Physician as Professional

20 May

The Physician as Professional

Here is someone . . . who knows what she’s doing.

My friend, a very good internist, had just started his practice in a small New England town and was making hospital rounds on his partner’s patients one Saturday morning. In those days, the early 1970s, he was somewhat of a hippie and dressed the part—flannel shirt, sandals, beard, and ponytail. His first patient,  an 80-year-old Yankee dowager, eyed him carefully—and promptly dismissed him. In a strong voice, she declared, “You won’t do!” What she meant was, “I don’t know you, but your appearance suggests to me that you’re a bit odd, and what I need is a doctor, in the image of my cur- rent physician—a properly dressed man, a real professional.” The packag- ing was wrong, and she would not look beyond that.

I tell my students this story in order to introduce the question, “What is a professional?” and to address the role of physician as professional. Is the physician merely a technician,  educated in anatomy, histology, and the other basic sciences and skilled in diagnosis and treatment,  or is there more? From whose standpoint  should we address the question? The pa- tient’s? The physician’s? The third parties’—hospitals, insurers, govern- ment, and related institutions? Or all of them?

A concerned family member gives advice to her relative with chest pain by saying, “When my husband had chest pain, his doctor gave him a stress

test.” The firefighter takes the blood pressure of someone who has a head- ache and says, “The blood pressure is normal.” What does the physician do that these well-meaning people cannot? What makes the physician a pro- fessional? What qualities, if absent, are cause for change to another physi- cian? Insights and answers to these come from listening to people in careers unrelated to medicine.

My long-time mechanic looks after my used Volvo. I am truly unin- formed about the way my car works, and so when I take it in, I rely on him to provide answers. I listen to his explanation, for not only does he tell me what he proposes to do or what he has done, but he tells me why. More than a technician, he helps me understand what is wrong in language I under- stand. As my car has aged, he has told me what is worth fixing and what is not, and when it is time to give up and trade the car in. Even though he has a potential conflict of interest—he works fee-for-service and clearly makes a living from fixing cars—I trust that he will not take advantage of me. Our first encounter proved that. The rear of my car shook whenever I drove over twenty miles per hour. He discovered the cause, a tire that needed to be replaced, sent me to a tire store, and did not charge me for his “examina- tion” and his advice. I invited him to talk to my class about the qualities of his work that make him a professional. Here are the highlights:

[Being a professional means having] technical ability and knowing where to go to get the answers. What you don’t know, you’ll continue to learn. The real profes- sionals take the challenges…. Updating the client, discussing options… integ- rity, going for the customer’s greatest good even though it may not be what they want. If what they want leaves them with an unsafe car because they won’t allow me to fix something essential, then I won’t work on it…. Accountability: If you make mistakes, it’s essential that you are up-front. . . . Diagnosis is finding out what’s right, which helps finding out what’s wrong…. Having joy in your work, which is infectious, inspires other people, converts problems into opportunities.

His closing words of wisdom: “Unless you are all of this, you’ll get a lot of one-time customers.”

A public relations expert who once worked for a hospital consortium also spoke to the class. She described her work as “a researcher, teacher, fa- cilitator, nudger, writer, and advocate… as ifI have a desk in every hospi- tal.” She said, Communication is two-way. It doesn’t work without feedback. Integrity and hon- esty are much more important than saying what they want to hear…. My job is to elevate the clients to think about the greater good….I get joy from watching the

light bulbs go off, when my clients and I are sitting around the table…. Being a professional is being comfortable giving away my ideas, like a teacher.

The president of a small recording company talked about all the experiences that I drew upon to be where I am, jobs that I had that I didn’t like…a passion for doing what I do….I juggle many connections. …I work with people around me who love what they do….I want to present music with honesty and integrity…. I’ve had to learn to negotiate relationships that reflect honesty and integrity….I learn new things about an industry from doing what I do every day. I’m learning all the time.

A public relations consultant talked about connections. When a poten- tial client called him with a project outside his area of expertise, he told the client that he would connect with someone who knew the field. His client asked that he oversee the project, even though he was not doing the actual work, because he recognized that the consultant would be his advocate.

Another speaker used to be an international “pork jobber,” a middleman connecting sellers with manufacturers. But he also made other sorts of con- nections. He used his knowledge of the market’s potential to make recom- mendations to manufacturers about their assembly-line layouts. He came up with new ideas enabling slaughterhouses to use pork parts they usually discarded. He applied what he had learned in new creative ways.

All of these people are “professionals.” Some, like the auto mechanic, had specific technical training. The public relations man and the pork job- ber learned much of their skill on the job. They all combine many profes- sional qualities: They are reliable and trustworthy; they neutralize any potential conflicts of interest with their integrity. They communicate well and help their clients understand. They are self-critical, collaborate with others, and know their limitations. They oversee and advocate for their cli- ents in complex situations. They look at problems in new ways and come up with original ideas. They create new connections between people and between ideas. They see additional opportunities that can benefit their cli- ents. They are experienced; that is, they not only have an awareness of simi- lar situations from their professional lives, but they are also sufficiently reflective to know what can go wrong and what to anticipate. They are pas- sionate about their work; they get joy from it. They work to build relation- ships with their  clients; without  the  relationships, they would be less effective.

A professional’s skills are transferable from one setting to another. The president of one corporation can move into a completely different setting with ease and use her insights and experience; all she needs is to learn the issues peculiar to the new position. And sometimes it even helps to have come from a different field, for then she can take a new, original, and cre- ative look at the new situation. And so it is not surprising that the pork ped- dler is now a hospital chaplain, and the recording company executive used to be a schoolteacher.

PROFESSIONAL QUALITIES OF THE PHYSICIAN

What qualities, beyond technical knowledge and skill, define the physi- cian as professional? Consider this complex medical history.

Following a neck injury that had caused arm weakness from pressure on his spinal cord, a 42-year-old man had cervical spine fusion surgery and was placed in a neck brace to immobilize his neck while it healed. Two days after surgery, he became confused. The nurse thought that his confusion might be related to the intrave- nous morphine being used for pain control. The neurosurgeon arranged for inter- nal medicine consultation. The internist explored possible causes of the confusion by reading the hospital chart, reviewing the story with the patient and his wife, ex- amining the patient, and performing a number of tests.

The internist stopped the morphine and corticosteroid medication, the other possible drug-related cause of his confusion, and the confusion cleared. But soon afterward, the patient had a respiratory arrest, probably related to aspiration of stomach contents into the lungs, and he required use of a mechanical ventilator for several days. When the ventilator was discontinued, he had difficulty swallowing. The neurosurgeon speculated that the swallowing difficulty was related to swelling of the upper airway from the intubation following surgery, but he realized that he had not previously seen this complication under quite these circumstances. The internist and the neurosurgeon agreed to obtain a neurological consultation.

For the neurologist, this was also a unique situation. She reviewed the history with the patient and his wife, read the hospital chart, examined the patient, and discovered several neurological findings suggesting cranial nerve deficit and ab- normal brainstem function. She reviewed the medical literature. She called the in- ternist to discuss the case and then ordered a specialized x-ray study (an MRI) of the brainstem and the upper spinal cord.

The MRI confirmed the neurologist’s conclusions. She felt that no specific drug or surgical treatment was necessary, for she anticipated almost complete spontane- ous recovery. The patient received a temporary feeding tube in order to avoid fur- ther aspiration from swallowing and continued with the neck brace and physical therapy.

During this illness, the patient and his wife became increasingly frustrated, an- gry, and depressed. Throughout that time, the internist provided them with infor- mation, interpretation,  and emotional support.

Following discharge from the hospital, the patient saw the neurologist periodi- cally to assess his swallowing and muscle function and the neurosurgeon to check on the healing of his surgical wound. The patient and his wife continued to see the internist at one- to two-month intervals.

A step-by-step review of the history provides many insights about the physician as professional. Returning to the history:

Following a neck injury that had caused arm weakness from pressure on his spinal cord, a 42-year-old man had cervical spine fusion surgery and was placed in a neck brace to immobilize his neck while it healed. Two days after surgery, he became confused. The nurse thought that his confusion might be related to the intrave- nous morphine being used for pain control. The neurosurgeon arranged for inter- nal medicine consultation.

Professionals have excellent technical skills. Neurosurgeons know how to diagnose spinal cord injury and do the corrective surgery. Internists know how to address the differential diagnosis of confusion, how to treat it, and ways to help prevent it from reoccurring. Some skills overlap.

Professionals know how quickly and urgently a problem needs to be treated. Most neck injuries do not require emergency treatment. Those with neuro- logical deficits, such as the arm weakness, may require urgent intervention to prevent permanent disability.

Professionals define the issues and know how to manage them. Unless we use our knowledge, experience, wisdom, and common sense, we cannot ade- quately address all the important issues. These issues are equally essential to the process of care as to insuring the best possible outcome. In the case de- scribed, we cannot overlook treatable causes of confusion and swallowing difficulty or neglect the human side of care.

Professionals know their limitations and when to call for help, and recognize that medicine is a collaborative profession. They recognize their personal strengths and limitations. They realize that a whole community of support is available and are at ease taking useful suggestions, even from patients.

Professionals know how to move efficiently within the system. They know the inner workings of the hospital and how to get things done quickly. When they hit a snag, they know whom to call. Like a good mechanic, they know the tricks of the trade. Like the savvy military noncommissioned officer who has been around for a while, they know how to get around the rules that get in the way. When the patient asks for another opinion, profession- als not only accede to the request but call to get a timely appointment, pass on the pertinent information, and make sure that the patient gets what he or she needs.

The internist explored possible causes of the confusion by reading the hospital chart, reviewing the story with the patient and his wife, examining the patient, and performing a number of tests.

Professionals look at problems in more than one way and are flexible in their approach. They see beyond the apparent confines of a problem to define it accu- rately and solve it. They approach decisions about diagnosis and treatment carefully and consider all the possible alternatives; they do not jump to conclusions. Though the solutions to most medical problems are straight- forward, some require real creativity. Professionals do not confine their di- agnostic  thoughts  to  the  data  at  hand  and  go beyond  the  apparent boundaries defined by the history, physical findings, time intervals, and preconceptions to define the problem completely. Real professionals es- chew an inappropriately narrow point of view for one that is flexible and creative.

And so in this case, the internist did not prematurely conclude that the confusion was drug related. Instead, he asked, “What  are the  possible causes of confusion in this postoperative patient, who is on intravenous feedings and had a long anesthesia?” He came up with this differential diag- nosis:

•  Drug-induced illness, from morphine or corticosteroids—and so he stopped them.

•  Stroke—and so he did a neurological examination.

•  Pneumonia—and  so he examined the patient’s lungs and obtained a chest x-ray.

•  An electrolyte disturbance—and so he checked the concentration  of blood electrolytes.

•  A disorder of the acid-base level—and so he checked the blood pH.

•  Hypoxemia (low oxygen level)—and so he checked the blood gas levels.

•  Hypoglycemia—and so he checked the blood sugar.

•  Anemia—and so he checked the hemoglobin.

•  A “silent” myocardial infarct, one without symptoms—and so he examined his heart and checked the EKG.

All of the examinations and tests were normal. While the nurse’s con- clusion that the confusion was drug related was correct, the physician had to explore other diagnostic possibilities to answer the question, “What’s the cause of the confusion?” lest another treatable cause be overlooked. Professionals know what can go wrong and what questions to ask.

The internist stopped the morphine and corticosteroid medication, the other possible drug-related cause of his confusion, and the confusion cleared. But soon afterward, the patient had a respiratory arrest, probably related to aspiration of stomach contents into the lungs, and he required use of a mechanical ventilator for several days. When the ventilator was discontinued, he had difficulty swallowing. The neurosurgeon speculated that the swallowing difficulty was related to swelling of the upper airway from the intubation following surgery, but he realized that he had not previously seen this complication under quite these circumstances. The internist and the neurosurgeon agreed to obtain a neurological consultation.

For the neurologist, this was also a unique situation. She reviewed the history with the patient and his wife, read the hospital chart, examined the patient, and discovered several neurological findings suggesting cranial nerve deficit and ab- normal brainstem function. She reviewed the medical literature. She called the in- ternist to discuss the case and then ordered a specialized x-ray study (an MRI) of the brainstem and the upper spinal cord.

Professionals know how to use the literature of medicine, including the text- books and journals, and how to use the medical librarian as a consultant in the search for information.

Professionals use routines that allow for clear and precise thinking in the face of problems never previously encountered. Routines usually lead to the precise definition of the problem and the remedy, even with problems we have never encountered. Part of our professional training is learning such rou- tines. Even though she had no previous experience with a problem exactly like this one in exactly the same setting, the neurologist fell back on a pro- fessional “routine” as she asked:

•  What is the name of the problem? She called it “dysphagia” or difficulty swal- lowing.

•  Where is the disease? Where in the body might the cause be? She considered a problem with the esophagus, but neurologic examination placed it in the site of the cranial nerve roots in the brainstem.

•  What specific disease process could affect the brainstem in this way? A blood clot causing permanent brainstem damage (stroke) and ischemia (temporary diminished blood flow to the brainstem causing temporary damage) were most likely.

•  What are the treatment choices? Of those, what is the best choice? Allowing time to elapse without specific treatment seemed to be the best course.

She called the internist to discuss the case and then ordered a specialized x-ray study (an MRI) of the brainstem and the upper spinal cord.

Professionals recognize that collaboration is an ongoing process. In their dis- cussion, the internist and the neurologist questioned each other, added in- formation, critiqued their hypotheses, and talked about the prognosis for the various causes of the brainstem abnormality, and only then did they proceed with the complex test. As a collaborative team, the neurosurgeon, internist, and neurologist knew what could go wrong and recognized the obligation to seek and offer advice. They also recognized that someone had to oversee the whole process and decided on the internist. An uncoordi- nated case runs the risk of mismanagement.

The MRI confirmed the neurologist’s conclusions. She felt that no specific drug or surgical treatment was necessary, for she anticipated almost complete spontane- ous recovery. The patient received a temporary feeding tube in order to avoid further aspiration from swallowing and continued with the neck brace and physical therapy.

During this illness, the patient and his wife became increasingly frustrated, an- gry, and depressed. Throughout that time, the internist provided them with infor- mation, interpretation,  and emotional support.

Following discharge from the hospital, the patient saw the neurologist periodi- cally to assess his swallowing and muscle function and the neurosurgeon to check on the healing of his surgical wound. The patient and his wife continued to see the internist at one- to two-month intervals.

Professionals try to minimize the chaos. They do this by approaching the sum of the problems and the patient and family in a systematic way. What was supposed to have been a straightforward hospitalization for this pa- tient—surgery, a week’s postoperative care, and discharge home—became chaotic. By interpreting all the information to the patient and his family, professionals provide an integrated message, reassurance, and moral support. Even when there are no treatments to alter or tests to monitor, periodic en- counters help to identify and address the patient’s and the family’s concerns and uncertainties. The internist became the final conduit of information to the patient and his wife.

Professionals are consistent in their demeanor. Regardless of whom we see or when we see them, we do not allow our mood to intrude on the transaction. We are the same.

Professionals treat each patient and family member respectfully. We help the patient and family through all the steps and transitions of an illness and recognize that each member of the family may have a different view of the illness and a different relationship with the patient.

Professionals neutralize conflicts of interest. As professionals, we do not take fi- nancial  advantage of our patients. Our patients’ needs are primary. Even though we may earn a larger fee by providing a more expensive service, we do only what is appropriate, no more, no less. The surgeon operates only when in- dicated. The gastroenterologist does a procedure only when it adds to the solu- tion. The psychiatrist sees a patient for neither too few sessions nor too many. Like my auto mechanic, the physician may well forgo a fee when a patient co- mes in with an obvious problem—a skin lesion that needs to be removed, a se- vere sprain—for which she would have to be referred elsewhere, even though he spends time and gives careful thought to considering the problem.

Professionals know how to talk to patients and their families in understandable language. We know that absent effective communication, the transaction is far more difficult.

Professionals are the patient’s advocate. In many ways, the internist was this patient’s advocate, moving the progress of his case along. He was skeptical about explaining away the swallowing difficulty as a result of the endotracheal tube; he suggested neurological consultation when the cause was unclear. He took the initiative to oversee the overall care of the patient once he had left the hospital. He helped the patient and his wife with their choices. When he involved consultants, he oversaw their work.

Professionals make connections. We connect with consultants. We con- nect our experience with new situations and transfer what we learned from one context to another. We connect information and ideas. We see con- nections between problems, how the coexistence of two illnesses can mod- ify the  choices of treatment,  and how a treatment  for one illness can adversely affect the course of a coexisting illness. We deal with many prob- lems simultaneously.

Professionals think ahead. We know what can go wrong. We know how to minimize surprises.

Professionals know how to validate and critique their own work. We ask, “Are my decisions haphazard, or do I draw on the lessons of my experience? What could I have done differently?” We are willing to admit that we have made a mistake. We are always learning.

A professional is someone who can do his best work when he doesn’t feel like it,” wrote novelist James Agate.1 We may not feel like it when we are tired, when we are troubled by something that is going on in our personal life, and even when we do not like our patient.

And finally, faced with a difficult problem or a difficult patient, master profes- sionals say, “This is fascinating.”

JUDGMENT

Professionals use judgment, a very special quality. A cardiologist taught it this way in a course on how to select patients for coronary bypass surgery.

A 50-year-old man, a nonsmoker in otherwise good health, had recurring chest pain. A cardiac stress test was positive. Coronary angiogram showed areas of nar- rowing in all three arteries. “How many of you would recommend bypass surgery?” the  teacher  asked. Everyone raised a hand.  “Now let me change the  circum- stances,” he continued. “Suppose he is 80 and smokes ten cigars a day. How many of you would recommend surgery for this man?” Nobody voted for the surgery. “We operated on George Burns two months ago and he has made a nice recovery.” [Burns, of course, was the  venerable cigar-smoking comedian who lived and worked for another twenty years.]

While rules of thumb—no heart surgery after a certain age, no surgery on smokers—are helpful guides, they are only a beginning. As we look more carefully at each patient as an individual, we learn to characterize the patient more precisely so that we can make important distinctions. Perhaps Burns got special consideration because of his celebrity, but that celebrity opened the door to more thoughtful consideration. Is age an absolute crite- rion, or should we consider someone’s intellect, productivity, vitality, and connections to family? Does smoking absolutely contraindicate the surgery when the risks of no treatment  are greater? Judgment involves knowing when to ask such questions and how to discover the answers.

Experience refines judgment. Judgment involves attention  to details, the “total of little things,”2 and integration of those details into clinical de- cisions. Practicing medicine is not like following a cookbook. Here are some other instances where judgment is important:

•  When a patient has gallstones and recurring abdominal pain: Gallstones do not always cause pain, and often no test answers the questions, “Are the gallstones causing the pain? Does the patient need surgery?” The physician has to decide.

•  When a person has recurring back pain for many years, and in the last week the pain has changed in intensity: The physician has to decide whether this change is more of the same or whether he has to search for an additional illness, such as cancer, to explain the change.

•  When a 40-year-old man has angina: Even though there is no real emergency, the physician has to decide whether to expedite the tests, because delaying the tests will prolong the patient’s anxiety.

•  When screening blood tests show some unanticipated abnormality and the pa- tient has neither symptoms nor objective signs of illness: The physician has to decide whether to go further.

Judgment is more than intuition. It involves integration of the history, the  physical examination,  the  tests,  the  clinical  context,  and  the psychosocial elements. Judgment involves looking at things in more than one way and testing them intellectually. Professionals know that there may be many possible answers. How we look at the essence of medicine—prob- lems, relationships, interactions  between medical problems, diagnosis, treatment, and prognosis—requires an open mind and an ongoing urge to ask, “Is there another way to look at this?” The more closely we analyze the elements of judgment, the better we can teach it.

Of the myriad judgments physicians make, one of the most important is deciding whether the patient has a serious illness.

A 32-year-old woman saw her physician because of headaches, recurring over sev- eral months. They occurred only on weekdays, were not associated with other neu- rological symptoms, and had gotten worse coincident with the uncertainties of the relationship with her boyfriend. Her physical examination was normal. Her physi- cian tentatively concluded she needed no further tests. The next step was to ad- dress the psychosocial issues. When she returned a month later, the headaches were gone.

Not only was it important to decide, promptly and tentatively, that the pa- tient did not have a serious illness, it was equally important to address the psychosocial issues. Ignoring that dimension of her symptoms would have prolonged her headaches and squandered the opportunity to help her ad- dress what was going on in her life. All of this takes judgment.

So from whose standpoint—the patient’s, the physician’s, the third par- ties,’ or all of theirs—should we address the question, “What does it mean that the physician is a professional?” Actually it is an integration of their concerns.

Surely, the system fails when it does not meet the patient’s needs, but physicians cannot accede to patients’ requests that are unwise or useless. With each interaction with patients and colleagues, physicians need to ap- ply their  professional standards. The  third  parties—hospitals, insurers, government, and related institutions—often  have useful information for patients and physicians to consider: cost, impact on the community, unrec- ognized community needs, and effective and ineffective treatment. But the third parties’ view is inappropriate when it dictates action that undermines professionals’ values and patients’ needs. And when there is tension, the remedy is to return to the axiom, “The patient is the center of the drama,” and ask, “What more can I learn from this dilemma?”

The drama of the Apollo 13 spacecraft rescue helped me to clarify fur- ther the answer to “What is a professional?” As presented in the movie of the same name, the spacecraft was seriously damaged halfway to the moon, and the three astronauts’ lives were in jeopardy. The problem was: Get them back alive using the available energy resources and equipment aboard the spacecraft. The solution drew on the expertise of many specialists. The new technology and equipment were important to their rescue, but they would have been useless without these timeless dimensions: defining the problem, using the available resources, collaboration among many experts, and someone to coordinate all of this and maintain morale. Wisdom, inge- nuity, common sense, efficiency, and genuine collaboration saved the lives of the astronauts.

In the transaction between the New England doctor and the Yankee dow- ager mentioned earlier, what went wrong? How could it have been done better? What was “unprofessional”? Both of them lost. She lost a good doctor. He lost a patient who might have been interesting to know because he over- looked the importance of the packaging, presentation, and first impression. If a person is going to call himself “doctor,” he should act like a doctor. First impressions  are important. Whether we like it or not, that first impression tentatively defines us for many people. Later on, we fill in the picture. When I first meet a patient who is on “isolation precautions” in the hospital because of infection, I am careful to show him my entire uncovered face before I cover it with a mask and get on with my examination. In that way, he sees more of me than a fraction of who I am. When I first meet a new class in the informal college setting, I dress up. In that way, they get an impression of me as a physician; later on, I come to class dressed more casually.

Patients want to be able to say, “Here is someone who will take things in hand, who knows what she’s doing.” They want to feel comfortable that the physician will do neither too little nor too much. The professional qualities of the physician protect the patient far more than rules, laws, and authori- zation to sue. These qualities are neither hard to achieve for the physician nor optional. They are implicit in every interaction. They are part of the job. They are what good doctors do all the time. These professional values keep physicians interested, stimulated, excited about their work, and fasci- nated.

The next chapter examines values in greater depth.

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