Tuesday, July 19, 2011

The Department of Human Nature: The Pervasive Sins of Doctors and Others

The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And we also know that there have been recent revelations of numerous occasions where practicing physicians have failed to live up to the ideal. The Wall Street Journal documented spine surgeons who did large numbers of spine surgery and received large payments from a medical device manufacturer. (http://online.wsj.com/article/SB10001424052748703395204576024023361023138.html) Pro Publica has shown that faculty at prestigious medical schools have failed to comply with university conflict of interest policies (http://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit/single) A Maryland cardiologist has had his medical license revoked and his hospital had to pay back Medicare millions of dollars because of allegedly inserting stents in patients who did not need them. (http://articles.baltimoresun.com/2011-07-13/health/ms-md-midei-license-revoked-20110713_1_midei-unneeded-stents-stent-business)

How can we support our fellow physicians and medical students so that we all strive to become the best caregivers we can possibly be? Is the problem with living up to the ideal a specific problem within medicine or is it a more general problem of human nature and the current cultural environment?

I am worried that the difficulty of becoming and continuing to be a compassionate, master physician is complicated by the mixed messages that we send and receive as we practice in an environment where there is conflict between the ideal culture and the real culture. In medical school this concept has been identified as the informal or hidden curriculum where medical students sadly emulate the unprofessional behavior of physicians and staff, instead of the lofty ideals listed in the catalogue. Everywhere I look in modern society I find a similar tension between what we say our ideals are in pamphlets and guidelines and how we actually get work done and manage our careers.

Billionaire Raj Rajaratnam is a very successful investor who is a graduate of the Wharton Business School at the University of Pennsylvania, one of our best and most prestigious MBA programs. He has also been convicted on several counts of insider trading. According to a profile in The New Yorker, Rajaratnam liked to call himself a “rogue” and encouraged his employees at Galleon to “get an edge” when making investments. The article states that Rajaratnam’s view of human nature was similar to Willie Stark’s in All The King’s Men: “Man is conceived in sin and born in corruption and he passeth from the stink of the didie to the stench of the shroud.” His younger brother Rengan, who graduated from the Stanford University School of Business is quoted as believing, “Everybody is a scumbag.” My impression is that insider trading is rampant among investors on Wall Street. http://www.newyorker.com/reporting/2011/06/27/110627fa_fact_packer?currentPage=2

The culture that Rebekah Brooks encouraged as editor of The News of the World featured cynicism, cut throat internal competition, and gallows humor. Phone hacking and using criminals as sources for exclusive scoops were standard operating procedures. "We used to talk to career criminals all the time. They were our sources," says another former reporter from the paper who also worked for Murdoch's daily tabloid, the Sun. "It was a macho thing: 'My contact is scummier than your contact.' It was a case of: 'Mine's a murderer!'”

“It was a don’t-get-caught culture,’ said the reporter of seven years’ standing. New staff would be given the cold shoulder until they’d proved themselves to be ‘thoroughly disreputable’ so their colleagues could trust them.

It was no place for anyone to pipe up and say: 'This doesn't seem ethical to me.' That would have made you a laughing stock." The News of the World, which was Britain’s most popular Sunday tabloid has been shut down, and at the time of the writing of this blog, the entire Murdoch media empire seems threatened by the phone hacking scandal.

http://www.reuters.com/article/2011/07/16/us-newscorp-notw-brooks-idUSTRE76F0O420110716

At first the Murdoch executives contended that the phone hacking and questionable reporting practices were limited to a single bad apple. Now it is clear that is not the case. We are now being told that the problems are the ethics of the British tabloid press, and that the Murdoch American companies are ethically run. However, David Carr of the New York Times has discovered what appears to be a similar culture at an American Murdoch company. Paul V. Carlucci the executive in charge of News America used to show the sales staff the scene in “The Untouchables” in which Al Capone beats a man to death with a baseball bat. Robert Emmel, a former News America executive who became a whistle-blower, testified in a civil suit with a competitor that Mr. Carlucci was clear about the guiding corporate philosophy.

http://www.nytimes.com/2011/07/18/business/media/for-news-corporation-troubles-that-money-cant-dispel.html

A disturbing and thought-provoking Christian Science Monitor article asks the question is the US a nation of liars? It summarizes the recent court cases of Barry Bonds who was found guilty of giving evasive answers to a grand jury, Casey Anthony who lied to police officers investigating the death of her child, Roger Clemens who was tried for allegedly lying to Congress about his steroid use, Anthony Weiner who resigned from Congress after admitting that he lied about his Twitter photos, and the Atlanta public school teachers who lied about tampering with student tests to make their schools look good.

David Callahan, author of The Cheating Culture, states, “Every day there’s new evidence of successful people who have cheated to get ahead, and it creates cynicism.” Douglas Porpora of Drexel University in Philadelphia, comments, “At a certain point, you’re watching all these jerks and you say, ‘What am I, a schmuck?’ A lot of people want to do the right thing, and after a while they say, ‘You know what? I’m going to follow the jerks.’”

http://www.csmonitor.com/USA/Society/2011/0719/Is-US-a-nation-of-liars-Casey-Anthony-isn-t-the-only-one

The problem of unethical behavior in medicine appears to be part of a much larger societal cultural problem. We need to hold each other accountable; we need to speak out when we see wrongdoing; we need to accept constructive criticism from our peers; we need to provide better role models for our medical students and colleagues. We need to be professionals who really do care more about our patients' well-being than our income or status in society.

5 comments:

  1. The ship has sailed; you missed the boat. Physicians of yore, sainted men and women who perpetually put their patients, their practice, their profession before themselves and their families did so BECAUSE of the unwritten contract with society that paid them back with income and status. Wave goodbye.

    You have conflated "compassionate care" with "ethical care". Your post is disingenuous on its face. One can be unfailingly ethical and be little more than a technical wizard, totally devoid of compassion whatsoever. What drives the compassion away is not the "am I a sucker" sentiment because one sees others getting away with unethical behavior, it's the "am I a sucker" sentiment that gnaws away with each small insult, each tiny lack of gratitude, each episode where the physician is denigrated by patient, payer, or nameless-faceless bureaucrat. At some point it becomes difficult to muster emotion of any sort unless it is resentment.

    No, good sir, the ebb of compassion has little to do with ethics and all to do with humanity. The ethical pratfalls that make the headlines are not the norm, they are rather the tiny stain on the white coat that cannot be ignored despite the progressing dimness of the color as white turns to grey, as the compassion leaches out from the daily pounding.

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  2. So, do you think that people are different today (less accountable, poorer role models), or are people the same, but incentives have changed?

    I think the people are the same- we're just as accountable and honest and compassionate as we used to be, but the relatively few bad apples get a lot of media attention.

    I hope, anyway.

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  3. Kent, great post as always -- thoughtful and thought-provoking. I have to add the constant barrage of political double-speak that pervades our media and civic conversation. Unless one is savvy and willing to think (something beaten out of most of us by our educational system), it is very easy to be duped by this device of demagoguery and start to believe that a lie is the truth. This is the liar paradox come to life in nothing less than Orwellian proportions. Again I think of Hannah Arendt and her "banality of evil." What a ubiquitously relevant insight!

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  4. Like, Share, 1+ , RT ... :-)

    Kent... great post. Couldn't agree with you more, as well as some of the comments in the thread too.
    /hjl

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  5. Kent, I always enjoy your posts whether I agree with you or not. Your post is one sided...as many doctors who lose face, ethics, and commitment, there are those whose commitment increases, interest strengthens and who become leaders and stand fast with their ethic and moral commitments as they are swept away by the tides of 'progress'. Many of these physicians observe and comment as you have about the 'poison' in our midst. As many go into medicine with idealism few really know the reality until it is too late...they hang on because they do not know what the alternative career paths may be. Most people in other walks of life change careers or move horizontally into something they enjoy. Medicine (government and insurance companies thrust upon it's practitoners responsibilities and work they did not sign on for. The job description changes frquently..In all careers job satisfaction often depends upon how much control the worker has over his daily routine and choices. The doctor has few, and he is the responsible party for all who work around him.
    Skyvision...great observations...our patients are ungrateful at times, hospitals treat doctors about the same way they treat orderlies, the government does not even recognize the free services we give (which cost the MD real money in lost income...absolutely no recognition as a partial tax credit, or deduction for those services. There would be very little problem with uninsured, and the govenrment would gain far more in the swap between tax credits and government expense for health care.

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