Medicine in Society
95
Who Are You? GARY G. KARDOS, MD, San Francisco T oward the end of a workday, while I was examining one of my patients, her 4-year-old son asked, "Who are you?" Although my answer was simple, it later struck me that this question is worthy ofmore serious consideration. On the demographic level a physician is a person with 20 years of formal education, specialized training, and a bare minimum of a year of postgraduate education who possesses a Physician and Surgeon Certificate entitling him or her to practice medicine. On the regulatory level a physician is granted a license to practice by a state regulatory agency ifhe or she provides this agency with proof of a diploma of Doctor of Medicine, evidence of satisfactory completion of at least a year of postgraduate education, and is able to pass a written licensing examination. Physicians remain under review oftheir professional activities, mental and physical health, and annual fulfillment of continuing postgraduate educational activities, and they are also subject to careful scrutiny for any deviations in competency or conduct that are brought to the attention of a state board. In addition, any malpractice settlement in excess of $30,000 is reportable (at least in California) to the state board of medical examiners. Any report or complaint by the public, peers, or others is investigated and may become the basis for a restriction to or even a revocation of this license. These control mechanisms are the price physicians pay for the societal trust in granting them licenses to practice medicine. So it should be. On the professional level a physician has undergone the scrutiny of his or her professors during medical school years and teachers and attending physicians during postgraduate training, as well as both written and oral examinations. After these rites of passage are completed, each hospital medical staff to whom a physician applies for hospital privileges carefully examines the credentials of the applicant; and after acceptance, a physician's competency and physical and mental health are subject to ongoing review. Acceptance by one's colleagues is a complex phenomenon and encompasses far more than mere technical competence. It includes personality, an ability to get along, acceptance of the community practices and standards, and the avoiding of too much windmill tilting. Should this last be evident from the very start, the labels of strange, difficult, egotistical, and the like rapidly become known, and success in practice is far less likely. In simple terms, the community of practicing physicians has habits, customs, and standards. The practice of medicine is a game with some written and some unwritten rules that have to be discovered quickly if one wishes to participate.
At the hospital level peer review of patient admissions, discharges, complications, and deaths is ongoing. If substantial deviations from professional standards of competency and character are discovered, corrective action may begin. Fair hearings with due process occupy a tremendous amount of medical staff leaders' time. Peer review protection is a complicated issue, and I can merely note that there are disquieting problems related to antitrust charges and the balancing act between the individual physician's rights and those of the profession and society as a whole. On the economic level today's physicians are accused of charging too much, earning too much, acting too businesslike, and lacking in humanity. There are too many specialists and not enough family practitioners, and there is a maldistribution of physicians, with too many congregating in urban areas. In such areas, intense competition and lack of patient volume are alleged to encourage physicians to recycle patients excessively, order more tests (especially if there is economic gain involved), and suggest more procedures, all to keep up the dollar flow. Although the percentage of physicians who actually do this is low, the public's and third-party payers' perception is that the opposite is true. Today physicians' voices tend to fall on deaf ears. Even when their reasons are completely altruistic, their recommendations are viewed with suspicion and distrust. On the moral level a physician's primary goal of beneficence encounters the current, almost singular, focus on patient autonomy. The complexities of modern medical care have geometrically increased and with this has come increasing attention to values relating to health and disease. Everyone is in the act, to the detriment of the physicianpatient relationship. All major moral theories, utilitarian, deontologic, and justice-based, fail to address analytically the resolution of values in conflict. At best, these theories give methodology to ethical analysis but not answers. Legal rulings in the United States have focused on competent individual autonomy, but this does not make such singular focus ethically proper. Two well-known ethicists, Joseph Fletcher, PhD, and David C. Thomasma, PhD, have called attention to the need to interpret values from within the physician-patient relationship. According to Thomasma, a moral model based on physician conscience that acknowledges the ethical issues for physicians, recognizes the need to preserve as many patient values as possible, and understands the need for a healthy respect for moral ambiguity seems far more appropriate than the present norm.I There are biologic norms within medicine. The ethical conduct of physicians needs to be interpreted in terms of these norms, concurrently recognizing
(Kardos GG: Who are you? West J Med 1990 Jan; 152:95-96) Dr Kardos is in private practice in San Francisco. Reprint requests to Gary G. Kardos, MD, 45 Castro St, Suite 227, San Francisco, CA 94114.
MEDICINE IN SOCIETY
96
patient vulnerability, patient wishes, and the sharing of relevant information. In addition, physicians must use their skills and implied power wisely and with great integrity. From a philosophical viewpoint, truly informed consent is not achievable, regardless of what attorneys say or wish. The impact of disease on individual autonomy is neither addressed properly nor understood by either legislators or many ethicists. In other words, the playing field between physician and patient is never level: patients are more vulnerable and physicians are held to much higher standards of integrity and must recognize explicitly the advantage specialized knowledge gives. In the final analysis, the success or failure of this unique relationship begins and ends with trust. On the personal level who are we? Granting that each of us has an image of what being a physician represents and what image he or she wishes others to have, are there any common threads that link one physician to another? I think that within each of us is an underlying intellectual curiosity about basic biology, its mysteries, and the amazing progress that science has made in defining disease and altering its course. Perhaps it is here that the phrase, sometimes to cure, sometimes to help and always to comfort, is applicable. There is also an element of altruism, of wanting to work with and help people. A part of being a physician is theatrical-not in any pejorative sense but rather in the individual physician's manner as one attempts to allay needless fear and convey confidence. This is, after all, a role model that has occupied prime-time television; and to some extent, all physicians are judged at least in part by their bedside manner. There is another part that, for want of a better term, is called egotistical. So long as this element is recognized,
understood, and properly compartmentalized, all is well. Only when such personal conceptions are distorted and the statement, I can do no wrong, is believed will trouble arise. Good physicians have to have reasonable confidence in their abilities to diagnose and to treat. Each of us must guard against the tendency to become hardened, insensitive, and unresponsive to the amazing frailty and heterogeneity of human illness. When feelings become encased in a thick layer of social concrete, we are called callous and uncaring, and we are also more prone to error because when such personality traits occur, there is a concurrent tendency to be less attentive to detail. Medicine is a profession that has grown from humble and superstitious beginnings to the scientifically based applied biologic science it is today-along with a degree of uncertainty and unpredictability. As physicians we must respect our origins, our uniqueness, and our responsibilities to the profession and the public, and we must not permit the profession to erode into a trade or business, regardless of the external pressures and forces. How we will achieve this cannot be predicted with the accuracy of a mathematical column of figures. That we must preserve professional standards and ethics requires daily reemphasis to ourselves, our patients, and to others. This use of the word others is truly intended to be disparaging. The others do not understand what it is to be a physician. I am also certain that many of them do not care to know. But we do. We need to let them know in no uncertain terms by the way we act, by what we do and say, and by continuing to show that we care. REFERENCE
1. Thomasma DC: Beyond medical paternalism and patient autonomy: A model of physician conscience for the physician-patient relationship, In Brody BA, Engelhardt HT Jr (Eds): Bioethics. Englewood Cliffs, NJ, Prentice Hall, 1987, pp 113-121
95
Who Are You? GARY G. KARDOS, MD, San Francisco T oward the end of a workday, while I was examining one of my patients, her 4-year-old son asked, "Who are you?" Although my answer was simple, it later struck me that this question is worthy ofmore serious consideration. On the demographic level a physician is a person with 20 years of formal education, specialized training, and a bare minimum of a year of postgraduate education who possesses a Physician and Surgeon Certificate entitling him or her to practice medicine. On the regulatory level a physician is granted a license to practice by a state regulatory agency ifhe or she provides this agency with proof of a diploma of Doctor of Medicine, evidence of satisfactory completion of at least a year of postgraduate education, and is able to pass a written licensing examination. Physicians remain under review oftheir professional activities, mental and physical health, and annual fulfillment of continuing postgraduate educational activities, and they are also subject to careful scrutiny for any deviations in competency or conduct that are brought to the attention of a state board. In addition, any malpractice settlement in excess of $30,000 is reportable (at least in California) to the state board of medical examiners. Any report or complaint by the public, peers, or others is investigated and may become the basis for a restriction to or even a revocation of this license. These control mechanisms are the price physicians pay for the societal trust in granting them licenses to practice medicine. So it should be. On the professional level a physician has undergone the scrutiny of his or her professors during medical school years and teachers and attending physicians during postgraduate training, as well as both written and oral examinations. After these rites of passage are completed, each hospital medical staff to whom a physician applies for hospital privileges carefully examines the credentials of the applicant; and after acceptance, a physician's competency and physical and mental health are subject to ongoing review. Acceptance by one's colleagues is a complex phenomenon and encompasses far more than mere technical competence. It includes personality, an ability to get along, acceptance of the community practices and standards, and the avoiding of too much windmill tilting. Should this last be evident from the very start, the labels of strange, difficult, egotistical, and the like rapidly become known, and success in practice is far less likely. In simple terms, the community of practicing physicians has habits, customs, and standards. The practice of medicine is a game with some written and some unwritten rules that have to be discovered quickly if one wishes to participate.
At the hospital level peer review of patient admissions, discharges, complications, and deaths is ongoing. If substantial deviations from professional standards of competency and character are discovered, corrective action may begin. Fair hearings with due process occupy a tremendous amount of medical staff leaders' time. Peer review protection is a complicated issue, and I can merely note that there are disquieting problems related to antitrust charges and the balancing act between the individual physician's rights and those of the profession and society as a whole. On the economic level today's physicians are accused of charging too much, earning too much, acting too businesslike, and lacking in humanity. There are too many specialists and not enough family practitioners, and there is a maldistribution of physicians, with too many congregating in urban areas. In such areas, intense competition and lack of patient volume are alleged to encourage physicians to recycle patients excessively, order more tests (especially if there is economic gain involved), and suggest more procedures, all to keep up the dollar flow. Although the percentage of physicians who actually do this is low, the public's and third-party payers' perception is that the opposite is true. Today physicians' voices tend to fall on deaf ears. Even when their reasons are completely altruistic, their recommendations are viewed with suspicion and distrust. On the moral level a physician's primary goal of beneficence encounters the current, almost singular, focus on patient autonomy. The complexities of modern medical care have geometrically increased and with this has come increasing attention to values relating to health and disease. Everyone is in the act, to the detriment of the physicianpatient relationship. All major moral theories, utilitarian, deontologic, and justice-based, fail to address analytically the resolution of values in conflict. At best, these theories give methodology to ethical analysis but not answers. Legal rulings in the United States have focused on competent individual autonomy, but this does not make such singular focus ethically proper. Two well-known ethicists, Joseph Fletcher, PhD, and David C. Thomasma, PhD, have called attention to the need to interpret values from within the physician-patient relationship. According to Thomasma, a moral model based on physician conscience that acknowledges the ethical issues for physicians, recognizes the need to preserve as many patient values as possible, and understands the need for a healthy respect for moral ambiguity seems far more appropriate than the present norm.I There are biologic norms within medicine. The ethical conduct of physicians needs to be interpreted in terms of these norms, concurrently recognizing
(Kardos GG: Who are you? West J Med 1990 Jan; 152:95-96) Dr Kardos is in private practice in San Francisco. Reprint requests to Gary G. Kardos, MD, 45 Castro St, Suite 227, San Francisco, CA 94114.
MEDICINE IN SOCIETY
96
patient vulnerability, patient wishes, and the sharing of relevant information. In addition, physicians must use their skills and implied power wisely and with great integrity. From a philosophical viewpoint, truly informed consent is not achievable, regardless of what attorneys say or wish. The impact of disease on individual autonomy is neither addressed properly nor understood by either legislators or many ethicists. In other words, the playing field between physician and patient is never level: patients are more vulnerable and physicians are held to much higher standards of integrity and must recognize explicitly the advantage specialized knowledge gives. In the final analysis, the success or failure of this unique relationship begins and ends with trust. On the personal level who are we? Granting that each of us has an image of what being a physician represents and what image he or she wishes others to have, are there any common threads that link one physician to another? I think that within each of us is an underlying intellectual curiosity about basic biology, its mysteries, and the amazing progress that science has made in defining disease and altering its course. Perhaps it is here that the phrase, sometimes to cure, sometimes to help and always to comfort, is applicable. There is also an element of altruism, of wanting to work with and help people. A part of being a physician is theatrical-not in any pejorative sense but rather in the individual physician's manner as one attempts to allay needless fear and convey confidence. This is, after all, a role model that has occupied prime-time television; and to some extent, all physicians are judged at least in part by their bedside manner. There is another part that, for want of a better term, is called egotistical. So long as this element is recognized,
understood, and properly compartmentalized, all is well. Only when such personal conceptions are distorted and the statement, I can do no wrong, is believed will trouble arise. Good physicians have to have reasonable confidence in their abilities to diagnose and to treat. Each of us must guard against the tendency to become hardened, insensitive, and unresponsive to the amazing frailty and heterogeneity of human illness. When feelings become encased in a thick layer of social concrete, we are called callous and uncaring, and we are also more prone to error because when such personality traits occur, there is a concurrent tendency to be less attentive to detail. Medicine is a profession that has grown from humble and superstitious beginnings to the scientifically based applied biologic science it is today-along with a degree of uncertainty and unpredictability. As physicians we must respect our origins, our uniqueness, and our responsibilities to the profession and the public, and we must not permit the profession to erode into a trade or business, regardless of the external pressures and forces. How we will achieve this cannot be predicted with the accuracy of a mathematical column of figures. That we must preserve professional standards and ethics requires daily reemphasis to ourselves, our patients, and to others. This use of the word others is truly intended to be disparaging. The others do not understand what it is to be a physician. I am also certain that many of them do not care to know. But we do. We need to let them know in no uncertain terms by the way we act, by what we do and say, and by continuing to show that we care. REFERENCE
1. Thomasma DC: Beyond medical paternalism and patient autonomy: A model of physician conscience for the physician-patient relationship, In Brody BA, Engelhardt HT Jr (Eds): Bioethics. Englewood Cliffs, NJ, Prentice Hall, 1987, pp 113-121
