Steve is a young physician in a very busy practice owned and managed by a for-profit organization. He is now four years past residency. Steve and I became friends when he was a third-year medical student. Three years ago, Steve and I began meeting at 6:00 AM on alternating Wednesdays to discuss his struggle to maintain his resolve to be humane toward patients and to exercise a strong social conscience in his practice of medicine.
Steve begins most days poised to be empathetic (i.e., the physician profile in column three). He is prepared to give disproportionate attention to his more vulnerable patients. He is ready to open himself to his patients’ suffering to the point of risking burnout. He intends to be meaningfully present with his patients. He grips firmly his integrity. He gauges his capacity to tolerate the moral dissonance he experiences from value clashes with some of his patients. He seeks to grow professionally for patient benefit as much as for personal security. He feels a nagging tension between his lifestyle interests – simple for a physician -- and his accountability to/for his patients.
Steve would violate his integrity if he refused to look beyond each patient’s presenting problem. He has seen far too much. However, he accepts that he is not yet one of those rare physicians who seem capable of saying “yes” to every deeply pained patient and enter yet another broken story (i.e., the physician profile in Column four). Fatigue, accountability to his other patients, administrative obligations, family responsibilities, reimbursement pressures, personal interests apart from medicine, and a host of other considerations force him to say “no” as often as “yes” and thereby to limit many patients’ access to his time, his energy, his heart. Instead, Steve triages his patients carefully to sift out the encounters in which he will enter more deeply into the patient’s story, in which he will make and impose on others the sacrifices to be fully ‘I and thou’ with the patient.
Even on his most exhausting days, Steve remains angered that malevolent physicians (i.e., the physician profile in column one) continue to escape detection – e.g., the resident who alters a chart to disguise an error, the primary care physician who ‘sees’ as many as seventy patients a day, the obstetrician who fraudulently convinces healthy women they need high-risk management and procedures to protect against premature labor/delivery, the researcher who fabricates data, . . . . Such physicians are criminals who assault patients. Medicine for them is a scam. They exploit patient suffering and desecrate the social fabric. For them, self-interest is everything. They are harmfully present with patients. They reduce patients solely to means for self-serving ends. Professional advancements provide cover for their hidden purposes. They have no conscience. They experience no moral dissonance. They have no professional integrity.
Especially on his most exhausting days, Steve might glance enviously toward the many flourishing physicians for whom the medical environment is most fertile (i.e., the physician profile in column two). For these physicians, a patient encounter is a sale; the patient, a consumer. These physicians are entrepreneurs who capitalize on the medical environment. Lifestyle incentives motivate them. They subtly sift out difficult patients from their panel of patients. They stay sufficiently detached from patient suffering to avoid any risk of being burned out. They have learned to make patients think they are present and care. They turn professional advancements into marketing tools. They lead unreflective lives. They have an easy conscience. But Steve is not seriously tempted to join their number.
However, Steve is troubled by how often he ends the day thinking of the next patient as one more demand; thinking of himself as a mechanic (i.e., this diagram’s bracketed tension). He ends many days numb toward patients and tired of confronting the medical delivery system. He feels acutely the loss of important family experiences as he does his job. He often sees little evidence that he is making a difference in the lives of vulnerable patients. He finds himself apathetic to patient suffering as the day’s paperwork drains him. He feels ambivalent toward patients for whom he has a dimming vision. He senses that his struggle to stay current with advancements in his specialty is posing subtle risks to patients. He is haunted by the look in his child’s eyes, a look that asks, “Dad, do you care more for your patients than you do for me?” He can sound defensive. He can look disheartened.
Steve begins most days poised to be empathetic (i.e., the physician profile in column three). He is prepared to give disproportionate attention to his more vulnerable patients. He is ready to open himself to his patients’ suffering to the point of risking burnout. He intends to be meaningfully present with his patients. He grips firmly his integrity. He gauges his capacity to tolerate the moral dissonance he experiences from value clashes with some of his patients. He seeks to grow professionally for patient benefit as much as for personal security. He feels a nagging tension between his lifestyle interests – simple for a physician -- and his accountability to/for his patients.
Steve would violate his integrity if he refused to look beyond each patient’s presenting problem. He has seen far too much. However, he accepts that he is not yet one of those rare physicians who seem capable of saying “yes” to every deeply pained patient and enter yet another broken story (i.e., the physician profile in Column four). Fatigue, accountability to his other patients, administrative obligations, family responsibilities, reimbursement pressures, personal interests apart from medicine, and a host of other considerations force him to say “no” as often as “yes” and thereby to limit many patients’ access to his time, his energy, his heart. Instead, Steve triages his patients carefully to sift out the encounters in which he will enter more deeply into the patient’s story, in which he will make and impose on others the sacrifices to be fully ‘I and thou’ with the patient.
Even on his most exhausting days, Steve remains angered that malevolent physicians (i.e., the physician profile in column one) continue to escape detection – e.g., the resident who alters a chart to disguise an error, the primary care physician who ‘sees’ as many as seventy patients a day, the obstetrician who fraudulently convinces healthy women they need high-risk management and procedures to protect against premature labor/delivery, the researcher who fabricates data, . . . . Such physicians are criminals who assault patients. Medicine for them is a scam. They exploit patient suffering and desecrate the social fabric. For them, self-interest is everything. They are harmfully present with patients. They reduce patients solely to means for self-serving ends. Professional advancements provide cover for their hidden purposes. They have no conscience. They experience no moral dissonance. They have no professional integrity.
Especially on his most exhausting days, Steve might glance enviously toward the many flourishing physicians for whom the medical environment is most fertile (i.e., the physician profile in column two). For these physicians, a patient encounter is a sale; the patient, a consumer. These physicians are entrepreneurs who capitalize on the medical environment. Lifestyle incentives motivate them. They subtly sift out difficult patients from their panel of patients. They stay sufficiently detached from patient suffering to avoid any risk of being burned out. They have learned to make patients think they are present and care. They turn professional advancements into marketing tools. They lead unreflective lives. They have an easy conscience. But Steve is not seriously tempted to join their number.
However, Steve is troubled by how often he ends the day thinking of the next patient as one more demand; thinking of himself as a mechanic (i.e., this diagram’s bracketed tension). He ends many days numb toward patients and tired of confronting the medical delivery system. He feels acutely the loss of important family experiences as he does his job. He often sees little evidence that he is making a difference in the lives of vulnerable patients. He finds himself apathetic to patient suffering as the day’s paperwork drains him. He feels ambivalent toward patients for whom he has a dimming vision. He senses that his struggle to stay current with advancements in his specialty is posing subtle risks to patients. He is haunted by the look in his child’s eyes, a look that asks, “Dad, do you care more for your patients than you do for me?” He can sound defensive. He can look disheartened.
