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Bringing the ‘funk’ back in medicine

I was doing the occasional ridding of clutter from that attic after a long week at work, when I came across a personal statement that I wrote while applying for medical school. One of the lines that struck me the most was: “I promise to serve with unadulterated compassion, a compassion that will drive me to deliver more every day.”

I think most of us enter medical school with a lofty ambition — an ambition fuelled by the want to ‘make a difference’ or ‘cure cancer’. In some ways, much of this gets dissipated by the time we get to set flight out of the hangar —  ‘Houston, we have a problem’.

Something’s amiss

It is well recognised that the current era in medicine faces a plethora of disillusioned doctors (a reference to the famed article in TIME Magazine — ‘The Epidemic of Disillusioned Doctors’). The ‘aetiology’ for this ailment is ‘multifactorial’, as most of us would document, were we writing in a patient’s notes.

According to a 2012 survey, nearly eight out of 10 physicians are “somewhat pessimistic or very pessimistic about the future of the medical profession”. In 1973, 85 per cent of physicians said they had no doubts about their career choice. In 2008, only 6 per cent “described their morale as positive”.

The psychologist Herbert Freudenberger originally brought the term ‘burnout’ to professional and public awareness in 1973. LaRowe describes compassion fatigue as “a heavy heart, a debilitating weariness brought on by repetitive, empathic responses to pain and suffering of others”, whereby nurses may absorb and internalise the emotions of patients and, at times, co-workers.

Yes, there is a point where our emotional responsiveness is blunted by the constant flood of suffering we see every day. But, somehow, it puzzles me how anyone can completely lose empathy and transmute into a person walking into the wards with the predominating thought ‘I just need to get through this’, as eager patients wait for their doctor. When I look in my rear view mirror — at my nascent years as a doctor — I realise that patients want to first know how much you care, instead of how much you know.

It is true that we don’t function as that quintessential country doctor with that trademark leather case, going from home to home, visiting our patients with time not being a constraint, ending the consultation with a cup of tea, really getting to know the patient. This picture is so ingrained in every person’s mind that it just seems to not go away, primarily because we hold on to visions that are most ideal to our existence, even if they may not be realistic.

With the rapidly-burgeoning medical advances which have remarkably alleviated suffering and added years to our life spans, there have come inadvertent consequences, primarily affecting the doctor. As the great historian Arnold Toynbee puts it: “Nothing fails like success,” as he summarised all of history — of society, institutions and people. 

The consequence is that our role no longer pertains to being by the bedside providing the healing touch — we have increasing time constraints characterised by an ever-increasing patient load (an ageing population with multiple medical issues, requiring multiple clinic appointments and hospital admissions), paperwork and administrative roles.

The media certainly hasn’t helped in preserving the sanctity of the profession. There is no dispute that there are unscrupulous individuals, but the same exist in every occupation. Recurring reports of doctors ‘doing grossly wrong’ and ‘being the greediest roost around’ not only disillusions the general public, but also the young, ambitious, idealistic medical student/intern. This public perception does plant a seed of doubt about whether they are really pursuing something worthwhile that will evoke pride in what they do. Soon, this transforms into contempt as they progress in their careers, when a barrage of increasing responsibility rocks a nascent boat that has just ventured into the unknown.

Many of these would start to describe a similar account that Dr Tom Murphy, author of  Physician Burnout: A Guide to Recognition and Recovery conveys: “During my last several years of practice, each day seemed like a monumental struggle similar to that of the Greek mythological character Sisyphus. I tried simply to survive each over-scheduled, jam-packed clinical day, but it was fruitless, since I would just have to go through the same ordeal the next day, and the day after that. Like Sisyphus, I felt condemned by the burden of rolling a heavy boulder up a monumental hill only to have it roll back down, repeating this process for the rest of eternity.’

Is compassion the answer?

I was intrigued to look up the etymology of the word ‘compassion’ and realised that, through the years, the word has evolved into its present form via multiple transformations. It has rather mirrored the evolution that it achieves as we are transitioning as doctors — meandering ways through a convoluted world where it is not just a job; it is a lifestyle choice.

Just as faith only develops if we cultivate it, so does compassion. Faith is akin to compassion. We are all born with a spirit of empathy, but developing compassion takes continued effort, as does faith. It is our compass in the epoch we doctors live in. It guides us to serve with a higher sense of purpose and helps us keep going, even if it means ‘not attending the long-awaited date night with the partner’ or ‘that visiting theatre group with the friends’ because a patient needs us. 

Dr Danielle Ofri exemplifies this point in her book, What Doctors Feel, when she notes that the rate of severe diabetic complications in patients of doctors who rate high on a standard empathy scale is a remarkable 40 per cent better than those cared for by physicians with low empathy scores. Dr Ofri observes that this difference is comparable “to the benefits seen with the most intensive medical therapy”.

How patients feel about their medical interactions really does influence the efficacy of the care they receive, and doctors’ emotions about their work, in turn, influence the quality of the care they provide. We really have to evolve a philosophy for coursing through the meanders of this profession. A work philosophy involving a central dedication to ‘excellence’ and weeding all that peripheral distracting noise — a trait that is fundamental to each individual and organisation that has had a lasting impact on society (read Steve Jobs and his obsessional quest to do so and thereby, in his words, “put a dent in the universe”). Isn’t that the main reason why all of us decided to take up the stethoscope in the first place?

Listening

I was called to consult on a patient who had an acute kidney injury (AKI), well after recovering from an episode of sepsis — something a tad unusual, especially in the absence of an offending factor. He was being lined-up for a number of unnecessary (not to mention expensive) tests to investigate the above, since the admitting team was unable to ascertain the cause.

On walking into the room, I met a lovely bohemian couple, who looked very well for their age and despite being in the hospital for quite a while, had quite the cheerful disposition about themselves. They were certainly intriguing personalities and I decided to spend time to have the unscripted conversation. In a matter of 10 minutes, he opened up that he had symptoms indicative of prostate obstruction that were leading him to wake up multiple times in the night and, thereby, he was drinking less water during the day. The cause revealed itself. He admitted that no-one had spent more than a minute with him, so that he could open up about his current embarrassing predicament.

Looking back at this, I realised that a mere interaction that involves  ‘observe, listen and examine’ can, most of the time, yield a diagnosis and have a domino effect. In the process, we can curb costs by eliminating the need for many unnecessary investigations and save our cash-crunched systems, avoid ensuing inadvertent harm, reduce inpatient stays (and avoid the constant bed manager calls!) and, above all, a satisfied and happier patient leaves the hospital.

It is truly an empowering feeling to look after someone. Somehow, this way we end up enriching our lives as well (look back at the way you felt even when you helped an old lady cross that bustling street). No wonder that, subconsciously, we identify with some superhero from time to time.  Famed surgeon and writer Atul Gawande reckons  “the difference between triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s about mastery of rescue”.

So what is not ideal in our current conditions in medicine? Is the monetary contraction an issue? We’re still placed among top-earning professions (forget Donald Trump). Is it the bureaucracy? I think we are responsible for putting the politicians/officials in our Government/trade unions in place to represent us. Is it time for change? You decide. Are the patients having growing expectations? There will always be a small fraction we consider to have unrealistic expectations, but the vast majority are so very appreciative of our efforts, even if we often fail in achieving the desired outcome.

I ask you to look back again and remember why you entered this realm to heal. I am certain that it will give you a chance to redeem yourself and improve not only your life, but your patients’ as well.

Let me end this by signing off with what I wrote at the end of my medical school personal statement, quoting Michael A LaCombe from the Annals of Internal Medicine: ‘The best [doctors] seem to have a sixth sense about disease. They feel its presence, know it to be there, perceive its gravity before any intellectual process can define, catalogue and put it into words. Patients sense this about such a physician as well: that he is attentive, alert, ready; that he cares. No student of medicine should miss observing such an encounter. Of all the moments in medicine, this one is most filled with drama, with feeling, with history.”

Dr Sam Kant is a former Registrar in Renal Medicine at Cork University Hospital, now doing further training in Maryland, USA.

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