“What can you do here that we can’t do at home?”
This question angered my resident. How dare a patient admitted to the hospital ask for justification of their plan? The progress note had already been written and orders entered; assent to the plan was assumed and having to walk the patient through the options would extend rounds considerably. What an inconvenience.
“Don’t believe the patient. Go to the old charts first, write your note, then confirm.”
The lady was jaundiced and I went to see her first. There was no right upper quadrant pain, but she had yellow eyes and skin. She was intensely itchy. I reported her history to my resident and made sure to mention her lack of liver pain, which disagreed with the note from triage. We examined her together and tried to consult medicine, but they were busy. We admitted her. Later I looked at his note, where “RUQ pain” was listed among her symptoms.
These are only a few of the experiences I’ve had so far in clerkship that capture the dehumanizing aspects of medical treatment. I hesitate to call it care as that word has certain implications of concern for a fellow human being. Assuming patient assent to your plan, not including them in the development of said plan and dismissing their experience of illness in favor of medical records — all these oppose an ideal of patient-centered care.
Informed consent is a cornerstone of current medical practice. It is an ongoing process that involves making people aware of their options and risks and ensuring they can apply those risks to themselves. Consent can be withdrawn at any point. In much of the care I have seen, simple assent is sought, without collaboration with the patient or significant discussion of options. The exception would be before surgery where doctors do discuss options and possible complications. I take this exception to be an example of medicolegal awareness on the part of the physician, knowing the risks of being sued and attempting to shield oneself from such actions.
There are other trends in our field: the SOAP note being completed without the patient, the plan being simply assented to without discussion, and the history taken without talking to the patient. Watching this occur and knowing how it conflicts with the stated values of our institution and profession is disconcerting. Furthermore, such actions will be mimicked by trainees and perpetuated. This indoctrination in dehumanizing medical practice is being passed on as part of the hidden curriculum of medicine.
I have seen few break these trends. Perhaps it is the demands placed on trainees, the glut of information and guidelines along with ever changing expectations or worries about future employment. Perhaps stresses can breed complacency and the use of short cuts. Perhaps the templates and tools we use aid in the dehumanizing of medicine. Either way, overcoming such trends is not as simple as another workshop on informed consent or a reduction in resident hours. These issues are systemic and connected with the structure of the health care system, the roles of physicians, the definition of health itself and much more.
Cultural change is required to overcome such issues, change that does not start in the classroom of undergraduate medicine. We need an anthropological and philosophical study of medicine, and we need society to aid in restructuring our approach. And just as importantly, we need institutions that work to preserve the humanity of those we serve and overcome current barriers to providing care rather than treatment.