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The Dangerous Devolution of Physicians into Technicians

As I sat in my institution’s white coat ceremony this past fall, I listened to our dean describe the process of selecting the newest batch of future doctors. I’m an MD/PhD student, so this is my fifth time hearing this speech, but the statistics still blow my mind: less than 3% acceptance rate, dozens of 4.0’s from top colleges, near perfect MCATs, countless research publications, non-profits, military service, peace corps, industry experience, patents and clinical trials. The sad thing is, this list really shouldn’t surprise me. I’ve eaten lunch with prospective students, given tours, and even advised many of the newly-white-coated students who sat before me that afternoon. Almost 90% of our applicants are screened out based on MCAT scores, GPAs and class rank. Yes, there is some consideration of their recommendation letters and personal statements, but everyone is so qualified that even those all start to look the same. Of course, we still interview a lot of students. Three days a week, September through February, 15 applicants wearing uncomfortable new suits parade through the admissions office and we use two 30-minute conversations to decide which three out of each 15 get offered a spot.

With more applicants than ever, and a relatively static number of medical school and residency spots, there has been an increase in the use of metrics such as standardized test scores, GPAs and research publications to differentiate between applicants. Unfortunately, an emphasis on the unquantifiable attributes of physicians — the qualities that actually differentiate great clinicians from good ones — seems to have fallen by the wayside.

Growing up, I fell in love with medicine by reading authors like Atul Gawande (Complications, Better, The Checklist Manifesto), Siddhartha Mukherjee (Emperor of All Maladies) and Oliver Sacks (Uncle Tungsten, Awakenings, Seeing Voices). Physician-writers such as these help bring the world of medicine and research to the general public. But even more than that, they show that doctors can and should be more than just physicians. As health care providers, we work at the intersection of the physical and emotional aspects of the human condition. With such a privileged position comes the responsibility to observe, analyze and foster the connection that exists between these two often segregated dimensions of humanity.  

As I look at the entering classes below me, my peers and even those residents and young attendings ahead of me, I find fewer and fewer people who exemplify the characteristics of both a successful physician and a true student of the human condition. We have virtually unlimited access to the most intimate and pivotal moments in the lives of essentially complete strangers. We get to witness the beginnings and ends of lives, the receipt of life-changing news, and the long-term trajectories of both slow recovery and rapid decline. We should, perhaps even more so than sociologists, psychologists and anthropologists, be the ultimate scholars of humanity. Yet, doctors, and residents in particular, are so overworked that they rarely stop to observe the world they exist in, to reflect on it and to share their reflections with others or even just with themselves.

When we have protocols, paperwork, charting, conferences, deadlines, required research, seminars and scut, it’s an accomplishment just to check off everything on our list for the day. The idea of adding yet another “to do” seems daunting, and when it’s a seemingly unproductive item, there is no impetus to add it. Indeed, if we treat reflection and writing as just another item on our list, then it will be unproductive. Without the proper attitude and approach, the exercises of quiet observation of our surroundings, processing of the happenings of our day and reflection on our own reactions and thoughts is a useless exercise. But, if we don’t dedicate the proper time to these activities, they will never happen. So how do we fix this?

I don’t have the solution, but I suspect at least part of the answer lies in the way that Dr. Oliver Sacks approached his life and his work. Dr. Sacks was a prolific writer on a myriad of topics, but the overarching theme of his work was observation of and reflection on the human condition. In books such as his New York Times bestseller The Man Who Mistook His Wife for a Hat, he used his patients’ disorders as starting points for broader meditations on the ideas of consciousness and humanity. In his chapter on the title case study about Dr. P — a man whose mysterious neurological disorder caused him to have to identify people by the clothing they wore — Sacks begins by describing the case details, as anyone would with a case study. But as his narrative progresses, Sacks transitions into the broader implications of how this patient’s disorder, and subsequent coping mechanisms, are reflective of the different facets of human mental processes. He then takes his musings one step further and reflects on how he approached this patient’s case, describing how classical neurological principles failed him, and finally his realization that in order to help the patient,  he needed to embrace him as a person, not a medical case.

“Of course, the brain is a machine and a computer — everything in classical neurology is correct. But our mental processes, which constitute our being and life, are not just abstract and mechanical, but personal, as well — and, as such, involve not just classifying and categorizing, but continual judging and feeling also. If this is missing, we become computer-like.”

Sacks understood that science and medicine should not be  segregated from the rest of human existence. Instead, the practice of science and medicine gives us a means by which we can examine and explore the broader human experience, not from a position of presumed higher understanding, but rather in partnership with the rest of humanity.

Most recently, Sacks had published a New York Times piece last winter titled “My Own Life,” in which he reflected on his recent diagnosis of terminal cancer.  While this type of article has become almost commonplace in our self-publishing culture of online blogs and Facebook pages, there is something special about the way Sacks communicated his personal reflections. He simultaneously combines the air of a detached academic with the sensibility of a vulnerable writer who invites us to share in his most intimate emotions.

“Although it’s up to me as a neurologist to diagnose the disease and to think in therapeutic terms, I always want to address the person as much as the disease, and I’m very glad my own doctor feels similarly. I’m not just a case to him, I’m a person responding to the situation. So I somehow sit between the biology and the humanist point of view.”

We, as health care providers, have the enormous privilege of being granted access to the most intimate pieces of a person’s being — both their body and their soul. Instead of treating this privilege as an item on our “to do” list, we need to embrace it as an opportunity to learn. We are taught to recognize patterns of symptoms and disease sequelae and reduce them to a simple diagnostic code. We learn to follow algorithms and execute standard treatment protocols. Already, I’ve found that this becomes repetitive and mundane and eventually, it will be just  another item on our checklist. What will never be just another checkbox, however, is a patient’s soul — that part that isn’t governed by biology, genetics or physiology. This part of medicine can never be repetitive or mundane, because no two souls are the same.

So instead of just looking at patients through the lens of medicine, what if we look at them through the lens of humanity? How does this change our approach to medicine? And, more importantly, how does it change our approach to life? Do we notice things about our patients that we wouldn’t have otherwise? Do we notice things about ourselves? Do we reflect on this? Do we tell others about our reflections?

The origin of the word “doctor” is from the Latin word for “teacher.” Our responsibility to patients is not just to diagnose, but also to educate them on their diseases. But, because we are students of not just the human body but of the entire human condition, so, too, must we become educators on the human condition. What we can learn from our practice of medicine goes far beyond biological or epidemiological phenomena, and so what we give back should also extend far beyond medical insights and education.

“Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”

Amanda King (2 Posts)

Contributing Writer

Yale School of Medicine

A sleep-deprived, sanity-deficient MD/PhD student torn between the exciting promise of what lies ahead and the grueling reality of what it takes to get there.