American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, August 29, 2014

Doctors aren't 'healers'

It’s a seductive idea. We doctors possess knowledge and experience which can not only help people, but can save their lives. We get opportunities to be the right person at the right time to offer the right help that makes all of the difference. It’s one of the greatest things about our profession. It’s also one of its greatest traps.

I’ve heard many doctors refer to themselves as “healers,” as if we have some special power to bring about healing in our patients. This idea confers some sort of a higher status and originates, to some, from a “higher calling” to a more noble life. Again, this is a logical step, in that we have opportunities on a regular basis to help and even save the lives of people. It’s natural to believe that somehow the healing power comes from our touch, or even from our knowledge.

It doesn’t. I am not a healer.

Healing is what the patient does, not the doctor. As a physician, I am certainly one who can help the patient find a faster road to healing, but I don’t heal. I help.

Why am I taking the time to talk about this? Why get stressed out over whether I am a helper or a healer? I think that the belief in doctors as healers causes significant harm to both doctors and patients, and that getting a better perspective about the roles of each will greatly improve the care given. Here’s why I believe this is a topic that needs addressing:
1. Doctors often fail at healing (and will always ultimately fail)

There are many patient problems that do not get better, despite my best efforts. There are countless pains I can’t remove, and many problems I do not solve. Even when I succeed, the success is always temporary, as a new problem will eventually come back. And if healing is our ultimate goal as physicians, we all are total failures, as all of our patients eventually die. If healing is held as our goal, we fight a losing battle. We are the soldiers in the Alamo, offering impotent resistance to an overwhelming force.

If I believe in myself as a healer, I will face constant disappointment and defeat.
2. When healing occurs, it is often independent of doctors

My patient may follow my advice and not get better, or may disregard what I say and recover from their problem. My direction is imprecise and imperfect, based on my knowledge and experience along with what I believe to be happening with the patient. But my experience and knowledge may not be right, and my interpretation of what is happening with the patient may be inaccurate. Healing is something that happens in the patient’s body. It’s when they get better, whether or not I am involved in the process.

Belief in myself as a healer is based on a falsely high opinion of my knowledge and abilities.
3. Patients who see doctors as healers will expect too much

I’ve seen it. I’ve heard people’s frustration when I’ve told them I can’t fix their problem or remove their pain. They feel like they shouldn’t have to hurt, or that if there is something wrong it’s because I’ve missed something. These are the folks who buy the “miracle” cures pandered by Dr. Oz and other profiteers. They hear the promises of health and wellness from the media and are disappointed when we can’t offer the same.

By believing I am a healer, my patients will eventually be frustrated and disappointed.
4. Doctors who try to be healers do harm to their patients

The pressure to find the “magic bullet,” or the unifying diagnosis leads many doctors to practice bad medicine. This is a pressure we all feel when faced with the powerless feeling some patients bring. This leads to the ordering of unnecessary tests, performing of unnecessary procedures, and prescription of medications that should not be given. I believe this is what drives many doctors to overly-prescribe narcotic pain medications and other addictive drugs. We don’t want to stand helpless; we want to do something.

To protect my role as a healer, I am drawn away from my training and toward the task of finding a miracle. In doing this I can cause significant harm.
5. To protect their status as healers, doctors will oppose any other perceived competition

Doctors in the past have been held with reverence by the general public. We possessed that “secret knowledge” that others didn’t have access to, knowledge that fueled our healing power. Now everyone has access not only to all of the knowledge we have, but also to others who offer alternatives. This causes many doctors to aggressively discourage patients to research their own problems and to attack alternative providers. In defending their turf, however, they are giving patients an ultimatum: us or them. More and more patients are choosing “them” because of this and are rejecting what we offer.

By clinging to our power as healers, doctors have greatly harmed people’s trust in our profession.

So what’s the alternative? Does it really make a difference what we call ourselves as long as we practice medicine? I think it does. Now that I’ve got time to choose the best way to practice, I’ve seen that there is a much better alternative to being a healer: being a helper.

Yeah, that sounds all dull and boring, I know, but it is not only more realistic, it is a much better way to practice medicine. Here’s why:
1. By being a helper, i always can succeed

I may not be able to fix someone’s pain, but I can reduce it or can help them get through it. Every visit is an opportunity to help someone, and once I have helped them I’ve done something that can’t be taken away. I don’t have to see disease as a foe to be defeated, but as an opportunity to give to my patient from my experience and knowledge. Even when patients ultimately succumb to death, I have many opportunities to help them do so with peace.
2. Being a helper keeps my priorities straight

I don’t have some crazy idea that I have special powers. I don’t believe that I’ve been “called” or “chosen” to do magic. I just help people. My focus isn’t on me (as if my care was not a performance), but on the person I am helping.
3. Being a helper keeps expectations realistic

If my patients see me as a helper, not a healer, they will listen to my advice with different ears. I am standing beside them, not above them. They are far more likely to listen to me when I am offering help, not pronouncing my wisdom.
4. Helping means doing no harm

The temptation to offer more tests, more procedures, or dangerous drugs becomes much smaller when I take the role of helper over that of healer. I don’t see a need to prove myself, and will consider the harm of actions much more closely. I won’t over-prescribe pain medications because I will see how it harms my patients in the end.
5. Being a helper lets me exist in the information age

Like it or not, I am compared to the homeopaths, the herbalists, the chiropractors, and the doctors on TV. When people embrace alternatives to the care I give, they are not necessarily rejecting me; they are seeking what they are when they come to me: to feel better and to lessen their fears about the future. If the help I offer is held next to the miracles promised by others, I think I will win. If patients are helped by others, though, then I should be glad for my patients, not upset about the success of my “rivals.”

We call what we do “health care,” which implies a relationship built for the sake of a person’s health. I believe the best way to accomplish this is to have a realistic view of who we are and what we do. I am not a healer. When I try to be one, I always fail and am always disappointed. I am a helper, and in taking that role I can always have opportunities to succeed.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Thursday, August 28, 2014

We used to make stuff

I like maps and charts. This map, from the Wall Street Journal, left me gob smacked.

Remember when we used to make stuff? Like cars? Clothes? Machines?

Apparently, most of what we do now is health care. That’s good if you’re a doctor, nurse, hospital administrator, or researcher. Especially good if you’re a health insurance executive. I suppose it’s good if you’re a patient. [We’re all patients.]

I’m left with a lot of questions.

If the health care industry is the largest employer in most states, is it because of health care’s unstoppable growth or manufacturing’s seemingly irrevocable decline? Or both?

What about California? I thought the tech industry employs lots of people, even if most of them are white males.

What about Oklahoma? I thought oil and gas were my state’s biggest industry. Nope.

At least Michigan’s #1 employment sector is still manufacturing. And Nevada’s is still tourism. Some reputations remain.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Wednesday, August 27, 2014

If doctors ran their practice like the airlines

Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for 2 hours of Wi-Fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.

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No taste for truth?

This will be brief, blunt, and—forgive me—perhaps a bit brutal.

I find it incredible that a culture embracing “junk“ not only as a food group, but one of its largest; and the junkiest of such junk as the preferential food for its children, keeps looking for something to blame for rampant obesity and chronic disease other than its own blend of naïve nincompoopery (we, the people); pecuniary propaganda(marketing, media); and predatory hypocrisy (industry). Rather than supporting the health of our bodies, our body politic is feeding off their willfully devised decay.

I imagine this may stick in some craws. What can I say? The truth does that sometimes.

Think it really matters if we fixate on sugar or fructose, meat or wheat, saturated fat or omega-6? I don’t:
No One Thing
Why Holistic Nutrition Is the Best Approach
Scapegoats, Saints, and Saturated Fats: Old Mistakes in New Directions
Fructose, and the Follies of History

Think we are actually clueless about the basic care and feeding of Homo sapiens? I don’t:
Feeding Homo sapiens: Are We Truly as Clueless as We Seem?
Diet, Weight, and Health: Confused Only If You Want to Be!
Knowing What to Eat, Refusing to Swallow It

Think any of the “my diet is THE best diet” claims are valid? I don’t:
Judging the Judging of Diets
Science Compared Every Diet, and the Winner Is Real Food
Can We Say What Diet Is “Best”?

Think Ancel Keys is the anti-Christ? I don’t:
Living (and Dying) on a Diet of Unintended Consequences
In defense of U research: The Ancel Keys legacy

Think we don’t know what dietary pattern is best for health? I think we do!
Can We Say What Diet Is Best for Health?
Prevention and management of type 2 diabetes: dietary components and nutritional strategies

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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