered medicine struggled to ensure the continuous progress and clinical application of medical science while upholding and advancing the ideals, ethics, and art of bedside practice. In 2011, this struggle continues but must give some ground to another challenge: With expanding health care costs and inequities at critical mass, the next generation of physicians must be taught how to integrate population consciousness into clinical practice.

Medical education, grounded in the doctor–patient relationship, focuses on the individual patient. The physician's contribution to public health is at best restricted to prevention and at worst viewed as an intrusion on the doctor–patient relationship or as a shot across the bow of patient autonomy. This sense of threat is legitimate; physicians' trustworthiness can be jeopardized when patients think their best interests are being subjugated to the public interest (e.g., undue focus by doctors on expenses and resource allocation). However, prioritizing the individual does not have to mean ignoring the population. In the aggregate, decisions made in one-on-one doctor–patient relationships have enormous effects on public health. One might say that we can no longer ignore the other 300,000,000 patients in the room.

Conversely, considering the population does not have to mean compromising the individual. Each of us benefits from living in a healthier society and perhaps even derives some satisfaction from contributing to that improved health. The dual individual and social benefits of preventive medicine are self-evident. Less obvious are the individual gains derived when doctors “deprive” patients of things they ask for. Prescribing generic rather than brand-name medications, recommending lifestyle modifications before pharmacologic remedies, and examining a patient's difficulty tolerating nonpathological discomfort all spare patients the expenses and side effects associated with their initial requests.

Going forward, medical training must continue to foster a trustworthy clinical foundation while equipping physicians to responsibly consider social context. Two key educational themes pertain here.

The first is ethics. “Patient autonomy trumps physician paternalism” seems to serve as an ethical framework for many medical students and residents. This circumscribed, binary moral system is inadequate for a contemporary medical practice that sees itself as embedded in a social matrix. While trainees must be admonished not to impose their professional or personal values on patients, they also need moral guidance in the use of negotiation, persuasion, and even confrontation with patients whose maladaptive approaches to health and illness have negative or expensive consequences for themselves and for society. Trainees should be taught methods of thinking morally through clinical decisions that have ripple effects beyond the office or bedside, whether the decisions involve action (e.g., mobilizing healthful habits), restraint (e.g., refusing to prescribe unnecessary antibiotics), or controversy (e.g., deciding whether and when to prescribe enhancement “therapies”). These methods can prioritize the individual patient while making room for recognizing and openly discussing with patients that they exist in relation to others and that rights (e.g., to self-determination, to health care) come with corresponding obligations (e.g., to be honest, to work toward health).1,2

The second is authority. To engage credibly and effectively in these discussions with patients, trainees need to learn to tap the authority of the physician's role responsibly. Educators must divorce medical authority from its common but superficial associations with paternalism and hubris. Genuine concern for patients' value systems and respect for the existential uncertainty that permeates medicine undergird important elements of the physician's authority.3 These distinguishing characteristics of medical professionalism are the source of a committed and trustworthy physician's influence on patients' lives. Introducing population consciousness into the doctor–patient relationship means using that trust-based influence to nudge patients toward doing things that are not easy and away from doing things that are not medically indicated. This task requires knowledge and moral standing—and the permission to use them responsibly. While patients ultimately grant us that permission, trainees first need it to be imparted, and modeled, by their teachers.

We purposefully offered no specific curricular suggestions related to the preceding themes. New knowledge is not called for here. Rather, we ask those entrusted with the education of future physicians to consider individual patients as parts of society and individual physicians as having authority and exercising it in a trustworthy manner. Modeling a medical practice informed by these ideas may help trainees reconcile the ideal of the doctor–patient relationship with that of being a responsible professional and citizen.

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1 Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”—Strategies primary care physicians use to deny patient requests. Arch Intern Med. 2010;170:381–388.
2 Brook RH. Rights and responsibilities in health care: Striking a balance. JAMA. 2010;303:2289–2290.
3 Osmond H. God and the doctor. N Engl J Med. 1980;302:555–558.
© 2011 Association of American Medical Colleges