The best doctors don’t care

It occurs to me there are several keys to being an excellent physician.  One must love science, enjoy hard work, have the courage to make tough decisions, carry a modicum of intelligence and suffer angst at receiving 94% on an organic chemistry test.  In addition, the very best physicians, those we admire and to whom we flock, have a secret weapon.  They do not care.

I do not mean that they are unfeeling or apathetic.  Quite the opposite, the best are driven, passionate, and have an indomitable love of their fellow man.  I do not believe doctors do not care what happens to their patients, families or community.  Leading physicians are often devastated by bad outcomes and have guilt from every mistake they have ever made.  Moreover, of course, the best are not aloof or uninvolved in life around them.  That is obvious.

What I mean is that gifted doctors do not care about the what or who of each patient.  They are not influenced by personality, background, or individual quirk.  They do not care about the dozens of ways in which human beings catalog, rank and segregate each other.  Exemplary doctors are not prejudiced by age, sex, race, religion or creed. They are not moved by height, weight or smell.  They ignore social status, politics, or dollars on the table. They are oblivious to whether a patient is beautiful, ugly or scarred. They are not arbiters of habits such as smoking, drinking or drugs, except as they affect that person’s health.  In short, the very best physicians care about each patient as a human being, and do not judge the human being who is the patient.

The problem is that suspending judgment is an art in itself, and while it is at the core of the medical role, it is not natural or easy.  This sort of passionate objectivity takes time, experience and training to develop.  Human beings survive by constantly looking for patterns and we have a nasty habit of turning those patterns into judgment and prejudice.   Learning to suspend this natural reflex, so that a physician can accept each patient as a whole, working within his or her individual strengths and weakness, is a monumental challenge. Nevertheless, as long as a doctor falls into the trap of treating “that fat guy with cancer” and not “the guy with cancer who happens to be overweight,” he/she will fail to give objective care.   Prejudices left unrecognized result in treatment that is biased and inferior, and not the best medical care.

Maintaining this sort of objectivity, loving man for the simple fact that he is man, is a skill that can never be completely mastered.  Even the best doctor is not Mother Teresa or Mahatma Gandhi. Each physician knows, if he looks in his heart, the particular type of patient that “gets to him.”  These patients try that doctor’s professional focus and there is always the risk of uneven medical care.  On the other hand, one of the great joys of practicing medicine is the continuous challenge and opportunity to improve, not just in the science of medicine, but the art, and such patients give each doctor a lifelong chance to grow.

Perhaps, this absolute necessity to treat each patient without judgment is what makes medicine unique and presents a special lesson.  Few other fields of life require the deliberate elimination of all prejudice.  The earth would be very different if we saw each individual’s characteristics and personality as what makes them special and instead of using those differences to segregate, built on those differences to benefit them and each of us.  It would make for an interesting world if we all played doctor and accepted every person for what they are.

16 Comments

  • I have comments on several of your columns. 1. Mother Theresa, it seems was not all she was made out to be. ( As an aside, Ralph Waldo Emerson went home for lunch every day.) 2. I fought with Hospice organizations for years in L.A. I made home visits to most of my dying patients. I could learn more in 15 seconds in the home than an hour in the office. Never charged for 'em. My patients on Hospice would say "but they only took my blood pressure-then they left!" Communication must become a 2-way street, which, I fear, is less than likely. 3. Finally, the dollar drives us all, some more than others. If medicine continues its current path, efficiency will trample compassion under its sharp heels, and time will suffocate the life out of empathy.
    • James Salwitz, MD
      I find it hard to believe that Emerson actually ever ate. I suspect Mother Theresa was more human, than icon, but still to be admired if only as an ideal. I absolutely agree in the value of walking into a patient's home. Even if I have "known" a patient for 10 years, what I know about them increases exponentially as soon as I walk in the door. Along that line I find that I have to push hospices to keep me in the loop, otherwise the only real contact I have is when I fill out the referral form and, two months later, complete the death certificate. Unfortunately, I agree fully with the threat to empathy from financially driven efficiency. Its not that compassion can not be given in an efficient manner, its that if the primary goal is to save dollars and not souls, humans suffer. Thank you very much for your observations. jcs
  • D Someya Reed
    I’m not sure I understand the intent of your sentence: Each physician knows, if he looks in his heart, the particular type of patient that “gets to him.” At first, I thought it referred to the “annoying” patient. A patient that the doctor, being human, might under treat with just the basics or choose to simply walk away from (refer elsewhere). But then perhaps it meant (because of the heart reference) the patient who “touches” the doctor in such a way to induce sympathy and makes it less likely he/she will be able to make objective decisions. I let it simmer a few days but no luck in reaching a single conclusion. Maybe you had something entirely different in mind? My immediate reaction to this post, however, was from the patient’s perspective. As much as patients want to know their doctor is blind to prejudices of any kind, they really want to know that their doctor is “the best doctor for them.” They want to know that their doctor “gets them”…understands them, their ailment(s) and their concerns. This is a tall order for doctors, especially from those patients whom they’ve likely just met. It can be done and is done by those doctors who simply listen. Not just “hear” but really listen. All patients know the doctors who “get them.” Even those who stubbornly refuse to admit it. Unfortunately, that doesn’t mean that the “annoying” patient will be any less annoying or the “overly needy” patient will not try to get a little more sympathy. But the “best” doctors also know when they’ve reached their patients. The rapport will be there. That’s what will get the communication going both ways. And, as in all things, time and money are the enemies of this actually happening. All doctors and all patients need to understand this. As to both yours and Dr. Kennedy’s comments, both of you have had not so good experiences communicating with hospices. I don’t find that surprising. Obviously, you both have seen my comments on other posts. I must point out that hospices, whether in person, on their websites or by phone, will always tell you that you can keep your own physician. They may even tell you that you can see that physician, if appropriate to their practice, for issues not related to the cause of your terminal illness (no curative allowed and they usually don’t dwell on who is responsible for your transportation). These will be said/done for marketing purposes even though hospices don’t like to admit to marketing to the dying. Getting hospices to keep a patient’s chosen doctor in the loop, well, that’s another thing entirely. CMS’ Conditions of Participation call for it. If CMS or the State agencies will not enforce it, though, nothing will change. To make matters worse, some hospices have “policies” that require both you, as patient, and your chosen attending physician to attend the interdisciplinary team meetings if either of you choose to be included in developing or changing the Plan of Care. Disturbing is not quite strong enough.
  • Your point about the "restrictions" placed by hospice care are a major reason I chose to visit dying patients, and do it for free. I could tell within 10 seconds after entering a home who was angry, who was resentful, and who was simply grieving. If those feelings were present, I wasn't finished doing my job. Sometimes I could do or say nothing more. But often, I was able to leave my patient a little more comfortable. Hospice care in my city is a business, with profit margins, salaries, and efficiency to worry about. Many hospice nurses are highly skilled and truly dedicated to their task. But time is money. Bottom line. Alas, in this setting, the "aura" in a home is too often missed, and even caring ministration is misinterpreted as "mechanical". Nurses or social workers who are good at their task are promoted to become administrators, and too quickly are forced to lose sight of the qualities that got them there in the first place. How does this happen? Part of it is the doctor's fault. Half of patients put on Hospice die within a week. To me, that means that somebody screwed up and didn't think ahead, or that an unrealistic promise of improvement was offered too late or inappropriately.
    • D Someya Reed
      You should be commended for the concern you show your patients. I hope family members have told you so. Good doctors don't hear it often enough. I agree with all you've said except for casting blame on doctors for short stays in hospice. Doctors are expected to promote hospice to their patients (hospice wants this to be their obligation) and yet are cast as blinded by the drive to “cure” or only seeking the money to be made. I don’t see the hospice industry promoting treatment options as an alternative to hospice even when the chance of improvement is there. Instead they maintain it’s the patient’s choice. Well, isn’t it the patient’s choice to stay curative? Why should doctors be responsible for the shortcomings of hospice’s marketing efforts and then be described as near “villains” only wanting to cause suffering to patients through machines, intubation, crushed chests and ribs, etc. If hospice truly wants to “partner” (non-collusively) with doctors then they need to be willing to share honest information. Doctors should have no more of an obligation than to offer this information to their patients and possibly offer to arrange a hospice consultation. No catchy phrases like “hospice is the more that can be done when nothing else can be done.” No intra-industry slamming of non-profits over for-profits. No patients benefit from this. Hospice then assumes all responsibility for end-of-life discussion as they claim to be “the experts” and “the gold standard” in end-of-life care. You won’t find an oncologist doing consultations for knee surgery. Detailed information needs to be available to the public regarding hospice usage which identifies the differences between hospice facilities so the public can make informed decisions. A perfect example of this NOT being done can be found on page 4 of NHPCO’s 2012 Facts & Figures: Hospice Care in America (from their website). 278,000 of the 1.65 million patients served by hospice in 2011 are listed as discharged “live” (16.85%). Reasons for this are “extended prognosis, desire for curative treatment and other.” These are “good” reasons, at least on the surface. Extended prognosis may well include patients who should not have been accepted as terminal in the first place. “Bad” reasons for this could be dissatisfaction with services provided, discharge for cause (reasons vary by individual hospice policy), forced rescission due to unusual high costs, etc. Every hospice that discharges a patient “live” absolutely knows why. If I have a choice of two hospices and one discharges 20 patients a year and the other discharges only 1 for reasons other than “they got better” or “they wanted to pursue a curative treatment,” is this not useful information for me? Additionally, this report states that “For 2011, NHPCO estimates that approximately 44.6% of all deaths in the United States were under the care of a hospice program (Figure 3).” Besides the fact of statistics prefaced with the phrase “estimates that approximately,” this statistic is incorrect based on the numbers used and should be 42.1%. This has been identified to the NHPCO but they refuse to change it and use the 44.6% as the way of saying nearly half of all deaths occur in hospice. The only fault I would attribute to doctors (relevant to hospice) is recommendations based on the “logic” that “a hospice is a hospice is a hospice.” Too many times, doctors recommend hospice without knowing anything about the hospices in the area. Who’s in the best position to honestly educate both doctors and the public…yes, hospice. Why won’t they?
      • James Salwitz, MD
        Given the explosive growth of hospices (we have 50 in tiny NJ alone), I applaud your thoughts on the need for transparency and data regarding quality and outcomes in the end-of-life healthcare space. You should note I am a fan of similar disclosure throughout the health industry, including regarding individual physicians. I had not thought of live discharges as being a low hanging fruit quality measure, but it clearly could be used in that way. I partially disagree with your thinking regarding end-of-life discussions and who should be responsible. I think the answer is probably both the primary treating MD (be it oncologist, family doc or cardiologist...) and hospice. The MD should start the discussion, because they know the patient's medical history best and can present the best balance of alternatives. They also have the closest relationship. Because the doctor needs to start the conversation, late referrals to hospice are more likely to be their "fault," especially when the doctor never brings up palliative care until the very "last minute." The hospice should continue the conversation by educating the patient and family about what services are available. Both should actively take care of the patient, while the patient is on hospice. One major flaw in the system, which is starting to change, is the failure of Medicare or private insurance to pay for palliative care which is not quite full press cancer care, but is not purely end-of-life hospice care. This area of palliative medicine, for example someone getting palliative radiation or chemo to control back pain from breast cancer in bone, is extremely valuable, but because it is not reimbursable (i.e. you cannot be on hospice while getting chemo or radiation because if you are getting treatment they do not pay for hospice and if you are on hospice they do not pay for treatment) is not available. It would really help to "bridge to hospice" if patients could receive both solid cancer care and supportive hospice (i.e. palliative) care at the same time. Thank you for your insightful comments, jcs
        • D Someya Reed
          I don't disagree that the doctor should be involved in the discussion. I do agree that they should bring it up and do so early on. You're absolutely correct that they know the patient/condition best. But if hospice wants to keep doctors at a disadvantage without telling them what they need to know to help their patients decide and, also, continue to try and cut the attending physician out of the picture (only need them for signoff) then the bridge to hospice will never occur. I believe that we have segregated palliative care as an entity that doesn't need to be segregated. By that I mean that palliative care is...at its simplest...good symptom control. Good symptom control can (and should) be done across the entire medical spectrum. Unfortunately, hard & fast standards of care, rules, laws, insurance risks and such come into play. If palliative care is brought up at the last minute then that is not a good doctor. We should be talking about futility of treatment and risks of adverse side effects when the concept of hospice is introduced...not pain control. If a patient's pain is what drives them to hospice then doctors aren't doing their job usually out of fear of legal/financial complications. Hospice should not be the place I go to get enough pain medication to make me feel better until I die.
      • Could not agree more. In my area, our primary hospital contracted with an agency which had clearly defined economic and political conflicts of interest. The arrangement was unfortunate at best. And so was the care. I'm aware of some very good hospice nurses, and some dedicated ones as well. And I was most grateful for their help. But I wonder, now that palliative and hospice care are becoming de rigeur, who will watch over them in the patient's and family's best interest?
        • James Salwitz, MD
          The need to better supervise and evaluate the quality of hospice care seems to be an increasing theme. I guess the good news is that home end-of-life care is becoming common. The challange will be to maintain standards. jcs
        • D Someya Reed
          Unfortunately, the answer to "who will watch over them...?" is "them" the patients and families. CMS only pursues hospice monetary fraud through the OIG. Patient complaints are left up to the States through their licensing entity's contract with CMS. In my State, L&C clearly does not want to get involved in patient complaints and claims they have neither authority over hospices nor the ability to enforce Federal law (Conditions of Participation, 2008). Both are untrue. They claim all they can do is refer to another agency and suggest complainants hire a civil attorney and sue in court. They and the hospice industry freely admit that the State does not enforce any sanctions against hospices due to patients' complaints no matter how egregious. Detailed testimony to relevant State legislative members, committees & such appears to fall on deaf ears but you will be told that if you speak out against hospice, "they'll start coming out of the walls" to shut you down. That part is true. But, sadly, most people experiencing a problem (problems) don't even come forward. It is difficult to relieve the death of your loved one in excruciating detail over and over again and it gets no easier with time. So what "tools" can we give "them" (the patients and families) to protect themselves from poor (or worse) staff or maybe good staff with poor (or worse) management either of which may not have the patient's best interest at heart? Education. The public doesn't want to talk about it. They don't want to hear that it happens. They really don't want to talk about death...anyone's. But if they know what good hospice looks like and acts like. If they know what rights they have, however minimal, they stand a chance of protecting themselves or their loved ones. Being informed wouldn't hurt even if they have the best experience possible under their individual circumstances. The hospice industry has had nearly 40 years to self-police themselves. They have no incentive to change the status quo. They feel that problems are rare because they state that good outcomes exceed the bad. So in an industry where the expected result (death, dignified or otherwise) has no chance to be re-done correctly, how many "bad" outcomes are OK?
          • James Salwitz, MD
            Is there any online rating system for hospices, as there is for physicians. Have any states yet mandated creating a registry of CMS or quality data? jcs
          • D Someya Reed
            In answer to your question (as I don't know where this will appear in the dialogue list): "Is there any online rating system for hospices, as there is for physicians. Have any states yet mandated creating a registry of CMS or quality data?" No, there is neither a rating system or state mandate. There isn't even a legally binding Patients Bill of Rights. No system of fines for breaches of anything, once every 8 year+ survey (their term for audit) schedule, etc. The only recourse CMS has with hospice is to revoke their ability to bill Medicare. The fact that you didn't know this, and I say this with absolutely no disrespect intended, illustrates my point that doctors (in general and I'm sure exceptions exist) refer patients to hospice with no idea of the quality of hospice(s) available to these patients. The patients/families must make this decision in the most stressful of circumstances. To make a comparison, I asked a friend who called as I was writing this...If you had no idea what a Toyota was other than a car and you had a pretty good idea what a car was, would you recommend that someone buy a Toyota? Doctors understand the concepts and philosophy of hospice but not the practicalities. That is left to the patient and family. So the patient/family selects one based on very little information available, mostly marketing brochures. The hospice may (and to be fair, not always) try to keep the doctor out of the loop for perhaps financial and/or control issues. The doctor may have to fight the hospice (as has been mentioned) to stay in the loop while all the time doing his/her regular practice. California, where I live, has a website that is a joint effort by the California Healthcare Foundation and UCSF at www.calqualitycare.org which is the best I've seen. I've actually met with the director of the project and was told that I am the only person in her decades of experience to ever come forward and talk about what actually happened in hospice. This lack of the families to come forward accounts for the absence of complaint data on the site. The eleven year average survey/audit schedule (as of 2008) accounts in part for the lack of quality information with the balance due to the lack of any enforcement. As I previously mentioned, only fraud $ are investigated not patient care or complaints. This makes the site, unfortunately, somewhat but not much better than going to your local State hospice association's list of hospices which is generally fed from the database maintained by the NHPCO. I've met many people since my wife died who have either tried to hold or have successfully held a hospice accountable for their actions in civil court. But what is the result of an award (and usually mediated)? The offending party admits to no wrongdoing and the injured party is not allowed to publicly discuss the case. Dollars won in this fashion may make a statement but no one can hear about it. Dollars won in this fashion can neither change what happened or prevent it from happening to someone else. That's why we need real laws to govern hospice.
  • D Someya Reed
    Just to get this post back on track...you can fault me for making it veer off in another direction...I'd like to add another thing about the "best doctors." The best doctors not only don't care who you are, where you're from, or any of the superficial things. What they do care about is how you feel. Not just physical hurting but emotionally and mentally. The best doctors will put a smile on your face just when you need it most. This is not through some false hope of improvement, outcome or cure but maybe just a wiggling of your big toe during morning rounds. Something that not only humanizes you but them also. My wife and I had the privilege of having some of the best doctors one could possibly ask for. She fell prey to the "fall in love with your doctor" syndrome with one and I enjoyed framing his picture next to our bedside and teasing her that I was going to ask him to autograph it. I did...he said he'd supply a better picture first. She asked me to do many things for her after she died. There was one she didn't ask me to do but I thought she'd like it. I went around and personally (and in person) thanked every good doctor who made her feel special. I know they appreciated it and didn't hear it often enough when I saw so many tears from so many eyes, both male and female alike.
    • James Salwitz, MD
      Doctors suffer the loss of every patient. I absolutely know that they really appreciate the thanks and support which they receive from families after a patient has died, perhaps more than docs understand. It goes a great way toward getting up the next morning and taking up the battle, once again. Thanks for bringing that love and support back to your wife's health care team. It makes a big difference not only for the physicians, but in the lives of future patients. jcs

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