Values and Dealing with Change
define ourselves by the sum total of our moral choices.
Among the questions prospective physicians ask are, “How do we deal with two conflicting views of medicine? On the one hand, medicine is a stimu- lating, satisfying, and challenging career; on the other, medicine is an insti- tution in the midst of great change and outside regulation. How do physicians deal with all the changes in medicine, where we have seen a transition from care by one physician to care divided among many special- ists, nurses with greater skills, growth in technology, greater access by pa- tients to information through the lay press and internet, involuntary shifts of patients from one physician to another because of insurance coverage, and less attention to the human side of medicine?” These are complex questions about values.1
The answers are based on a number of assumptions, among which are:
• A values-based professional career provides the opportunity for consistent and thoughtful practice and promotes the highest level of service. Early statements of values in medicine include the Hippocratic Oath and the Oath of Maimonides.2 Students often write their own statements of values, and I have included one example at the end of this chapter.
• Values guide decisions, validate positions, and prevent ethical drift. Values help to protect patients from abuse.
• Change is a reality of our personal and professional lives. A values-based career helps to ensure professional satisfaction and cope with change.
Values influence physicians’ decisions as much as their knowledge and experience. Attending to values enriches each clinical experience. When we have values against which to measure our actions, we can declare more easily, “I won’t do that. It conflicts with my values.” Consciously or uncon- sciously, values help to define the physician.
Ethical matters include patient autonomy, the right of patients to make their own decisions, the right to privacy, and the question of competence to make an informed decision. Clinical decisions must integrate the patient’s values into diagnostic and therapeutic choices, for example, the choice be- tween a mastectomy for cancer of the breast or a breast-preserving proce- dure (lumpectomy). And the physician’s values must be integrated into choices, for example, physicians who cannot accede to a request to termi- nate a pregnancy because of religious convictions.
There are clinical decisions in which the patient’s values conflict with the physician’s, for example, the son who declares, “Do everything you can for my father,” while the physician believes that attending solely to comfort is a better choice. There are decisions in which members of a family dis- agree among themselves, such as how to proceed with their parent’s care. Values help to clarify differences and reasons for conflict.
There are clinical choices where rules by outside agencies must be inte- grated into clinical choices, for example, when a doctor declares, “I am un- able to do this test [admit this patient to the hospital, make this referral, etc.] because the patient’s medical plan doesn’t allow it.” There are choices regarding career tracks, such as suburban or inner city practice, primary care or a specialty.
And so the next question is, “What are the challenges to our values?” Those considering a medical career or beginning as medical students are usually sensitive to the human needs of patients; often that is why medicine is so attractive to them. As they experience more intense patient contact, and certainly by the time they reach postgraduate medical residency train- ing, time pressure and the message “Don’t get too involved” often chal-lenge that sensitivity.
The cost of becoming a physician is substantial, and recouping the cost may affect our choice of specialty or practice style. Financial issues can be a strong motivator, but if earning power were the only motivation, all doc- tors would choose high-earning specialties. They do not, because of skills and aptitude, length of training, the nature of the professional life—and values. One undergraduate saw that “compensation goes beyond wages. In-tellectual and social benefits can be as attractive as economic compensa- tion.” Partly because of values, physicians choose to be internists or cardiac surgeons, to be a fulltime doctors or work three-quarters time, to practice in a city or a small town, to be home for dinner with the kids or not make it un- til much later.
We choose our style of practice on the basis of values. When I was a med- ical student, I heard this from more than one of my community-based teachers: “This is the way you do it in the medical center—the thorough way, spending time with each patient—but you can’t do it this way once you’re in practice.” A colleague recently told me, “Whether a physician spends ten minutes or twenty with a patient will be market-driven.” Insur- ance companies, managed care organizations, and other third-party payers sometimes dictate rules that have impact on everyday decisions: length of stay in the hospital, choice of referrals and tests, and length of time spent with a patient. Yet no more would we ask a surgeon to remove a portion of diseased bowel in fifteen minutes when it ordinarily takes more than an hour, than should we ask an internist to explore a patient’s medical history in fifteen minutes, when it usually takes forty-five. Doing it the right way is essential to our integrity as doctors.
At the conclusion of Woody Allen’s 1989 movie, Crimes and Misde- meanors, the character to whom he always returns says, “We are all faced with moral choices…. We define ourselves by the sum total of our moral choices.” Here are some moral choices physicians make. They are actually statements of value.
• Always remember that the patient is the center of the drama.
• Pick the right place to practice. The location—small town or big city, the cul- ture, and the values of the office and hospital setting—is just as important as the choice of specialty. The same physician can be unhappy and unfulfilled in one position and flourish in another. The same patient can feel alone and unat- tended by one physician and respected and truly cared for by another. From one of my teachers, not a physician, I learned, “Who you are depends on where you are.”
• Maintain your sense of creativity. Do something new each year.
• Maintain your integrity.
• Do not hedge on time. The quality of the transaction depends on time.
• Devise a thoughtful integration of personal life and practice.
• Do not compromise. Responding to a question regarding “technically oriented” directors who “don’t respect the actor’s craft,” actor Paul Newman once ob- served, “The pace never controls the actor, the actor controls the pace. The sec- ond that that happens [the pace and the director control the actor], the actor
loses his humanity.”3 The second that outside pressures begin controlling us as physicians, we lose our humanity.
Loss of humanity can occur not only in relation to patients but also in re- lation to our professional associates. I know of conflicts within partnerships, not over the quality of care the partners are providing, but rather over office logistics—and values. With tongue in cheek, one partner observed, “It’s not the money, it’s the money.” I know of a physician who left a partnership be- cause one of his associates, a technically competent doctor, treated patients and staff disrespectfully. I know of one who left a lucrative practice for an- other one less so because he felt devalued. He decided that even if he made less money, it was more important that he maintain his integrity.
The Illness Narratives by Arthur Kleinman provides good text for teach- ing about values.4 It contains stories about eight contemporary physicians, each of whom has a different way of looking at patients, practice, and chal- lenges. I ask my undergraduate students to describe how each approaches the challenges of practice. One junior wrote:
Each [physician] blends his/her personal beliefs, professional ideologies, cultural biases, individual personalities, and life philosophies to develop a role in the physi- cian-patient relationship. One important characteristic is how the physician views the patient and views himself. Is the patient a “diseased patient,” a “diseased person,” or a “person with a disease”? Is the physician there to fight the disease? To fix the patient? Or to talk with the patient [about] what the problems are and find possible solutions?… [Physicians who] view the patient as a business transaction differ greatly from those who view the patient as a person in need…. Those who view being a physician as merely a daily routine respond to their patients very dif- ferently from those who view being a physician as a way of life.
I also ask, “How does each of these physicians deal with the dilemmas they face in medicine?” The student continued:
[In the text, the] young medical student… is unsure of his role and responsibilities as a physician. [He] feels great compassion and emotion for his dying patient. Al- though he realizes that the emotions are understandable, he fears that it may com- promise the quality of his care…. [My hope is] he will realize that compassion and empathy are fundamental to a physician’s care and do not conflict with providing efficient, quality care.
Of another physician described in the chapter, a sophomore wrote:
[He] deals with the dilemmas of medicine by tapping into his experiences as a pa- tient and as someone who has felt the grief of losing a loved one. These feelings
help him to better identify with the patient, thereby providing the kind of care that does not just deal with the patient’s body, but with all aspects of his or her life. He immerses himself in his work, not only because of his love for what he does, but partly out of a need he feels to be effective. This need, in combination with his childhood experiences, helps to define how he deals with any dilemmas he may en- counter in medicine.
A junior wrote, “I believe that each physician can incorporate his own personal value system into his practice. . . . What patient wouldn’t prefer a physician interested in the caring and healing aspect of medicine over one whose ability is suffocated by legal and political facts?”
In a first-year course at the University of Minnesota, medical students also address questions of values. One constructed a personal mission state- ment with a set of values.
Above all, I will be a good husband and father. I will set aside time to spend with my immediate and extended family and my close friends and will help them whenever I can….I will maintain balance between work and home….I will remember that the patient is the center of the drama. I will always view patients as individuals rather than as cases. I will not make assumptions about patients; instead, I will lis- ten to their stories. I will give culturally competent care….I will remember that patients have very individual reactions and perspectives….I will willingly teach others what I know….I will scrutinize my actions for consistency with my beliefs and values. . . . I will answer for my mistakes.
A classmate observed:
In dealing with patients and families, honesty is as valuable as knowledge. No amount of medical education will teach a student to tell the truth and maintain professionalism while treating people, yet it remains [essential] to the practice of medicine…. It does not take a long time to tell the truth, just as it does not take an excessive amount of time to be a compassionate physician…. Almost all of the pa- tients that we have met with this year have asked for the same basic things: If you don’t know the answer to a question, don’t make it appear as if you do. If you do know the answer to a question, be honest and present it in an appropriate manner. And, most importantly, listen. It makes the patient feel that you truly have a stake in their well being.
Undergraduates and beginning medical students get the picture: Their task is to maintain their values and to refine them. “How can I maintain my values in the face of all the outside pressures?” they ask. There are many ways.
Talk. Protect confidences certainly, but share stories, dilemmas, and val- ues with a confidant, a peer, a life partner. Look to others, not necessarily physicians. Clergy, social workers, nurses, patients, and their families all have wisdom.
Listen. Listen carefully for clues to patients’ values. Be aware that buried in what patients tell you may be important clues to their values, which may explain their struggles, clarify reasons for conflict with the physician and others, and give clues to the remedy.
Read. Read critically. Books, both nonfiction and fiction, and newspa-pers are filled with stories with value-laden issues.
Reflect. From colleagues, discussions, books, conferences, and after each encounter with patients and their families, ask, “What did I learn?” Look for meaning. Leave time for reflection.
Teach. When we teach, we need to think and express ourselves clearly, define ourselves and our values, and defend what we have to say. When we teach, we model behavior and enter into a relationship with students and yet another opportunity to learn.
Choose models, physicians you admire, and find out about them. We might surmise that since physicians do not talk about values in their day-to-day conversations, they do not think about them. Yet all the physi- cians who have spoken to my classes have been profound in their reflec- tions, and each has presented a personal creed. An academic orthopedist who cares for patients with especially complex problems, oversees a resi- dency program, and does research has these priorities: “my family, my work, and my health, both mental and physical.” A family practice specialist talks about her quest “to help patients make sense of their lives” and the im- portance of “self-forgiveness for making mistakes.”
For the physician, there is, in fact, an implied triad of roles: I am a profes-sional; I am a physician; I am (insert your name). Each role implies certain values. A clear set of values leaves little room for compromises of time, re- sources, accessibility, or compassion. To the extent that any of these values are compromised, we should simply declare, “This won’t do.”
First-year medical students at the University of Minnesota Medical
School each January go through a rite of passage, the White Coat Cere- mony, as they start to see patients. The 2001 program for that ceremony stated, “The respect that society assigns to the physician is related to the professional values and responsibilities of this calling. The compassion, kindness, self-sacrifice, scientific expertise, ethics, humanity, and equa- nimity of future physicians require that these values be taught and modeled by us.”
Each physician is a guardian of the values of the profession. The physician knows best the details and nuances of individual patients and their ill- nesses. As their advocates, physicians efficiently shepherd patients through the system. We protect them from unnecessary testing and treat- ment and also from frivolous intrusion by third parties. In a greater sense, we also protect ourselves from incremental drifts of values. And as the guardians of the values of the profession, we set examples and are models for students, colleagues, and hospital and office staff. The rules, the real rules, are the values. Not only do the values protect the patient, they safe- guard the integrity of the physician.
In this context, a physician can look at change and see challenges and opportunities. We expect patients to adjust to change all the time— change in health, life expectancy, and other losses. Why should we not ex- pect physicians to do the same? Change is a reality of medicine, just as it is of any career. Change is a reality of life.
In cases where care by one physician has been divided among many spe- cialists, the opportunity arises to provide better care, as does the need for someone to coordinate that care. Where nurses have developed even greater skills, there is more opportunity for nurse-physician partnership, sharing of responsibility, and learning from each other. With growth in technology comes the opportunity to treat more precisely and preserve more lives and the responsibility to use the technology wisely without us- ing it to replace careful thought and clinical judgment. Where patients have greater access to information through the lay press and the internet, there is the responsibility to provide them with interpretation and profes- sional judgment. Where insurance coverage forces involuntary shifts of pa- tients from one physician to another, there is the responsibility to reassert the importance of the doctor-patient relationship. And where there is less attention to the human side of medicine, there is the need to reclaim this dimension as essential to good care.
When students take all of these reflections and integrate them with their own observations, they begin to understand the many different ways to be a complete and fulfilled physician. Ultimately, that is the goal of ad- dressing the question, “What’s it like to be a physician?”