Many 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:
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
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?
Dr. Google in the ER