I used to work as an anesthesia tech at a hospital in Austin, TX. I was surprised the first time a doctor asked me, his incredulous tone dripping with disbelief, “Why would you want to want to go to medical school?” It wasn’t the last time that happened, it wasn’t exactly making me excited to go to school, and it wasn’t a flattering reflection of the doctors that said it, but physician cynicism about the future of health care wasn’t something new to me, either. People fear change, but I think people’s perceptions about impending change are shaped just as much by their perceptions of themselves, especially the interacting dynamics between themselves and their evolving environment.
Personally, I know that I have changed significantly since my time working at that particular medical center. I remember my first clinic site visit of medical school, when a mother brought her 10-year-old son to the pediatrician, and I listened patiently and sympathetically as the mother recounted symptoms of anxiety, depression and anger in her son, along with subtle inferences about this family’s meager finances and broken family dynamics. The pediatrician told me in confidence, after I had taken the history alone, that these symptoms were exaggerated: the mother was yearning for a quick fix, or even worse, desiring benzodiazepine medication for herself. And I believed the pediatrician.
Shortly thereafter, I wrote an essay about the patient-doctor fiduciary relationship, and the need to inflict short-term harm by calling child protective services in cases where the long-term household instability could be improved by requesting intervention from state agencies. I had been influenced by the pediatrician’s “diagnosis” of the family; I still believe that it is difficult, but necessary, to remove pediatric patients from deleterious environments if the situation warrants such intervention, but I didn’t think of the child’s family as the source of the problem until the physician suggested it. I also wrote about the need to be honest with one’s patient, and how the “nature of [medical] information, as personal as it is, and the unique intellectual power [and training that] doctors possess, make honesty a prerequisite in doctor-patient relationships.” I still hold this belief in utmost regard.
However, many doctors’ skepticism about the honesty of their patients, and the fact that face-to-face acknowledgement contrasts so starkly with back-room cynicism, casts a shadow of doubt on my faith in honesty as it pertains to the medical profession. I’ve never witnessed dishonesty, and I don’t label the aforementioned example as such, but not every patient encounter is a case of forthright conversation, either. While I re-read my idealistic beliefs from a year earlier, I realized that I’m adopting some of the cynicism that I’ve witnessed in others since matriculating into medical school, but I know that it’s largely a by-product of a new environment.
I recently assisted in the care of a diabetic kidney-transplant patient at a volunteer clinic near my school. Because he was a long-standing patient of the clinic, we could review his chart and progress for the past seven years, but the long list of updated medications for various health problems made it difficult to keep track of his case. The fact that he didn’t speak English exacerbated his case, but I did my best to act as translator for our small team of volunteers. The patient’s voice was soft and calm, as if he was resigned to the myriad of problems afflicting his body. His chart chronicled “non-compliant insulin therapy” several years earlier, which the fourth-year medical student read without surprise. In retrospect, I can’t imagine the trepidation this man must have felt, waiting four hours for a group of gringo doctors-in-training to sort through his paperwork, perform exams, deliver news through a mediocre translator, and not just that day but for the past seven years, relying on such resources to manage what he knew to be a complicated, if not unpromising, case.
Little does he know of his caretaker’s skepticism about the adherence to his therapy, a product of an ingrained physician belief that many patients either do not care or simply refuse to listen to their doctor. In broken Spanish?! Who knows if I even enunciated his instructions clearly; no wonder I recognized the resignation in his voice. Yet we come to believe what we experience, that diabetic patients are “non-compliant” (it says so in his chart), probably because they’re lazy or don’t care, right? This patient experience came after I wrote about patient autonomy in yet another essay. I talked about how the best possible patient care, however subjective that concept may be, can be defined by the patient’s conferred knowledge and his informed decision, a responsibility that entails the doctor foremost. What I didn’t address are the gaps in communication, half-truths, and patient-doctor skepticism that have permeated through the consciousness of both parties, intentional or not, and how self-perpetuating these beliefs can be. I recently saw an ethics article wherein Dr. Hébert wrote, “Lack of candour or outright deception, even when well intentioned, can undermine the public’s confidence in the medical profession.” No, I do not believe that doctors are deceitful, but our attitudes have shaped our perceptions, and Hébert’s words ring like a warning rather than an observation.
I’m sure many students have taken opportunities like this to rant or focus on the pessimistic drift they’ve begun upon since entering medical school, yet I don’t see the need to conform to such an attitude, whether its after-effects can be seen in the older physician population or not. If I hold autonomy among the utmost of covenants in patient interactions, then I will value that same level of importance for myself, avoiding popular belief, and shaping my own perceptions. Change is inevitable, but it isn’t required after nine months of medical school. One year ago I said that my school’s white coat ceremony made me feel no different in terms of my professional or personal development, and honestly, I still feel that same way. I change slowly, but I hope I’ll acknowledge that change, recognize it, and avoid its many pitfalls. French author Francois de La Rochefoucauld once said, “The only thing constant in life is change.” That is only one of the many reasons why older doctors questioning my desire to join their profession seemed so outrageous, because like everything, the essence of being a physician is changing. Unfortunately I dread some of the unavoidable changes that I will undergo by their age, a product of my perceptions molded by the dynamics of my environment, but others I welcome, because I have infinite faith that the future I head towards will be different, improved and definitely worth it. Call me naïve if you want.