The life of the patient and the soul of the physician are always at risk—RABBI SAMUEL EDELS, 17th-century Polish Talmudic scholar 1
Arrogance among physicians is, regrettably, common and detracts from the nobility of our profession, its dignity, and the quality of medical care. Arrogance may be manifested in diverse ways, such as lack of proper respect, consideration, and good manners toward patients, nurses, and other ancillary staff; failure to pause, listen, and share a friendly word or two; being abusive or critical of subordinates, sometimes even in the patient's presence; and (for male physicians) addressing women condescendingly using terms such as “dear” or “honey.”
Unfortunately, this important subject has been only touched on in the literature. 2–15 Also, it is generally omitted from the teaching of medical students and residents. Ethics —and particularly the need for humility in the physician— warrants greater emphasis in medical training, both in the classroom and, more critically, by example.
TEACHING HUMILITY BY EXAMPLE
In an earlier era, it was more common for medical students to have the good fortune to learn the qualities of humility and ethical behavior from the examples of their professors, whom students admired and sought to emulate. Allow me to cite such an instance from my own medical training.
It was in the early '50s and I was a medical student on rotation at Kings County Hospital in Brooklyn, New York. Patients were, for the most part, housed in large rooms, or wards, accommodating approximately 18 patients each. Every bed had a moveable curtain that could be pulled when privacy was needed.
Cardiovascular surgery was just beginning. Dr. Charles Hufnagel, professor of surgery at Georgetown University School of Medicine, an innovator of open-heart surgery, had come to visit our hospital. The residents presented “my” patient to Dr. William Dock, a distinguished cardiologist and professor of medicine at my medical school. Mrs. Gonzalez was 27 years old, the mother of four, and in congestive heart failure consequent to mitral stenosis, which she had developed as a young girl following a bout of rheumatic fever. She spoke broken English.
Dr. Dock examined her and then spoke in simple terms to this impoverished, immigrant young woman, whom he addressed as “Mrs. Gonzalez.” He patiently explained that she needed a newly devised operation to open up a scarred bit of her heart. He proceeded to take out his pocket handkerchief and illustrate how a misplaced seam might be slit open. He also explained the grim outlook if she did not have the operation, the uncertainty of success with this new procedure, and its hazards. He then asked Mrs. Gonzalez for her consent to have a visiting specialist (Dr. Hufnagel) perform this lifesaving operation just two days hence.
Mrs. Gonzalez replied that before deciding whether or not to proceed, she wanted to review the matter with “her personal doctor.” (None of the charity, or “service,” patients ever saw a private physician. It would have been far too expensive to do so.) Dr. Dock, unfazed, asked, “And what might be the name of your personal doctor?” She replied, “Why, Dr. Berger —right back there,” pointing to me, a lowly medical student, on the outermost periphery of the Grand Rounds entourage. Without so much as blinking, Dr. Dock replied, “By all means, discuss it with Dr. Berger… perhaps he will agree with my recommendation.”
Needless to say, I conveyed to Mrs. Gonzalez my enthusiastic concurrence with the eminent Dr. Dock. Dr. Hufnagel operated successfully two days later. I held the retractors, and Dr. Hufnagel permitted me to feel the patient's beating heart. It was a memorable moment for me. Three weeks later (there were no HMOs in those days, and hospitalizations were much longer than they are now), Mrs. Gonzalez left the hospital with a normally functioning heart and a favorable life expectancy.
Now, almost 50 years later, Dr. Dock's example of humility, courtesy, and respect remains with me.
WHY ARROGANCE AMONG PHYSICIANS PERSISTS
I would like to reflect on the possible etiology of the current state of affairs in which arrogance is so common among our colleagues.
Arrogance among physicians is a product of intersecting and mutually enhancing variables, both sociologic and psychological. With regard to the sociologic factors, medicine has long been viewed as a noble profession, indeed as a sacred calling. Physicians were expected to serve the needs of the patient with small attention to their own material rewards. They were generally recognized as scholarly, well-educated, dedicated members of the community. However, this honored position in society could seduce some physicians into the corruption of arrogance. This occurred more easily in the days when patients' ignorance and naiveté facilitated exaggerated reverence for the “all-knowing and powerful Doctor.” Also, many patients—particularly those who were poorly educated or recent immigrants—felt too intimidated in the doctor's presence to ask questions or to expect to be treated as equals. (Unfortunately, this situation sometimes still occurs.)
During recent years, the prestige and respect for physicians in our country has gradually eroded. One reason is the greater public awareness about health and medicine in this age of the educated, informed, and questioning consumer. There has been abundant negative publicity about physicians' mistakes, greed, wealth, and self-serving behavior. The emergence of HMOs and similar medical care groups has served to emphasize the business aspect of medicine and diminish the humane doctor—patient relationship. The advent of increasingly sophisticated technology has also fostered this impersonality. The physician has become a “provider” and the patient a “health consumer.” This distancing of the doctor from the patient breeds a kind of “system arrogance,” in which the patient is no longer seen as a human being but simply as a job to be done cost-effectively.
Let us turn our attention to the psychological elements. Many doctors are drawn into the profession in part by their own unconscious concerns about illness and mortality. There is the hope of extending their own lives and forestalling death. Death becomes the enemy, with the physician as the St. George who will slay the dreaded dragon of mortality. This reluctance to accept the inevitability of death (which is on all of our agendas) with a modicum of serene resignation sometimes breeds a kind of arrogance expressed by the use of unwarranted elaborate procedures and “heroic measures” to delay the patient's demise.
Another psychological pressure—the physician's awareness of his or her special knowledge (equals power) in the doctor—patient relationship—is the most critical variable in the development of arrogance by the physician. The possession of some power can delude the susceptible into imagining that they are all-powerful. Add to this the tendency of the very ill and suffering patient to regress psychologically to a childlike emotional state in which the physician is unconsciously viewed as an omnipotent and omniscient parent who is sure to protect and save the suffering child.
I suggest that this regression, with its accompanying tendency to idealize and deify the doctor and expect miracles, is directly proportional to the gravity of the illness, the patient's state of consciousness, and the drama of the occasion. For example, a semicomatose, severely injured auto accident victim who is being attended by a neurosurgeon in the emergency department is more likely to deify and thereby foster arrogance in the physician than would a patient with a minor skin eruption who is fully alert and attended to, on a relatively frequent basis, by the dermatologist. The patient's longing for an omnipotent physician/parent/God to save him or her taps into the latent arrogance/grandiosity/hubris of some physicians. In effect, the patient is unknowingly fostering the very physician attribute of arrogance that the patient, as well as society, decries. It is an unwitting (translation: unconscious) emotional collusion between the doctor and his or her patient. Although, indeed, patients may wish their doctors to be God, they will accept the failure of that longing if the doctor is but human.
It behooves each of us physicians to remember that we are but instruments of healing and not its source. We should not exaggerate our own importance. We are all, physician and patient alike, made of the same clay and travel the same path—“from dust to dust.”
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