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