My friend is a respected oncologist at a prestigious American cancer centre where international patients come to seek his expertise. It’s uncommon for him to ask my counsel but I can tell he is troubled. Under his care in hospital is a young patient, the daughter of influential parents, diagnosed with incurable cancer. Experienced surgeons have deemed the cancer inoperable and the oncologist has admitted the patient for palliative care. The parents are devastated. Faced with the prospect of loss, they pledge to leave no stone unturned, and recall an early conversation mooting a liver transplant as the only potential cure. But transplants carry high morbidity and mortality and it had become apparent with time that this patient’s trajectory would not be altered by a transplant.
Nonetheless, in the final days of the patient’s life, a surgeon at a rival cancer hospital told her parents that he could have performed a transplant earlier had they sought his opinion instead. In that one ambit claim, the surgeon trashed the entire value of considered opinion made by people who knew the patient. He did not once talk to the treating team.
The parents reacted to this new advice as if jolted by electricity. Phone calls and emails start flying in to my friend, some painfully inquiring, others implicitly accusing or just confused, each suggesting compromised care and raising the prospect of an overlooked miracle which was, sadly, a mirage in the desert of their desolation. Meanwhile, the patient is now dying of liver failure. My oncologist friend laments that this was a time for the parents to sit with her and reconcile to her impending death. My friend wishes that the surgeon had facilitated this realisation instead of revisiting a simmering tension between doctors about who is better. His compassionate support for the family will become even more important in the face of this last minute and unnecessary disagreement between doctors that overlooked the best interest of the patient.
His account takes me back to the time one of my patients ended up in a faraway emergency department with uncontrolled cancer pain. To find this large, stoic man reduced to a whimpering, defeated mass was distressing enough but when the palliative care physician there initially refused to see the patient, I was astonished. She believed that the patient needed urgent care, “but since you oncologists think you can do everything, maybe you can do this too.” My heart sank at the thought of having a turf war as a patient lay dying. That needless, prolonged conversation to soothe egos happened at the cost of patient care.
Do doctors argue, fuss and fight? Do they have trouble working with each other in genuine collaboration? Absolutely. The medical profession as a whole abounds with fragile egos and deep vulnerabilities. But does it affect patient care? You bet – in obvious ways when we disagree on a plan, say surgery versus no surgery, antibiotics versus no antibiotics, but in far more subtle ways when by choosing expediency over healthy debate doctors go along with what other doctors want. This is how many patients end up having expensive and duplicated tests and dubious interventions. In this age of piecemeal medicine, frankly it is easier to let each doctor have his or her own “right of way” with the patient even though it doesn’t feel right and is not right.
As the patient-centered care movement gains force, much is being said about the doctor-patient relationship, and there is good reason to make this sacrosanct part of medicine as good as humanly possible. It is heartening to see medical students, doctors and bureaucrats waking up to this. Then, there is a whole body of literature about the power play between doctors and nurses, vexed to this day. Scholarly articles are still being written advising nurses on how to handle arrogant doctors.
But I can’t help thinking that the hidden shame of medicine may yet turn out to be the doctor-doctor relationship, that powerful force which ultimately influences how doctors treat their patients.
I heard of an incident in the operating theatre where a surgeon became so angry with the trainee for wrongly positioning a patient on the table that he pinned the trainee to the wall to show him how it was done, leaving some nurses crying.
Lest you think bad behaviour is unique to surgeons, my general practitioner friend recently received a belligerent call from a hospital registrar. The registrar patronisingly told her that she should not be caring for complicated pregnancies, unaware that my friend was one of a diminishing number of obstetric-trained GPs.
Physicians are typically thought of as gentler denizens of the profession since they work with their minds rather than instruments. Yet I recently counselled a distressed physician who had been repeatedly verbally harangued by two senior colleagues in closed meetings for poor performance without any substantiation beyond “it’s just a feel”. The physician knew he had grounds for complaint but chose job security above injured pride, losing weight and sleep in the process. Imagine how each incident affected the doctor and imagine undergoing variations of it throughout a long career.
Extreme cases of doctors behaving badly are reported but the majority of every day incidents are not. The truth is, no doctor would dream of it – there is an extraordinarily high level of reticence among doctors to be seen as “precious”.
This is not to imply that hospitals are a place of internecine warfare. For many, the true joy of medicine comes alive in the relationships formed with patients. It’s hard to quantify the problem but the subtle slights, small tensions and hostilities between doctors add up to significant mental stress, the effects of which can spill widely. Increasingly, it seems that doctors can practice good medicine without feeling all that good themselves.
A psychiatrist colleague observes that a common reason why doctors see her is to figure out how to coexist peacefully with other doctors. She jokes that researchers hate clinicians as people who feed off their intellect. Clinicians scoff at lab doctors who don’t inhabit the real world. And clinician-researchers, derided for being too much of one or the other, are never sure where they belong. General practitioners are sick of the condescension from specialists. Specialists tussle among themselves and with entrenched hierarchies.
Research, here and abroad, points to increasing levels of anxiety, depression and burnout among doctors. We traditionally invoke factors such as long hours, demanding patients and unending bureaucracy as the cause but perhaps it is worth asking what role doctors play in harming each other, however unintentionally.
Medical training would benefit from acknowledging this at an early stage and focusing on practical ways of not just resolving conflict but crucially, on avoiding it. Who knows, we might find that a course on How To be Nice to Your Fellow Doctor would ultimately rain benefit on the now ubiquitous course on How to be Nice to Your Patient.