The very best physicians do not judge their patients

It occurs to me there are several keys to being an excellent physician.  One must love science, enjoy hard work, have the courage to make tough decisions, carry a modicum of intelligence and suffer angst at receiving 94% on an organic chemistry test.  In addition, the very best physicians, those we admire and to whom we flock, have a secret weapon.  They do not care.

I do not mean that they are unfeeling or apathetic.  Quite the opposite, the best are driven, passionate, and have an indomitable love of their fellow man.  I do not believe doctors do not care what happens to their patients, families or community.  Leading physicians are often devastated by bad outcomes and have guilt from every mistake they have ever made.  Moreover, of course, the best are not aloof or uninvolved in life around them.  That is obvious.

What I mean is that gifted doctors do not care about the what or who of each patient.  They are not influenced by personality, background, or individual quirk.  They do not care about the dozens of ways in which human beings catalog, rank and segregate each other.  Exemplary doctors are not prejudiced by age, sex, race, religion or creed. They are not moved by height, weight or smell.  They ignore social status, politics, or dollars on the table. They are oblivious to whether a patient is beautiful, ugly or scarred. They are not arbiters of habits such as smoking, drinking or drugs, except as they affect that person’s health.  In short, the very best physicians care about each patient as a human being, and do not judge the human being who is the patient.

The problem is that suspending judgment is an art in itself, and while it is at the core of the medical role, it is not natural or easy.  This sort of passionate objectivity takes time, experience and training to develop.  Human beings survive by constantly looking for patterns and we have a nasty habit of turning those patterns into judgment and prejudice.   Learning to suspend this natural reflex, so that a physician can accept each patient as a whole, working within his or her individual strengths and weakness, is a monumental challenge. Nevertheless, as long as a doctor falls into the trap of treating “that fat guy with cancer” and not “the guy with cancer who happens to be overweight,” he/she will fail to give objective care.   Prejudices left unrecognized result in treatment that is biased and inferior, and not the best medical care.

Maintaining this sort of objectivity, loving man for the simple fact that he is man, is a skill that can never be completely mastered.  Even the best doctor is not Mother Teresa or Mahatma Gandhi. Each physician knows, if he looks in his heart, the particular type of patient that “gets to him.”  These patients try that doctor’s professional focus and there is always the risk of uneven medical care.  On the other hand, one of the great joys of practicing medicine is the continuous challenge and opportunity to improve, not just in the science of medicine, but the art, and such patients give each doctor a lifelong chance to grow.

Perhaps, this absolute necessity to treat each patient without judgment is what makes medicine unique and presents a special lesson.  Few other fields of life require the deliberate elimination of all prejudice.  The earth would be very different if we saw each individual’s characteristics and personality as what makes them special and instead of using those differences to segregate, built on those differences to benefit them and each of us.  It would make for an interesting world if we all played doctor and accepted every person for what they are.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Anthony D

    “When I am able to resist the temptation to judge others, I can see them as teachers of forgiveness in my life, reminding me that I can only have peace of mind when I forgive rather than judge.”

    -Gerald Jampolsky-

    • James C Salwitz, MD

      Perhaps that is one of the roles of the physician in society … to be teachers of forgiveness.
      Thanks,
      jcs

      • rbthe4th2

        Hmmmm wish I could say that of a former doc, who did judge me and others. I had him tell me I pushed his buttons, and pointed out a number of uneven medical care decisions he gave, how he treated me. Dr. Ego didn’t like it. I’m glad we’re no longer together, but there’s someone who couldn’t forgive or forget. Thank you for the article Dr. Salwitz. I can still dream of a doc who doesn’t judge. Wish they were in this area.
        RB

        • James C Salwitz, MD

          I am glad you have left Dr. E. I have little understanding and no sympathy for a doctor who even allows himself to have buttons. Not in the job description. Keep looking, there are great docs out there.
          jcs

          • rbthe4th2

            It seems it is endemic to the practice itself. Another person I know had the same experience with another doctor in the practice. I’ve had several of them blame me for “non compliance” when it is clearly in the records that different doctors are telling me different directions. One says eat high protein, another says you need more green leafy veggies and another says you need to eat soft foods, less fiber, and another higher fiber. All documented. Got any suggestions? It seems most docs don’t want hard cases any more.

          • James C Salwitz, MD

            Very tough. I have two thoughts. First, the obvious, to educate yourself about you medical condition as much as possible. Second, perhaps more important, is to make certain you are seeing only one doctor. That way the doctor learns about your case, notes what does or doesn’t help, and develops a bond. Doctors tend to “start all over” when they see a complex case for the first time. The relationship, over time, is key.
            jcs

          • rbthe4th2

            Thank you for your comments. Yes, do so, but using peer reviewed medical literature gets me in trouble. I was told to go to a few different specialists, trying to coordinate all the various suggestions became the problem and no one person was going to handle it. Then I got blamed because I tried to take the best of everyone. Oh well …
            I appreciate the wonderful docs here. Lots of good ones are trying. I’m hoping I get that lucky one day.

  • http://methodicanarchist.keepandshare.com/ Jim Englert

    I’ve seen a good deal of interaction between physicians and alcoholics, running the gamut from strident judgment to non-judgment. And there is no doubt that your prescription for non-judgment makes far more significant and consistent contribution to eventual health.

    • James C Salwitz, MD

      At its most basic, non-judgement is not only necessary, it is what works.
      Thanks,
      jcs

  • PMD1234

    This is without doubt the hardest, requiring biblical strength of character, I wish I had it all the time. I try, really try. All I can do is take a deep breath, and try.

  • Barry Nuechterlein

    This is a wonderful article. It is hard to learn this. Maybe I find it so much easier to agree with the author’s viewpoint because I am visibly imperfect myself. I have a BMI of about 38. It has been worse, I used to have one of 45, but I know it’s bad.

    I hope my patients can see me as a doctor, not as a “fat doctor,” or (worse, as the nursing staff at one hospital where I did a locums called me) Dr. Barry-atric.

    Of course, my patients aren’t obligated to suspend judgment, but I hope they will. I AM obligated to suspend judgment, and I do my best to do so. I am imperfect at it, but I do my best.

    • guest

      I gained some weight and avoided going to my doctor, because I was embarrassed. I finally went in and immediately said something about my weight gain and what I was doing to try and take care of it. I muttered to him how I was embarrassed about it. He was very understanding and said, “I could stand to lose some weight, too. You know, doctors are human. We struggle with stuff just like you do.” I really appreciated what he said.

      He’s the best. I realize I shouldn’t have been so quick to assume he would judge me. We all struggle with something.

  • A_Surgeon

    Could not disagree more – with almost all of you. The greatest physicians are exceptionally good ‘judges’ of their patients. They also have a well developed sense of what the patient wants to hear: what will be acceptable. They accept there are some things you cannot change (in terms of character, personality or outlook) and treat accordingly. They judge, but keep their judgements to themselves. They do not assume till proven otherwise.

    We have drifted into this warm, fuzzy utopia where patients are always right and it is our job to give them whatever they want. They are not and we should not. There is, however, a problem: we are hamstrung by fear of litigation and other unreasonable external sanctions that we must also be great physicians by reading the signs of our times.

    “It is more important to know what kind of person has the disease than what disease the person has” Sir William Osler. Oh for those halcyon days …..

    • rbthe4th2

      Sorry, but having too many physicians make snap judgements about people (and they be wrong) is what has led us to the mess we’re all in: us vs. them. I’ve seen docs that once they get their minds set on something they’ll ruin a patients’ reputation, blacklist, etc. rather than admit they’re wrong.

  • http://briarcroft.wordpress.com/ Emily Gibson

    Dr. Salwitz,

    I’m stumbling on this a little late but your insight is no less appreciated. My patients taught me this in my 20 years of part time detox work in our community. Sometimes the best medical tool I could pull out of my black bag was a love for the suffering human being in front of me. It proved to be enough to care, care deeply and without judgment.

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