Doctors' Fear of Professional Failure

I first would like to have my visitors here read a comment by a medical student to my blog thread "Telling Patients They are Terminal" in August 2005.

Dr. B-As a current medical student and future physician reading your posting, “Telling patients they are terminal” I felt a surprising emotion: fear. My feeling of fear came from your comment that physicians often cause much of the confusion that surrounds end of life care. Specifically you stated that certain physicians will order more aggressive therapies and more diagnostic test when they know in their hearts that there is nothing more to do but ease the pain. In this situation, as you stated, the families will often get an unclear message as to the condition of the patient and how much time is left with their loved one. This confusing message that doctors often give patients can translate into disastrous effects. In this example the family might not understand that the last few days are near and the opportunity to say goodbye may pass them by.It is easy to say that such physicians that give unclear messages are "bad doctors." However, although I promise to be the best physician possible I fear that I could someday make the same mistake. As a student among so-called "overachievers" in medical school the idea of failure is so frightening that we all work as hard as we can. In fact this fear of failure is what was selected for when we were accepted to medical school among thousands of applicants. Certainly this culture of fear will increase competition and cause us to study harder and ultimately work harder. So, as a medical student it is easy to see how a physician, who is deathly afraid of failure, would try to guard himself/herself as a human by squeezing any feeling of personal success out of every sick patient. However, as evident here, the patient's best interests may not always be aligned with those of the physician.It is clear then that a truly great physician is one that is not afraid of being exposed to the feelings of failure (and this rational should be taught in school) and is able to identify the patient's needs as much more important than any feeling of personal success. I guess a good way to look at this situation is that a physician can gain a small victory of personal success by giving a clear message to the patient and his/her family so that the concluding days are filled with love and goodbyes. By acknowledging small victories like this a physician can maintain his/her sense of purpose and provide the best care for patients all the while.

It is my impression that this medical student was expressing a very valid issue that is not only related to this student personally but one which is part of the makeup of virtually all medical students: the fear of failing.
It is that fear which along with other considerations motivates medical students to continue on through medical school despite the long hours of study and in the final clerkship years, the long hours of work with patients and in addition to the giant financial investment and considerable loss of free time.  A question is whether this fear of failing continues on throughout the later professional career when the student has become a physician with a host of varying patient responsibilities. I would agree with the student that medical students  are probably selected by medical school admissions committees displaying evidence of being unwavering goal directed.

The question becomes, if fear of failure is what may keep a medical student on the track to reach graduation and obtain a doctorate degree, does this "motivation" lead to become a "great physician" or even a good one?  As the student wrote "a truly great physician is one that is not afraid of being exposed to the feelings of failure..."  It appears, however, that underlying fear of failure continues onward in the careers of many physicians.  A doctor's self-denial of a patient's terminal illness and expression of that denial to patient and family may represent such fears and lead to unwise further treatments and contributing to "mixed messages" by the professionals regarding the patient's prognosis. The fear of failure, I suspect, beyond fear of malpractice actions  is also suggested by how surgeons explain operative deaths or operative errors to the family.

Fear of failure, as the student suggests, causes the physician to set his or her own self-interest above that of the patient and hopefully that is not what being a physician is all about.  What is obviously needed is education for the doctor-to-be or the doctor him or herself about how to cope with failure. And I am not sure that this topic is high on the list in medical school's curriculum or beyond and  education or emotional support might be available only for those who have already demonstrated they are symptomatic or request psychological, spiritual or ethical help.

I think the coping education for professional failure that stresses ethical medical behavior should be as important a teaching subject as technical medical/surgery courses on how to devise and practice toward professional successes in patient treatment. ..Maurice.

Graphic: From Google Images

Should Pathologists Be Physicians??

What I am about to write I am sure will be considered by some as controversial and perhaps likely illogical but after a bit of consideration I felt I just had to write the question to my ethics blog.  "Should pathologists be physicians?" and if not, shouldn't the profession be noted by their members bearing a different doctorate (a PhD) rather than an MD or DO as is currently the case? So, some may ask who are pathologists and what do they do and why does the name of the degree make a difference?  I would say that pathologists are professional men and women whose interest is how human disease or injury is expressed in anatomic or functional ways and through research and examination provide a service to physicians and the physicians' patients in making a diagnosis of the living ill through a laboratory test or anatomical conclusion. They also provide a service, beyond that to the medical profession, families and to the civic community, law enforcement and public health by their work in coroners' offices and hospitals as they diagnose the mechanism which led to the individual's death.

 But the basis for my writing this thread is my understanding, after years of an internal medicine career interacting with pathologists,  that in the many active roles of being a pathologist, except for the occasional pathologist directly performing a procedure such as a needle biopsy on a live human, virtually all of their work related to the living patient is that of inspecting fragments of tissues either through the microscope or directly examining the patient's gross organs or tissues which were to be or were removed by a surgeon or other physicians. Some pathologists operate their laboratories or do scientific research in their field of interest. Clinical pathologists are primarily consultants for the patient's physicians, the latter being the professionals directly responsible for the patient's care and treatment. On some occasions pathologists may communicate directly with the patient or family to explain the findings. Though their professional input may be essential to diagnosis and treatment and their diagnostic decisions clearly an ethical and legal responsibility to the patient, nevertheless, the pathologists are not direct caregivers as are physicians.

So what does the description of the work of a pathologist have anything to do with their doctoral title or their primary care of a patient? My primary argument has to do with the training necessary to obtain the MD or DO degrees. I have been teaching medical students for over 25 years and though they start out with dissecting a cadaver for learning anatomy and they are provided extensive education in physiology, pharmacology and pathological changes in the human body, the primary orientation of their four years of medical education to obtain their MD or DO is how to interact directly with a live but sick human.  My issue is whether those who become pathologists really need all those hours, days, weeks, months and years of  intimate and intense attention and care to the daily changes in the history, physical, evaluation, diagnosis and treatment of a live patient. Wouldn't it be more appropriate for pathologists to begin their careers within a separate educational environment, not to directly study to become physicians but instead to follow a program  of education to become pathologists, learning  the day to day patient responsibilities of a pathologist which are quite different than that of a physician? Starting out in the direction of pathology and not a direct patient caregiver would save pathology students 4 years of time and perhaps excessive and unneeded education and 4 years of tremendous unnecessary expense. Currently, this is not the case and after 4 years of medical school comes many more years of specific training in pathology for those who have decided to make pathology as their career. My view is that the 4 years of medical school education for them is largely a waste. The training for pathology should start out in the details of pathology as needed for the career itself and the degree of doctorate would most appropriately be a PhD . In these days where the cost of medical education continues to rise both for the student and the medical school and the societal need, particularly now in the United States, for more trained physicians to attend to the increasing numbers of patients, particularly for general care, there should be changes in medical education programs to make the programs fit the goals of the students and eliminate unnecessary education.

Oh, I know a very realistic argument against what I have written. Yes, the majority of students finishing college and accepted for medical school enter medical school without a clear idea of what medical specialty they want as their career. It may be only until the 3rd and 4th year clinical clerkships that a specialty becomes a goal. Pathology may be a specialty only selected in these later medical school years or even later in education and experience.  But completing college with a direction specifically to pathology requires the construction of a graduate school of pathology and then  to educate undergraduate students about this career: this career of significantly contributing to the health and welfare of the living as well as contributing to the benefit of society even when dealing with the deceased. This should be an activity as priority for organizations like the American College of Pathology and other professional organizations, to work to develop such schools. Then work with university career counselors and science departments to provide students, particularly those who are planning to apply to medical school with introduction, knowledge of pathology as a career contrasting to the life and work as a physician. Experiences should be created including the "trailing" of the professionals at work.  Then, rather than applying and being admitted to medical school, the students would move directly into a post-graduate school program to become pathologists, not physicians, and with a PhD after their name.

In conclusion, a philosophical and practical question is whether a pathologist could still contribute to the living  and to society and science without the first 4 years of training to become a physician and an MD or DO degree. Is there something intrinsic to a pathologist's profession that demands he or she be a physician? I would like to read responses to this suggestion of mine by pathologists and non-pathology physicians and the general public, knowing the conditions and needs of the 21st century. ..Maurice.

Graphic: Anatomy Dissection Room from Google Images