Leadership in Health

Time for a respectful approach

Sometimes I am ashamed to be a member of the medical profession, when I hear from my patients how they have been mistreated by my colleagues. I don’t mean that the treatment they received did not follow reasonable medical guidelines or was incompetent. I mean that they were not treated with respect. They were treated as inferiors or of lesser intelligence and they came away feeling they were not worthy of the doctor’s time or efforts.

I have recently referred a number of patients to my colleagues and had some disappointing returns. Two of my patients did not even qualify for an appointment because of their insurance status. Another specialist told my patient she could not be experiencing a side effect of a medication because none of his other patients complained. Another patient waited 12 months and drove 4 hoursto be seen and my referral letter requesting a procedure was not even read and the patient was dismissed within 5 mins. No return correspondence was received in any of these cases. Another friend has her child at a Children’s hospital once a month for 12 months and rather than feeling part of the management plan, she feels her opinion is not being heard nor her views on her sons condition respected. She has lost trust in her treating team and doesn’t know who to turn to.

What is it with modern medicine practice? When did we lose focus on treating our patients with respect?It feels like we are succumbing to the business of medicine and forgetting what is important and different about our profession.

Medical Mentors

When I trained in a large metropolitan hospital in Melbourne 25 years ago, I gained great respect for the men and women who trained me as they instilled in me a sense of duty and respect for my fellow humans who I was given the great privilege to treat. They often reminded us as healers that we should not discriminate in regards to those who we treat. Nor should we offer an inferior level of treatment or interest in patients who do not meet our perverse ideas of who is worthy of treatment. I was reminded of this tenant of medical practice watching a documentary on a US emergency physician volunteering in Mosul, who was receiving patients from both sides of the conflict and treating them without regard to the uniform they wore or the religion they followed. He was also teaching the locals this tradition.

Fred Hollows once said;Every eye is an eye, when you’re doing the surgery there that is just as important as if you were doing eye surgery on the prime minster or the king.

This is the healing tradition but appears to be lost in our modern medical dichotomy of insured and non-insured.

The Surgeon Salesman

Surgical consulting work does not always translate into procedural work. Much of our work is spent in diagnostic workup, education and administering non-operative treatments. In fact, this is when the real thinking is done. The procedural component of being a surgeon is very enjoyable but in the most part does not require a great deal of decision making as the plan is done before the cutting begins and most operations are quite formulaic. It is a bit like a big race where the training before the event over many months is what wins the race.

There is unfortunately a perverse incentive to proceed through to a procedureearlier than perhaps indicated as the remuneration is significantly higher for this type of treatment. This is a trap and we should be aware of this influence on our practice and remain as independent advisors for our patients. When recommending a surgical approach, I ask myself if this is what I would recommend for my family member. Perhaps it would be better if surgeons only saw patients that were going to be operated on by our colleagues and visa versa. Would we be so keen for patients to have the procedure if we were not going to be the technician?

Of course, many of the operations we do are very effective and we may sell our patients down this pathway because we are believers in the results of our interventions. In some circumstances, surgery should not be the last resort and some operations are life-saving. Unfortunately, there isn’t a condition that can’t be made worse by an operation, particularly if performed too early or for an inappropriate indication. The father of orthopaedic hip arthroplasty, Sir John Charnley, was very careful in his patient selection and to whom he trusted operating rights. I am sure he would not have “over sold” his operation despite its revolutionary improvement in outcomes. It is because of his conservative approach performing an innovative operation that the results were so good and the procedure became accepted and commonplace.

The Patient Centred Approach

I often hearmy colleagues saying that they have to comply with the patient’s wishes to have surgery or they will go elsewhere. Complying with a pushy patient is not a patient centred approach and we have to be careful not to blame our ‘trigger happy’ tendencies on patient demand or on our competition. Early on in your career it is particularly difficult to recommend patients wait a little longer before they commit to surgery or consider a second opinion as you may be worried the patient may go elsewhere for treatment. I have learned that the “fickle” patientis actually best off with someone else anyway and if I can coach a patient through the course of their condition with or without surgery then they are often grateful for the time they had to make a decision about the operation and are satisfied that they exhausted all other reasonable options and went into the procedure with “open eyes’. This is very important in the circumstance that they do incur one of the inevitable complications we all experience from time to time.

We must therefore educate our patients so that they can have the best information to make an informed decision when considering surgery or alternative approaches. We will earn the trust of our patients more so when we are prepared to manage them without surgery, if safe to do so. We should listen to the patient to understand the thinking that underlies their decision making. Sometimes their thinking is flawed and this can be corrected with simple education. Most patients expect to be listened to above other expectations so we need not be afraid they will go elsewhere. When we listen we will have met their main expectation.

I enjoy working with people from all walks of life and often learn the most from those who appear to have the least material wealth. These patients are not entitled and are often very grateful for the time I spend with them. They can be engaged in the treatment decision process even when their health literacy skills are poor if a little time is spent educating them on their condition and its natural history in a way that they can understand. Often these patients ask the most pertinent questions once they understand the procedure and the indications.

Surgeons as Doctors

Somewhere in history it became tradition that when a doctor becomes a surgeon he drops the title of doctor. Not every surgeon has adopted this tradition and I believe it is elitist and also counter intuitive. The day I graduated from medical school and I could finally call myself a doctor was one of the proudest days of my life. I am not sure why anyone would want to give up that title and the tradition of healing that is assigned to people with that title. It has also been recently highlighted to the RACS that female surgeons do not typically find assigning a Ms or Mr to their title as helpful and so the gender bias of this antiquated tradition is even more bemusing.

Until recently, I have always worked in the public sector. I enjoyed this work and it allowed me to continue to teach my craft to the trainee surgeons and junior doctors. Treating patients who do not have easy access to a surgical solution is also a very enlightening experience and teaches you to use all your healing skills and not just resort to procedural medicine. I am grateful I got to see patients travel through the “natural history” of their condition. For some patients whom I thought surgery would be the best solution when I initially saw them for their condition, had spontaneous resolution of symptoms. I also saw how many slowly deteriorated or remained stable for some time and were not as emergent as they may have seemed at first. Other patients deteriorated more quickly and I got better at identifying this group of patients and I now act more proactively when I recognise this type of patient.

I was also privileged to work in a multi-disciplinary team of allied health professionals over the last decade and I learned many different approaches to patient care that did not involve surgical or even medical treatment. I got to see how these approaches can be complimentary to the more “medical” approach. Patients were often more satisfied with their treatment when they received care within the team and received consistent messages from different members to reassure them on their pathway. I can strongly recommend being part of a team approach and it gives patients more choice when choosing their treatment plan and it reminds us doctors that we don’t know everything!

Regaining Respect

I believe most doctors and surgeons got into this profession with noble intentions. Somewhere along the line many of us become busy and overworked, cynical, distracted or bored, and lose that spark for our profession. Burn out is very common in doctors and this needs to be addressed so that our patients can regain respect in our profession. I think it may help if surgeons remember to be doctors again, and doctors remember to be humans again so we interact with our fellow humans and patients with humility and compassion.

I will leave you with the words of my idol Fred Hollows;

If you don’t want to serve, don’t do medicine. Because the whole tradition of medicine is going to the sick and tending to the sick.