Teach caring people how to be caring doctors

Let’s talk for a moment about medical education.  I went to a work-related party recently and rode in the elevator with a dear friend who is my contemporary, and a more senior and highly regarded faculty member known for her work in medical education.  Both were afraid for the future of medical education in different ways.

My contemporary was concerned that the emphasis on the use of advanced technologies like ultrasound will make residents dependent on these devices and unable to function without them. The more senior doctor was actually concerned that residents weren’t learning technologies adequately, a seemingly opposite opinion.

Then I read a nice post by a medicine intern: Is deep learning in medical education possible? In it, Dr. Peteet expresses his concern that superficial and strategic learning outweigh deep learning in medicine, and that the residency process emphasizes individual learning of acute illness in a large hospital setting and that the skills of collaboration and teamwork needed in the current medical climate are ignored.

Then I read posts touting the advantages of technology in the areas of both education and clinical practice, with both authors managing to emphasize the removal of the doctor from the hands-on care of the patient.  One was a wide-ranging and extremely optimistic evaluation of emerging diagnostic tools in the form of computer algorithms.  The other talked about simulators and simulated patients and how awesome and helpful they are.

Look.  You want to learn to be a doctor?  So go doctor.  On people.  That’s what doctors used to do.  Now you’ve got an office where the patient logs in in the waiting room to their personal data page, prints out an algorithm-generated list of medical priorities.  The patient then sticks their hand in another computer and gets their vitals taken.  Then they sit in another office and a nurse comes in and repeats all the information the computer has and asks you what your symptoms are.  She enters it in her computer, which generates a list of what is wrong with you based on your symptoms from most likely to least likely.  Then the medical student comes in and repeats it all and enters it in his computer, which he is adept at because he majored in molecular biology and biochemistry.  The resident then comes in and tries to do the same again but his beeper keeps going off.   Another technician comes in and does an EKG with his little machine.

The medical student takes his computer (given to him by the medical school) to his simulated patient in his artificial classroom and plays out scenarios involving how to break bad news to this patient or how to do a rectal examination.  The student then simulates doing a venipuncture on the simulated patient.  The resident sits in the back room updating the computer program that tracks his team’s inpatients and calling radiology because he can’t find the ultrasound machine he must have to do an arterial line on 98-year-old Mrs. Jones.

Meanwhile back at the office the actual real patient has not been seen or touched by an actual doctor since his arrival.

We have arrived at this utopia in a variety of ways, starting with the way we pick our medical students and going all the way through how we organize our private practices.  Medical students come fully equipped with a knowledge of how to get ahead in an academic situation and are adept at superficial and strategic learning.

Those who have a deep and abiding care for real people either don’t get in or don’t get far before that care is beaten out of them by the constant demands of technologies that remove the real people from their care.  Residents are used as grunt labor and to fill seats and write orders and chase down x-rays.  The intern sits in the lounge entering data in a computer while the attending deals with the gunshot wound.

We doctor real people.  Forget the radiology images.  Throw out the simulator.  Send the practice patient home.  Sabotage the robot.  Teach caring people how to be caring doctors.

Of the patient sitting right in front of us.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.

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  • Ron Smith

    Hi, Shirie.

    What a really great article! Good job!

    Re:
    ‘Look. You want to learn to be a doctor? So go doctor. On people. That’s what doctors used to do. ‘

    ~and~

    ‘Meanwhile back at the office the actual real patient has not been seen or touched by an actual doctor since his arrival.”

    ___
    I guess I’m a strange cat from the average digital aficionado that posts here and practices medicine. Three decades in Pediatrics have had their effect on me professionally, personally, and in other ways.

    I still think the best medicine is learned at the bedside or in the exam room with an experienced practitioner teaching the nuances that cannot be gleaned from most text books. Some of the most important things I learned about Pediatrics were never in print.

    The advent of high technology offers so many pitfalls as you have elaborated. The physician whose main focus is on a backlit screen of information *about* their patient reminds me of the parents who stood with me at their neonates bedside day after day in the NICU. They easily became absorbed by the monitors and the numbers and the alarms and its almost as if they were looking around for the remote control that had to be in the NICU bed somewhere! ;-)

    What makes a good physician then? You have to be able to assimilate the digital data while keeping the patient in focus. What I teach students and residents whenever I get the opportunity, is to understand, that there is a part of medicine inside of me that simply *knows* pretty much what is going on. That’s the result of *practice*. The questions to parents have become second nature and are not a ticked-off checklist, and they integrate smoothly into the extremely social nature of the entire medical examination. I always remember that these are people, and not medical subjects.

    I try to take their fears, needs, and desires into myself and mix my knowledge and expertise with it to give them my best thoughts and recommendations. Though the complaints are often repetitive, the people themselves are each different and they have come to mean a great deal to me. I try to keep my nose off the computer screen as much as possible and communicate.

    To up and coming physicians, nurse practitioners, and physician’s assistants, I say watch what we old codgers do! Imitate us. Take the best of us, chunk out the bad, and make things better. Use technology as a tool, but don’t let it rob you of best professional experience I can think of!

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • rbthe4th2

      Well said Dr. Smith.

    • Shirie Leng, MD

      Dr. Smith – you sound like the kind of doctor I want my kids to have. Thanks so much for reading!

  • Rachel Phillips

    The current use of technology in healthcare such as EHRs do take the physician and the healthcare team away from hands on patient care but that is not the fault of technology… it’s the fault of those who designed the technology and those who are forcing this ridiculously expensive, immature technology with penalties and incentives on our already stressed, floundering system. What these systems do is make the user (healthcare team) perform for the technology, not the technology perform for the user.

    I like this article because I think many healthcare providers become callous to the needs of the person by focusing on the disease, test results, treatments, computer charting etc. As an ICU RN, I’ll never forget this one particular day with 2 very deteriorating patients on vents and drips and at about 11 a.m. (after taking care of these 2 patients since 7 a.m.), focusing on stabilizing their clinical states, I was checking all the IV lines, drip doses, restraints, adjusting the ventilator tubing,.. and looking down through this mass of plastic tubing I caught sight of two very wide, very fearful eyes intently and almost imploringly looking up at me. Suddenly I realized that I had not even talked to this poor person buried under all the equipment and I felt a sudden rush of shame. I immediately stopped what I was doing, apologized to the patient, explained everything that was going on, what the plan was, reassuring them and from that day forward made the person and not the disease state the first and foremost priority. A little shame goes a long way!

    • rbthe4th2

      Thank you for caring, sharing and for recognizing another human in distress.

    • Shirie Leng, MD

      Thank you Rachel. I have done the same thing in the OR! I have to remember that my normal habitat is the patient’s brand new and very scary experience.