The medical hierarchy shift

by Carolyn Thomas   @HeartSisters   

treeJWVein-3832108_1280Many years before I finally left a decades-long professional relationship with my family physician, I had observed distressing changes in her practice. I didn’t say anything about these changes at first. They began with her new all-cash medical aesthetics clinic (think: nonstop before-and-after Botox videos looping in every exam room).

She did not post an actual sign in her waiting room telling her longtime patients what we all knew: “I Am No Longer Interested in the Practice of Family Medicine”  – but everything about her behaviours clearly announced that she’d already moved on without telling us.     .

One of the reasons that I said nothing in response to how she was gradually changing her practice at the time was my own entrenched acceptance of the hierarchy of medicine.

I grew up old-school. When I was a child, our family doctor held a revered position in our home (second only to Pope Pius XII, whose framed portrait hung on the kitchen wall). Dr. Zaritsky made house calls, delivered all five of my mother’s babies, and seemed to know everything about our family. He was the boss of our family’s health care. My parents never once questioned his medical advice, or sought a second opinion, for to do so would be insulting to the doctor.

Now, however, physicians are expected to embrace advances that Dr. Zaritsky could never have even imagined, things like patient empowerment and shared decision-making. Patients now feel free to leave online reviews of their doctors. They seek peer-to-peer health information from patient support groups. They openly question their physicians, and then consult Dr. Google for more answers. (Personally, I wouldn’t buy a coffeemaker without Googling first, so of course I’m going online for something as important as my health, too).

Some physicians respond to this perceived loss of respect by buying unfortunate coffee mugs that warn:

Don’t confuse your Google search with all my years of medical training!

A November 2018 survey conducted in 35 countries by the global education charity Varkey Foundation still ranks physicians as the most respected profession.

There’s a difference, though. We seem to hold the profession itself in high regard, yet a growing number of individual physicians are not feeling the  love. The hierarchy seems to be  shifting.

Dr. Dike Drummond is a Mayo Clinic-trained family physician who now spends a lot of his time working on the prevention of physician burnout. He describes this burnout as a downward spiral with three distinct symptoms:

  • physical/emotional exhaustion
  • reduced sense of personal accomplishment
  • depersonalization

It’s that last symptom that patients often notice first:  depersonalization.

Depersonalization, according to Dr. Drummond, includes the development of a negative, callous attitude toward patients and their concerns. The cardinal signs here, he warns, are cynicism, sarcasm and “feeling put upon by patients.”

As I have frequently noticed on social media, the blame for this burnout among medical professionals is often directed at the very people who inspired physicians to enter the practice of medicine in the first place: the patient, that self-absorbed, misguided sod who just can’t comprehend the problems that one’s doctors are facing.

Why do so many doctors blame patients?

When depersonalization happens in the traditional hierarchy of medicine, it may be heightened by what sociologists describe as a dominant group holding power in a given society (doctors) suddenly being disturbed by those who have historically had little power to dare question that dominance (patients).

Dr. Jackson Katz is an educator, author and filmmaker. In his TED talk, he had this to say about those who represent a dominant group:

“One of the ways that dominant systems maintain and reproduce themselves is that the dominant group is rarely challenged to even think about its dominance.

“It’s one of the key characteristics of power and privilege – the ability to go unexamined, in fact being rendered invisible in large measure even in the discourse about issues that are primarily about them.

“The dominant group doesn’t get paid attention to while they’re busy pointing fingers at others.”

No patient I know wants to be labeled as “difficult”, for we know that this label can demonstrably impact the quality of care we will receive. An interesting study on difficult patients(2) reported in the journal Health Affairs found that even though patients voiced a strong desire to engage in shared decision-making about treatment options with their physicians, several obstacles inhibit those discussions, including:

  • even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations
  • physicians can be authoritarian
  • the fear of being categorized as “difficult” prevents patients from participating more fully in their own health care.

When patients are called “difficult” just because they dare to speak up on medical issues that matter to us, we risk being dismissed or criticized for our efforts by those in the dominant group.

A small personal example: while presenting to Emergency with chest pain, nausea, sweating and pain radiating down my left arm, I was sternly scolded by a nurse who told me that I must stop asking questions of the E.R physician who had just misdiagnosed me with acid reflux:

“He’s a very good doctor, and he does NOT like to be questioned!”

The unacceptable question I had dared to ask the doctor that day as I was being sent home in mid-heart attack, already feeling embarrassed for making a big fuss over nothing, was this:

“But Doctor, what about this pain down my arm?”

Many patients who speak up can be accused of widespread “doctor-bashing” (as I have been for merely using the word “misdiagnosis”). Some patients are called names, as I have also been; some of my personal favourites include myopic, misleading, unhelpful, inaccurate, unfair, to list just a few aimed at me by one New Jersey Emergency physician. He didn’t like the word-for-word excerpt I had quoted from Dr. Catherine Kreatsoulas, a Harvard researcher who studies how women describe their cardiac symptoms in the E.R.

What I know is that it’s far easier for an angry person to attack a lowly patient than a Harvard researcher.

The dominant group has power, privilege and social status, and can feel entitled to react swiftly to voices saying what they don’t want to hear. That’s depersonalization for you. And until recently, patients (again, those who have historically had little power to dare question the dominant group) have accepted that traditional hierarchy with little resistance.

But another recent assault on the dominant group is now emerging: enter young medical trainees, as described in the European Heart Journal in May, 2019. (3)

“Medicine is painfully slow at accepting change. One reason for this slow transformation is that the current majority of the practicing physician workforce grew up in a society that emphasized deference to elders and submission to authority, when most teaching was done in traditional lecture halls with a one-way flow of information from lecturer to student.

“However, enacting change may become easier, as the millennial generation enters the workforce (including healthcare), and medical school curricula are increasingly shunning the traditional methods of teaching for more interactive methods.

“Millennials often view hierarchies as relics of an older era, and are more amenable to breaking down traditional roles and embracing open communication.”

The times, as Bob Dylan sang in 1964, they are a-changin’. . .

Pointing accusatory fingers at people who annoy you simply by needing you is very tempting. But depersonalization is not unique to doctors.

Whether you work in medicine or in a school classroom (teachers, for example, have the highest burnout rate of any public service job), depersonalization can be found.

Studies attribute burnout rates among nurses to low nurse-to-patient ratios, long shifts, and, ironically, dealing with difficult doctors who, as a British Journal of Nursing study described, “regard nurses as their hand-maidens.”(4)

If you really want to avoid burnout, don’t work in public accounting, where juggling heavy client loads, frequent business travel, crushing tax season schedules, and relentless filing deadlines throughout the year lead to prolonged periods of extreme stress and exhaustion.

Those who work in retail or the fast food industry suffer significantly high burnout rates due to very low pay, monotonous tasks, high staff turnover rates, job-related depression, and “not feeling valued.”

When it comes to medicine, however, my hunch is that most patients are, in fact, quite concerned about our own doctors’ professional frustrations. We hear them. We get it. We really do.

We value and respect good medical care, and want to trust that the physicians who provide good care will be around for a long time. We certainly don’t consider physicians to be our enemies, and are puzzled to be considered as such by any of them.

But the thing about being sick enough to seek medical care is that it’s often impossible to truly focus on the wants and needs of your physician when you’re ill or in pain or frightened. Perhaps that’s why some frustrated doctors openly refer to their patients as narcissistic“.

Patients cannot and must not be viewed as both the cause of and the solution to physician depersonalization.

It’s a pretty scary time to be a patient, in fact. So if you think it’s tough these days to be an overwhelmed doctor, just try being sick.

1. Yale Medical Library. “Women Medical Graduates in the 1940s and 1950s”, Yale University. http://exhibits.library.yale.edu/exhibits/show/100-years-women-ysm/women-medical-graduates-in-the

2. Dominick L. Frosch et al. “Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making.” Health Affairs. May 2012 vol. 31 no. 5 1030-1038

3. Muhammad Siyab Panhwar, Ankur Kalra. “Breaking Down the Hierarchy of Medicine.” European Heart Journal, Volume 40, Issue 19, 14 May 2019, 1482–1483.

4. Castledine SG. “Dealing with difficult doctors.” Br J Nurs. 2008 Nov 13-26;17(20):1305.

Image: JW Vein, Pixabay

.

Q:  How has your own history with physicians changed since your childhood?

See also:

Patient privacy, modesty, and staff burnout

Denial? Or doctorly deference?

When patients feel like hostages

Dr. Google in the ER

When doctors become patients

Patient engagement? How about doctor engagement?

 

15 thoughts on “The medical hierarchy shift

  1. I just returned from Victoria (October 10, 2019) where I had an angiogram at the Cardiac Short Care ward at the Royal Jubilee Hospital after waiting for 23 weeks though I was identified and referred as SEMI-URGENT at the beginning of May 2019 by my cardiologist Dr. Iqbal.

    The cardiologists and the nurses actually involved in doing the angiogram procedure were caring, patient and empathetic individuals. Regretably, the same could not be said of one of the nurses on the ward who shall remain nameless. She was rude, arrogant and totally insensitive to my needs or the needs of other patients. I am reporting her to the Patient Quality Care office on the island as no one should have to be subjected to the kind of abrasiveness and intolerance this nurse manifested to me and others.

    I had to be taken to the Emergency at Nanaimo Regional Hospital on Friday morning October 4 2019, due to what was believed to be an unstable (and unrelenting) angina attack. The nurses and doctors and technicians in the Emergency department and on the Cardiac ward where I was subsequently placed were so understanding and supportive. I was transferred to the Royal Jubilee Hospital on Tuesday October 8 to have an angiogram. As it turns out, the angiogram showed that I had minimal blockage in my arteries, not over 70% in the main artery as was indicated seemingly by the CT heart scan I had at the end of March 2019.

    I want to thank you so very much for the blog that you do and for the book that you have written. Both were incredible resources for me during the past 6 months. They helped me to get through what I found to be an excruciating time in my life experiencing constant chest pain, nausea, sweats, shoulder and arm and jaw pain.

    The cardiologists at the Royal Jubilee Hospital affirmed to me that my symptoms that have been manifesting themselves since mid October 2018 are not heart-related. So continues the journey to determine what indeed is making me sick if it is not heart disease. Wishing you the very best of what life has to offer. Keep up the good work. What you do makes an incredible difference.

    Liked by 1 person

    1. Hello Rose-Marie – thanks so much for sharing your experience here, and also for your kind words about my blog and my book.

      Yours is a ‘good news-bad news’ story throughout, isn’t it? Bad news to endure unrelenting angina (ouch!) but good news in Nanaimo with understanding supportive cardiac staff, who transferred you to the Jubilee (also good). But also bad news to be told your case is “semi-urgent” is frightening (and what does that even mean? is it URGENT or is it NOT?) and then to have to WAIT.

      Then good news about the caring and empathetic staff at the Jubilee cath lab, but REALLY bad news about that cardiac short-stay nurse. Good news that you will be sharing your opinions with the Island Health Quality Care folks about her behaviour. This is your right as a patient and a taxpayer, and your report may be personally responsible for preventing any future patients on that unit from being treated in a rude, arrogant and insensitive fashion!!!

      The news that your symptoms are NOT heart-related could be perceived as good news, but only if that news is accompanied by an alternative diagnosis and a treatment plan! If not cardiac, then what? I hope that you have been given some referrals for what comes next to help solve this mystery. I’m not a physician so cannot comment on your specific case except to say that “constant chest pain, nausea, sweats, shoulder and arm and jaw pain” sounds dreadful – and sure sounds cardiac in general!

      I don’t mean to poke the hornet’s nest, but have any of your docs considered <strong>coronary microvascular disease</strong>? (a non-obstructive condition often missed on standard diagnostic tests – including angio, which is the gold standard for diagnosing obstructive coronary artery disease, but not MVD). Dr. Tara Sedlak in Vancouver is a cardiologist with expertise in MVD (she trained with Dr Noel Bairy Merz in Los Angeles). She might be able to rule out MVD if you’re still stumped about what is causing your distressing symptoms. You can self-refer to her clinic by getting your GP to fax a referral request for an appointment to her at 604 875-5504. Again, I don’t mean to interfere – but it might be worth a try. Meanwhile, consider starting a Symptom Journal: date/time of day/ nature of each symptom (intensity, duration, description), what you were doing/feeling/thinking/eating in the hours leading up to a severe symptom episode etc. Often we can see a pattern start to emerge – also, quicker for docs to scan a one-pager of your Symptom Journal than listen to patients’ verbal descriptions.

      Good luck to you, Rose-Marie…

      Like

  2. As a child, I was rarely ill and don’t remember a family physician. However, in my chosen profession as a Registered Nurse for over 40 years, mostly in teaching hospitals, I experienced physicians at every level…both domineering and collegial.

    THEN I became a patient and discovered a whole new relationship with my personal physicians. Even before I learned to google I found one of the best ways to choose a personal Physician was to ask a Nurse that knew them….

    When I moved to Denver and did not know ANY physicians I found myself in need of a surgeon.I called the Surgical ICU at the local University Hospital and asked an ICU nurse Who is the best thyroid surgeon on staff?

    I believe that burn out is each physician’s and nurse’s personal issue that needs to be looked into by them. Everyone employed in any profession needs to periodically examine why they are working where they are working? Is it still fulfilling the reason they started working there? Every job has stresses, do they have a plan for handling stress in their lives?
    Are there working conditions that could be improved by approaching the employer?

    I have several physicians at my HMO who were able to find a better balance in their practice by leaving private practice or leaving tenured University positions to get more time to spend with patients by becoming an HMO salaried physician. When “trying to make a profit” in private practice and “cutthroat academic competition” were removed from the equation, they were able to be the patient-focused physicians they desired to be from the beginning.

    Taking personal responsibility is the name of the game for both patients and physicians…. along with not caring what other people think of you.

    In the 1980s when I resigned my position as a nursing supervisor to go back to floor nursing, my fellow nurses were shocked; no one had ever done that before. Getting ahead, getting a title, getting a bigger salary was the accepted goal…. rather than being the best at what you do and being fulfilled.

    My Cardiologist wants my input. He has learned over the past 8 years there are things I know about my body that are more informative than any textbook. He has grown as I have over the years. His nurses think I email him too often… I really don’t care what they think.

    My Cardiologist and I together have solved problems through phone and email that prevented numerous emergency room visits. He was a good physician to start, hopefully now an even better one.

    I know the Canadian health care system is different than the one here in America and I have often wondered if your socialized system offers more more patient and physician satisfaction than ours? From your accounts, maybe not.

    Liked by 1 person

    1. Hi Jill – I’ll start with your last comment first: Canadians continue to rank our health care system higher than Americans rank theirs. (Ours is not perfect, of course, but all Canadians know that we will get world-class care without ever needing to lose our homes or declare bankruptcy). Best short explanation of the reality of Canadian healthcare was, in my opinion, when Dr. Danielle Martin spoke to a US Senate hearing. Watch it and see what you think…

      Some of the medical care issues I’ve experienced here are those shared universally, unfortunately, no matter the private or public systems, particularly when it comes to women’s heart disease – except I don’t have to pay for them here.

      It sounds like you’ve been able to achieve a good balance that works well for you with your current cardiologist. It also seems that being a trained nurse, and knowing what and who to ask, is an advantage!

      While it’s true that personal burnout is the personal responsibility of each of us, my guess is that it’s actually more like depression: very gradual onset, worsening in severity while overwhelmed people try in vain to “normalize” symptoms and work harder/smarter.

      Like

  3. At 78, I’m old enough to remember house calls. They were when you were sick in bed.

    Now one is expected to get up, shower/shampoo, with Congestive HEART FAILURE, I need to take a bit of rest now, get dressed, prepare a water thermos, drive! to the MD. OH YEAH, see if I can get an appointment, hope this round doesn’t include diarrhea or UTI/urgency, park, walk to the office, wait, may be sent to a lab, at another location.

    Or wait until it gets worse, call an ambulance, go through ER WAIT, AND WHEN FINALLY SEE DOCTOR or nurse. “You should have gotten help at the first sign of this.”

    Liked by 2 people

    1. I’m imagining all the perils of simply making it to see a doctor!

      The housecall era was what healthcare bureaucrats would now boast about as “patient-centred care”. It made perfect sense: why should a really sick person be expected to drag themselves out of bed to travel to the doctor’s office (thus risking getting sicker, or making other people sick too?)

      I read once that Dr. William Osler (often called the “father of modern medicine”) established a home visiting program in which his Johns Hopkins University medical students could learn about the living conditions and personal problems of their patients.

      He believed that these were often the cause – not simply the result – of illness.

      Liked by 1 person

  4. It starts with the medical school entrance requirements. Too much emphasis placed on above-average “Intelligence” – ie, high scores from school, and none placed on the personality of the candidate.

    This results in too many temperamentally unsuited, but arrogantly intellectual graduates… Add to that the social imperative to be $ucce$$ful, and we have the recipe for our current mess.

    Liked by 1 person

    1. Hello Janet – I believe this was absolutely true – until improvement during the past couple of decades. Hence the traditional brainiac doc with zero people skills.

      My (now former) GP once warned me about a specialist she was referring me to: “You will hate him. He has no bedside manner, but he’s an excellent diagnostician.” The expectation seemed to be that somehow, we can’t have both in the same person (e.g. skill and personality).

      I’ve had the privilege recently of being asked to provide personal references for two young women applying to med school (both schools here in Canada), and I was SO impressed by the questions the schools are asking now.

      Yes, they’re looking for people who are smart, of course, but that is clearly not enough anymore. The reference questions were focused on the applicants’ volunteer activities, community involvement, friendships and character. It was SO encouraging (and both, I’m thrilled to say, were accepted by their first choice universities!)

      There is a shake-up in medicine these days, clearly observed in examples like female physicians organizing to fight the systemic Old Boys’ Club gender bias against women – especially in cardiology. Cardiologist Dr. Megha Prasad at Mayo Clinic recently wrote that 63% of female cardiologists report experiencing discrimination compared to only 22% of males.

      Lots of work to be done, but as Dr. Prasad writes, the reality does improve with every generation. Maybe we are just waiting for the Old Boys’ Club members to die off…

      Liked by 1 person

      1. I mentioned to my (female) cardiologist that, in my experience, male cardiologists tended to be more than a little arrogant and authoritarian. She almost burst out laughing before covering her mouth and pulling herself together, to answer with a noncommital “you may be right.”

        In my experience (and of course, there are always exceptions in both directions), female doctors are more likely to be collaborative, whereas male doctors (who benefit from TWO separate hierarchies here–three if they’re also white) are more likely to be more authoritarian, impatient with patients. Honestly, that’s why almost all of my doctors are women now. Something in the way we’re raised, I think.

        Thanks for sharing Dr. Katz’s comments. They apply profoundly to my workplace, where the people on top keep trying to discover the source of “the problem” in the workplace, often hiring consultants to discover it, never once considering that THEY (the bosses) might be “the problem.”

        Liked by 1 person

        1. Thanks for this, Wendy! You raise such an important point: this ‘dominant group’ behaviour applies everywhere, not just in the medical profession.

          There have been a number of studies (this one from Harvard, for example) suggesting that (in the Emergency Department, for example) patient outcomes actually improve if they’ve been seen by a female doctor compared to a male doc (one exception: if seen by a male doc who also works alongside a number of female docs!)

          Personally, I know from my own experience that there are wonderful, kind, caring, skilled male physicians, and there are female physicians I would never ever want to see.

          I have an assortment of docs, and I LOVE them all (specifically, a female GP, male cardiologist and male pain specialist). These are the special ones: clinicians who don’t need empathy training because they were born empathetic…

          Liked by 1 person

    2. Oversimplification, I think. Why would above average intelligence lead to “arrogantly intellectual graduates”? Do you think personality plus greed is the “recipe for our current mess”? Do you believe that all doctors can be defined by these statements?

      How about taking young, idealistic individuals and putting them into an abusive situation where they are terrorized and ridiculed, work extremely long hours studying and trying to learn the complexities of modern medicine, and giving up their 20s (that’s on average 7 years and up to 15) to become physicians?

      Interestingly enough, I am making the same salary I made 20 years ago, hardly a social imperative to be $ucce$$ful.

      Like

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