Perspective
The End of the Medical Deity
Deciding what’s right for a patient is no longer about bringing them around to the doctor’s way of thinking.
By Therese Zink, M.D., M.P.H.
There is no longer a medical deity. During my medical training in the 1980s, the concept of a god-like, all-knowing physician was disintegrating. In 1999, the Institute of Medicine’s watershed report “To Err is Human” dealt the fatal blow. It pointed out that preventable mistakes by medical personnel in hospitals killed more than 44,000 patients a year, more than the number who die each year from suicide (34,600) or homicide (18,400). Clinics and hospitals retooled and struggled to build a “safety culture.” Medicine was turned on its ear. It became O.K. for staff to check and recheck each other’s work. It was not only O.K., it was a co-worker’s responsibility to ask questions if a physician’s order did not seem right.
This culture shift should have been a huge relief to physicians. However, it required us to recalibrate our thinking about apologies. And we had to learn another skill: how to explain to patients and families the collateral harm that can and sometimes does accompany our remedies.
During my residency, our team studied Mr. Brown’s chest X-ray. What looked like a snowstorm obscured the bottom half of his left lung. The image of Mr. Brown lying on his left side showed that the white opacity had shifted and confirmed fluid in his lung cavity. We needed to insert a needle into his chest, draw out the fluid, and send a sample to the lab to diagnose the cause—infection, cancer, or heart failure.
By that time, I had done a half-dozen taps. I explained the procedure and risks to Mr. Brown and his son—that causing a leak in his chest could necessitate inserting a chest tube. I helped them sign a consent form that said we had discussed the procedure, including the risks and benefits. As Mr. Brown sat upright, I painted his back near the lower part of his ribs with betadine soap, injected lidocaine to numb his skin, inserted a needle and drained two ounces of straw-colored fluid. Mr. Brown breathed easier. “All went well,” I told him and his son.
Test results from his lung fluid suggested infection, and I wrote the order for antibiotics.
Later that day, Mr. Brown was gasping for breath. Almost as pale as his sheet, he sat upright in his bed and sucked air through his open mouth. He had suffered one of the complications—his lung had collapsed. We explained the new procedure, obtained another signed consent, and inserted a 1-cm diameter tube in his chest. It would remain there for several days.
Mr. Brown’s condition worsened. He spiraled downhill for reasons we could not figure out, and three days later, he died. Throughout Mr. Brown’s decline, our team discussed the case with his son. We apologized for his father’s death. Had the lung tap precipitated his decline and caused his death? Probably not. Still, I felt guilty.
Current research shows that it is best to apologize when something goes wrong. In the past, physicians made statements to downplay errors in order to avoid malpractice claims. This was driven to some degree by the medical deity mindset. Physicians decided what was best for the patient and presented the risks and benefits in a manner that recruited the patient and his/her family to the physician’s way of thinking.
Now, physicians are encouraged to be transparent from the beginning: Be honest with patients when there is uncertainty about a diagnosis or treatment, when there is no clear answer about how to proceed. Provide as much education as possible about the risks and unexpected outcomes of the different options. Be frank when the course does not proceed as hoped. We are to say, “I am sorry. The treatment has not helped. … This is what happened. This is what we are doing about it. We will keep you informed. Is there anything else you need?”
In this way, we become partners with patients and families, taking into account their values and goals. We weigh the pros and cons of the many treatment options as best we can and decide how to move forward. Together, we negotiate the subtleties that separate illness from health. In an imperfect world, this is a good place to start.
Yet, how realistic is it? In the heat of a crisis, when a patient treads water in an ocean of fear or pain, the list of risks is long, and the probabilities are complex, how much can one hear and process? Patients and families hear what they want to hear. Sometimes, with non-English-speaking patients, we have to talk through interpreters. These conversations can take time and are easier if a trusting relationship exists between the physician and the patient. But establishing such a relationship is often impossible in today’s disconnected health care delivery system, where a patient is admitted by an emergency physician and cared for by a hospitalist, neither of whom knows the patient. Patients, families, and physicians yearn for black and white instead of the many shades of gray.
A wife tells me that she and her husband did not understand that heart bypass surgery might cause damage to the brain and result in some dementia. Now, she watches over the retired engineer in the same way she did her children. She resents the medical team and is angry about the outcome.
An elderly woman tells me she is not using the cream I had prescribed at an earlier visit. She had seen me for a vaginal itch. After an exam, I prescribed estrogen. Thirty years of menopause had thinned her skin causing discomfort. When she came in for a follow-up, I asked if the cream was helping.
“I’m not taking it,” she said. “I read the entire package insert, and it said I could get cancer.”
I explained that was true, but at 79 cancer was unlikely. “You won’t be using that much and cancer is a long process. The increased comfort may be worth it.”
Physicians are in an untenable position. It is impossible to cover every risk, to anticipate every possible outcome, to have exactly the right words for a patient and his or her family.
I confess, in reality, it is much easier to be the medical deity. Explaining the probability of a certain risk happening is a complex discussion, often too complex for some patients to understand, and it takes time. As the medical deity, I am cloaked in authority and presumed control. I know what is good for the patient, and that is what we will do. The patient will not question my wisdom or omniscience.
Playing the medical deity, however, does not work today. No physician can or should determine what is best for a patient. There are endless possibilities, and patients and families may have values and goals that are different from our own. Some are motivated to eat right and exercise religiously; others prefer to pay for a pill. Some are ready to die; others are willing to keep trying for a miracle. Given finite resources, we must help patients make the tough decisions realizing they involve messy conversations and negotiations. Perhaps that is where we start, one imperfect human to another in an imperfect world. MM
Therese Zink is a professor in the department of family medicine and community health at the University of Minnesota.