Wednesday, August 15, 2012

Physicians, Humility and the Transformation of American Healthcare


“A disease and its treatment can be a series of humiliations, a chisel for humility”
                                                                                                                                           Laurel Lee
                                                                                                                                        
“Fullness of knowledge always means some understanding of the depths of our ignorance, and that is always conducive to humility and reverence.”                                 Robert Millikan

“Humility is nothing less but a right judgment of ourselves.”                                  William Law

“Early in life I had to choose between honest arrogance and hypocritical humility.  I chose the former and have seen no reason to change.”                                                Frank Lloyd Wright

“Humility is the foundation of all the other virtues hence, in the soul in which this virtue does not exist there cannot be any other virtue except in mere appearance.         Saint Augustine
                                                                                                                                 


Three physicians got me thinking about humility.

At the health care innovations summit in Washington, DC earlier this year, I heard Atul Gawande, MD call for medical schools to do a better job at training physicians in humility, discipline, and teamwork (http://careandcost.com/2012/02/03/notes-on-the-care-innovation-summit/).  In a 2010 Stanford School of Medicine Commencement speech, Dr. Gawande stated:

“And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had:  values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and perhaps above all, humility – for we need humility to recognize that, under conditions of complexity, no technology will be infallible.  No individual will be, either.”

Eric Van De Graaff, MD wrote a blog titled “Why Are So Many Doctors Complete Jerks?” Dr. Van De Graaff was chagrined when his own mother was disappointed when he became a physician; she “had a deep-seated disdain for doctors.”  Dr. Van De Graaff answered his own question with two theories. His first theory was that some physicians “let the glory of their careers go to their heads and begin to treat patients and underlings like chewing gum on a movie theater floor.”  His second theory was that physicians act like jerks when emergencies occur and they feel overwhelmed and frightened.

Dr. Van De Graaff offers two simple rules, which he admits he sometimes does not follow:

“Rule #1:  It is simply not allowable to be impolite, mean, nasty, or snippy with staff or patients even when you are in a stressful situation.

Rule #2:  Whatever is stressing you is probably stressing those around you as much or more. Under those circumstances you have to go out of your way to be kinder and more understanding.  As a doctor, you control the mood in the clinic and operating room even if you can’t control the situation.” (http://www.kevinmd.com/blog/2012/08/doctors-complete-jerks.html)

A physician left the following comment on the above Van De Graaff blog post:

“Frustrations and stress mount, yes. I think in medicine we should be aware that continuing bad behavior is partially the responsibility of us all. We have social standards and maybe should ask ourselves how much have we allowed these actions to continue? None of us function in a vacuum.  We all have the ability to affect change and reward positive communication.”

How do we as a community of physicians respond to these three physicians who are clearly calling for physicians to exhibit more humility in our practice of medicine?  Do we know how to affect this change in behavior in our colleagues and ourselves?  T. S. Eliot once wrote, “Humility is the most difficult of all virtues; nothing dies harder than the desire to think well of oneself.” (‪Shakespeare and the Stoicism of Seneca.‬ ‪An address read before the Shakespeare Association 18th March, 1927)‬

The English words humility and humble are derived from the Latin noun humilitas and the adjective humilis which can be defined as grounded, from the earth, respectful, unassuming, modest, and low.  Humility is often contrasted with the terms pride, haughtiness, and arrogance (See the Frank Lloyd Wright quotation at the beginning of this post).  Humility has been held up as a virtue in both religious and ethical writings. 

Pride and arrogance are commonplace among physicians and provide the punch line for the famous New Yorker cartoon where a physician goes to the front of the line in heaven “because he thinks he is God.” In the Christian tradition, part of humility is self-knowledge about the limits of one’s own skills, knowledge, and authority.  (http://www.wikihow.com/Be-Humble)  When a professional like a physician or a teacher does have superior content knowledge when compared to the patient or the student, arrogance is an all too common attitude.  Bertrand Russell was talking about teaching, but his lesson applies to physicians as well:

“In the presence of a child [the teacher] feels an unaccountable humility – a humility not easily defensible on any rational ground, and yet somehow nearer to wisdom than the easy self-confidence of many parents and teachers.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)

The Harvard psychiatrist Robert Coles thought the greatest achievement of his mentor physician/poet William Carlos Williams “was to teach doctors honest self-scrutiny, to show how ‘we become full of ourselves, self-preoccupied, so caught up in either our importance or our own affairs that we can’t listen and pay attention to other people, even our patients at times.’”  (Carlin Romano. America the Philosophical, New York:  Knopf, 2012).

Honest self-scrutiny of physician limitations is particularly relevant now that medical group practices, hospitals, and integrated delivery systems are undergoing process work redesign in order to respond to federal health care and payment reform.  Socrates criticized craftsmen and poets for assuming that the knowledge and expertise they acquired in one area meant that they were experts in any area under discussion. (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)   Having sat in on many lean workgroups, there is a tendency for physicians to pontificate on subjects about which they know little. 

Another component of humility in Christian teachings is the recognition of the contributions and skills of others (http://www.wikihow.com/Be-Humble). Dr. Gawande has spoken eloquently about how traditionally medicine has emphasized   independence and autonomy (acting like cowboys) and how the complexity and need to decrease per-capita costs now require physicians to work effectively in interdisciplinary teams, even when they are not the designated leaders (acting like pit crews) (http://page2anesthesiology.org/2011/teamwork-humility-and-generosity-opening-session-with-atul-gawande-m-d/) In my experience consulting with physician groups, I have noticed that doctors are much more willing to listen to another physician, rather than a non-physician advisor who may have more content expertise relevant to the problem under discussion.  Developing more skill in this component of humility would help develop effective and efficient teams. 

If the physician does not maintain the correct balance between authority and humility, difficulties can arise in taking the patient’ s story and wishes seriously or in not critically assessing the patient’s wishes that may be unknowingly harmful to his health.  Dennis Gunning discusses this ideal balance in teaching history:

“It is hard for a teacher not to feel uneasy when faced with a fourteen-year-old giving an unorthodox interpretation of a piece of source material.  We really have to school ourselves not to ‘put him right’, not to sweep his interpretation aside (or, equally bad, apparently accept it, but in such a way that everybody knows that we are just humouring the student.)” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)

One does not have to recall that the first definition of doctor in the Oxford English Dictionary is “teacher, instructor; one who gives instruction in some branch of knowledge” to see how Gunning’s advice might apply to the physician/patient relationship. 

How difficult and important this balancing act can be for physicians is highlighted by our need to continuously improve the care we give our patients.  Henry Sidgwick in 1874 commented on how strange it is for those who are experts to embrace a humility that requires a low opinion of one’s self. Would it make more sense to try for an accurate appraisal of one’s abilities? “Sidgwick suggested that the value of humility lay in its ability to temper the emotion of self-admiration, and to prevent appropriate self-esteem…from turning into self complacency.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf) Sidgwick believes that those who lack humility will exhibit self-satisfaction and complacency that will prevent the recognition of the need for continuous improvement. 

When organizations need to change behavior, they rarely consult philosophers and theologians about humility; they usually look to rules with some sort of policing mechanism and incentives.  And we now have hospitals and payers instituting rules governing physician conduct, pay for performance incentives, and patient satisfaction surveys to encourage us to improve.  I have described elsewhere why physician report cards are fraught with difficulties (http://thehealthcareblog.com/blog/2010/08/21/trust-me-im-a-doctor-vs-physician-quality-report-cards/ and http://kentbottles.blogspot.com/2010/08/physician-quality-report-cards-part-ii.html) and why pay for performance programs often fail (http://www.kentbottles.com/pdfs/Pay-for-Performance-Why-It-Will-Not-Work.pdf). 

Barry Schwartz and Kenneth Sharpe in Practical Wisdom: The Right Way to Do the Right Thing (New York:  Riverhead Books, 2010) make a convincing argument that hospitals and medical groups should add training in practical wisdom in addition to their rules and incentives.  Drawing upon Aristotle’s Nicomachean Ethics, they think physicians need to be able, with humility, to choose between “right things that clash, or between better and best, or sometimes between bad and worse.”

“Rules can’t tell experienced practitioners how to do the constant interpretation and balancing that is part of their everyday work. Consider the doctor who has been well educated in the rules of how to practice medicine, but is constantly called on to make more complicated decisions.  How should such a doctor balance respect for the autonomy of her patients when it comes to making decisions with the knowledge that sometimes the patient is not the best judge of what is needed? How should the doctor balance empathetic involvement with each patient with the detachment needed to make sound judgments?... How should the doctor balance the desire to tell patients the truth, no matter how difficult, with the desire to be kind?”

Schwartz and Sharpe teach us that practical wisdom “depended on our ability to perceive the situation, to have the appropriate feelings or desires about it, to deliberate about what was appropriate in these circumstances, and to act.”

My favorite example of practical wisdom is their discussion of a hospital janitor who cleans the room of a comatose young man and then later is confronted by the patient’s father who claims the room has not been cleaned.  The janitor exhibits practical wisdom by remembering that his goal is to care and comfort patients and their families, and so he cleans the room again so the father can see him do it.

“And when the angry father confronted him, Luke also had to sort out conflicting aims.  There were other legitimate things he might have chosen to do.  Be honest:  tell the father he had cleaned the room already.  Be courageous:  stand up to the father’s anger and refuse the unfair demand to clean the room again.  But Luke had to determine how to balance these competing aims in this circumstance.”

It seems to me that a better and deeper understanding of humility by the physician community of the United States would serve all of us well in this time of rapid change and health care reform. 






5 comments:

  1. Thoughtful and written with love.

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  4. Thanks so much Dr. B for this profoundly insightful post. As a patient, I've experienced extremes of humility (or lack thereof) in the physicians who have treated me, including my own three favourites - my GP, my cardiologist, and my pain specialist - who are neither proud nor arrogant, but genuinely caring, skilled caregivers and all-round decent people.

    I do want to add my observation here about the title of Eric Van De Graaff's KevinMD post you quote: "Why Are So Many Doctors Complete Jerks?" As I know personally from having my own posts re-published on KevinMD, the author's original title is not necessarily what KevinMD editors end up using as an attention-grabbing headline. I'm guessing that Dr. Eric himself did not write that unfortunately inflammatory title. There are jerks practicing medicine, just as there are jerks who are patients - and that's true for every single profession, too. Let's not increase the adversarial 'them vs us' divide any more than absolutely required!

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