A technician can be defined as one who knows every aspect of his job except its ultimate purpose and social consequences.
SIR RICHARD LIVINGSTON (ATTRIB.)
WHEN I was a first-year resident—an intern—I was struck by the uncomplaining endurance of my peers. We only spent about 15 percent of our time with patients; most of what we did was write orders and notes, stand in the hallway on rounds listening to or giving lengthy clinical presentations, and answer pages for an endless litany of requests from hospital staff requiring more orders and more notes. There’s nothing odd about any of this—many jobs consist of mundane work—except that we did it for up to 110 hours a week during some months, and, when on call, for 36 or more hours at a time (current rules limit work stints to 80 hours a week and 28-hour shifts). Another strange thing was how infrequently people questioned the logic of what we were going through. In fact, there was a certain pride and gallows humor, with jokes like “the problem with every-other-night call is that you miss half the cases!”
Residents gave it their all, remaining remarkably conscientious even without sleep. One senior pediatric resident who supervised me looked for things to do well beyond what the patient came in for. During nights, I would try to finagle a way to get at least an hour of rest before a long “post-call day” that might not end until seven or eight o’clock. But that was rarely an option with Dr. Ivory, who drove her interns as hard as she drove herself. Nothing was back-burnered. Whether a child was admitted with an asthma attack or a concussion, she’d want a full review of the vaccination history before morning rounds, to see if the immunizations were up to date. That could require running down to the medical records department to locate the file (this was before the advent of the electronic medical record) as more patients flowed into the emergency department. She also requested I order lots of tests to look for rare conditions, and then follow up on the results right away. I found that if I did everything she wanted, she’d look at me approvingly, which I craved.
This perfectionist tendency is cultivated in medical school, where tests, typically multiple-choice, focus on minutiae, and where the attending physician might ask you anything about your patient’s medical history, lab values, and so on. On the surface, such an exacting standard seems good for patient care. After all, who doesn’t want a doctor who is full of facts? And doesn’t hierarchy and a boot-camp environment foster exactitude, endurance, and discipline? It does. But the problem with obsessive behavior is that it represents a loss of perspective that comes with a price. Sure, if you keep checking whether your stove is on or your garage door is open, you might conceivably find one day that it is, but at what opportunity cost? What’s left out of patient care as a result of such behavior?
What’s left out is the individuality of the patient. We did things to people without finding out what challenges they were facing and what they most needed from us. Medical students and residents are immersed in a task-driven culture that objectifies the patients we are supposed to care about. At work I’d make long lists and then feel satisfied as each item got checked off, particularly on post-call days when “tucking all the patients in,” as we called it, was the only way to get out—like parents who, after putting their children to bed, could finally rest. The first priority every morning was to discharge patients so their beds could be filled with new ones. A delay occurred if we had to meet with their families to discuss, for instance, whether they could return home or needed to go to a nursing home. One of the disincentives to spending time with patients was that doing so cut into time for completing tasks. Task completion drove us and was the measure of our success.
How did such a state of affairs come to pass? First, it’s important to acknowledge that practicing medicine really does require following a lot of steps. When patients are admitted to the hospital, the doctor’s orders specify everything that happens, including what they will eat (“diabetic diet”), their activity level (“up in chair”), how often they’ll be awakened at night (“vitals”), and what will happen if they stop breathing (“code status”). This all keeps staff busy. And when the various scans and blood work come back, the resident has to piece it all together to figure out what to do next. While challenging at first, it soon becomes routine. I remember the first time I admitted 12 patients during the night—the maximum allowed per call shift—with two interns under my supervision, and experienced the satisfaction of knowing that I knew what I was doing. I imagine it’s similar to the pilot in training who gets to a point where they realize they’re not likely to crash the plane, even in bad weather. Physician and pilot have, respectively, achieved competence.
However, a plane is an object, and a patient is a person. Philosopher and theologian Martin Buber distinguished between two ways of experiencing the world: as “I-It” or as “I-Thou,” with the former referring to the manner in which we relate to people as if they were objects and the latter as how we should strive to relate to them as people. Unfortunately, we are prone to relate to others as objects once they have labels. Hence, “It” refers to all that we place into categories, including chairs, tables, and, yes, patients. Relating to a person as a “patient” is an “I-It” relationship when they are thought of as predominantly belonging to that category. Sometimes doctors subcategorize, and patients become “leukemics” or “diabetics,” and so forth. Residency is almost perfectly designed to reinforce the “I-It” nature of the doctor-patient relationship when the latter becomes the object of a set of tasks.
How do we come to objectify other people, to relate to them as an “It” rather than a “Thou”? I don’t think we start off that way. Our first interaction with another person is typically at our mother’s breast. Within minutes of birth we enter into a reciprocal relationship where we cry for milk, and the more milk we consume, the more is produced. By six weeks of age we are making eye contact with our mother during breast feeding, and throughout the months that follow this relationship is paramount. The subsequent connections that we make, typically with another parent and/or sibling(s), are also highly engaged.
As infants we are so dependent on others for everything that we don’t initially differentiate self from other. Such knowledge comes mostly through the experience of frustration—of not getting what we want when we want it, and hence realizing that what other people do is not under our control. Whereas we can put our hand in our mouth anytime we want, we can’t make someone else put food in our mouth—we need to convince them to do that for us. We soon learn that the hand that feeds us belongs to someone else.
Hence boundary clarity, which may be defined as the capacity to differentiate that which is us from that which is not us, evolves as we adapt to life outside the womb. In the years that follow, we explore the world around us driven by insatiable curiosity. This is not just a human phenomenon. Kittens are famously curious, and their moms swat them away when they are about to try something foolhardy. Human parents do that too. I recall watching my daughter as a toddler put an extension cord in her mouth while observing me with a mischievous look on her face as I ran toward her to snatch it away. She did it repeatedly as a form of play that, while frustrating for me, taught her how to influence my behavior. As she got older, she became curious about nearly everything.
The point is that children, from early infancy, are eager to learn about the world and people around them. They soon acquire the basics: how to engage with key figures in their lives, an awareness of boundaries, and, after acquiring speech, the value of asking questions. So, what happens? How do we go from such a promising start to the gradual adoption of “I-It” and an uninquisitive acceptance of the status quo?
The disengaging process also starts early, with our parents signaling us to stay out of other people’s business and not to talk with strangers for our safety (when, in fact, children are more likely to be victims of sexual or physical violence from people they know well). As a result, we develop an “us-them” mentality about the world, where the nuclear family is “us” and most of the world is “them.” Just as our inclination to engage with anyone and everyone as a toddler is discouraged, so too is constant questioning. A problem with curiosity is that it can pose a threat to social conventions that maintain order through control and hierarchy. It’s hard to explain many of those conventions to a logical, inquisitive mind. I recall my daughter as a preschooler questioning the rationale for table manners, conventions related to nudity in public, and how she could be sure we existed. Answering any one of these requires considerable thought, particularly with the added challenge of communicating with a person whose vocabulary and life experience are quite limited. Add to that the sheer volume of inquiries, which can wear parents down to the point where they rebuke children for asking questions. An exasperated response, such as “Because I said so,” discourages curiosity.
It also cuts off the opportunity for engagement. Author and pediatrician Alan Greene observed that when his children asked, “Why is the sky blue?” they weren’t just looking for information. In fact, concisely answering the question got a cold stare. What they wanted was an interaction, with give-and-take. A brief conversation about the different colors in the sky or the sun and the planets delighted them even if it didn’t get around to addressing the question. I’d also add that returning to the original question is respectful, and looking for the answer together can be another shared activity.
Hence, curiosity and interpersonal engagement are intertwined in childhood, and shutting one down also shuts down the other. Schools, unfortunately, often suppress both with their emphasis on rewarding answers based on passive learning. It was sad to see, but I do recall that my daughter’s curiosity diminished substantially as she entered high school, probably related to some poor but time-consuming course material. A required physics class began with instruction on how to predict the direction of an electromagnetic field as current flows through a wire, without any background on what an electromagnetic field is. She had to memorize a mnemonic involving pointing the thumb of her right hand up and making a fist. That was sufficient to pass the test. Such abysmal course design is a turn-off for an inquisitive mind, yet still seems to be common even at top-ranked schools.
Similarly, premedical and medical school education can extinguish curiosity—and socioemotional development—by essentially holding the mind hostage. I learned early on that if I wanted to become a doctor, it was going to require intensively focusing on what I was told to do, and that it would entail years of preparing for high-stakes exams written by people who had immense power over how I spent my waking hours. If the writers of those tests are wise in their judgment of what future doctors need to know, then the system works. But if 30 percent, or 40 percent—or perhaps more than half—of the material is not relevant, then there is a massive opportunity cost. What are the costs of keeping students mentally exhausted by memorizing voluminous material they’ll soon forget while they sacrifice acquiring other skills, both interpersonal and intellectual—including inquisitiveness? And, is this an unavoidable consequence of intensive training, or some form of social control?
In my first-year medical school immunology class I got slapped down early on when I questioned what we were taught. Although I wasn’t a science major, I did take a year off between college and medical school to work in a molecular immunology laboratory with a pioneering team. A year later, when I discovered that the immunology instructor was teaching outdated material, I was savvy enough to know that I needed to broach the problem diplomatically. During a lab break, when I had a chance to discuss it out of earshot of others so as not to embarrass him, I showed him studies that were more current. I was careful to sound friendly and casual when I asked him what he thought of these newer findings, but it still didn’t go well. What I heard was a variant of “Don’t try to teach me immunology, you little pipsqueak.” I recall thinking, as I went back to my lab bench and microscope, that I wasn’t going to question anything else in medical school, and I didn’t.
It’s been said that “every system is perfectly designed to get the results it gets,” and that’s evident for the pipeline that produces doctors. Those students who are perfectly designed to gobble up information, rapidly learn new tasks, and not ask out-of-the box questions seem to flow smoothly along. The system is made for them. Those who can’t fit the mold get stuck at some point, unable to pass. A middle group muddle through, but their slowness doesn’t go unnoticed. I fit it into that third category. During residency, I was often asked, “Why are you still here?” on post-call days, as it took me longer to finish my work than most others who had already left to go home and sleep. An attending once observed that “if you were married, you wouldn’t stay so late,” as if I had nothing better to do than stumble around exhausted after 36 hours trying to finish up my work. Appearing efficient is what counted, perhaps even if it meant cutting corners, like spending less time than needed with a family or patient who needed to talk. The pressure was for conformity.
The go-go pace of internship seemed to suit a lot of my peers better than it suited me. This was in part because most were faster at learning how to do things than I. On morning rounds, the resident or attending would rattle off orders without enough information for me to follow what it was I was supposed to do. I’d jot down key words I’d heard and then later show them to another doctor to see if they could decipher what I was being told. My sense that I was not up to par was confirmed one afternoon, mid-internship, when my senior resident said, sternly, that I was “not performing at the level expected at this stage.” I recall hearing this at least two or three times that year. During the first nine to ten months of residency, I often looked around and wondered if I could think of anyone who might be as slow and confused as I.
The residents who seemed so efficient and smart also hung out together, bar hopping on nights off. In medical school, and even as premeds, they were the cliques who knew how to work hard and party hard. In organic chemistry in college I recall students who exhibited a remarkable capacity to sit in lecture for hours every day filling up notebooks with neatly written, detailed mechanisms, followed by long lab sessions, followed by a high-stakes exam at the end of the week. Weekends were for catching up on sleep, followed by partying, and then back into the cycle early Monday mornings.
An important difference between me and most of my peers was my learning disability. It was something I couldn’t run away from. I was aware that while others knew what was going on in class, I was lost. To survive I had to find new ways to learn on my own. I could not go out partying when I needed to keep my mind in top form at all times so that I could focus on my studies. I’ve often wondered how actors and rock stars are so productive while drinking so much and getting high. How do they even remember their lines on stage when they’re intoxicated or stoned? Medical school prompted the same wonderment at my peers’ cognitive abilities under self-imposed duress.
Others who pursue professional training soon after college, such as most law students, have similar lives, what some call a prolonged adolescence. But there is a difference, which is the destination. The destination for future physicians is not a corporate office or a firm. It is at the bedside of a woman, man, or child who is frail, frightened, in pain, nearly naked in a hospital gown, or in some other way vulnerable and exposed—a person with fears and needs that twenty-somethings who are generally healthy, ambitious, task-oriented, and prone to escapism do not often contemplate.
It’s not that all medical school students have led rosy lives and are unfamiliar with struggle and suffering; it’s that personal struggles are concealed and inner turmoil suppressed. When I was training, it seemed as if nobody had any problems—except when awful things happened, such as when a resident I occasionally took call with committed suicide about a week before completing the program. People kept their struggles to themselves, and that appeared to suit the administration just fine. While there was probably a counseling service one could seek out, I don’t recall anyone telling us about it.
At the medical school where Simon taught for over 30 years, he maintained an open door policy—literally—in order to give students a place to confide their struggles. Over the years he heard countless stories about child abuse, spousal abuse, substance abuse, depression, post-traumatic stress disorder (PTSD), and other sources of suffering among a group of young people who looked on the surface like they had won life’s lottery. Simon quoted Thoreau’s dictum that “the mass of men lead lives of quiet desperation.” He once commented that while he thought it was hyperbole the first time he heard it, he didn’t think so anymore. Like their patients, many young physicians know despair. But the conventions of medical training do not facilitate coming to terms with emotions. Rather, trainees bottle up feelings and focus on projecting assuredness as they move from task to task and patient to patient. Emotionally stunted, they are inaccessible to their patients, as they are inaccessible to themselves.
I’m not implying that self-knowledge is a necessary prerequisite for a contented life or to be good at a job. It’s just that it is if you are a physician. Surely, many who are not inclined toward self-examination are good neighbors, hard workers, and trustworthy to their family and friends alike. My dentist described his dad, an immigrant from Greece, that way, saying, “He was still parking cars at Wrigley Field for Cubs games when he was 85 years old, and sharp as a tack. He never reflected much about himself, as far as I could see, but we always knew we could count on him.”
Simon observed that, in this respect, Socrates was wrong when he famously said, “The unexamined life is not worth living.” But the adage does apply to physicians, who must examine themselves and the lives they live because of the work they do and the socialization pressures of medical training. Otherwise they will adopt disengaged behaviors and rigid ways of thinking. After mastering book learning and multiple-choice test taking, they enter the clinical years of their training applying the same skills of compulsively completing assigned tasks. They mimic what they observe. Hence, if their professors talk down to them, they adopt similar ways of relating to more junior trainees and to patients. Because they expect perfection of themselves, they avoid delving too deeply into the struggles their patients are facing for fear they won’t know what to do with what they hear. When their patients are unappreciative or even oppositional, they take it personally, lacking the boundary clarity to recognize this isn’t about them.
Unprepared, developmentally, for the doctor-patient relationship in its real life complexity, they retreat. In place of a fulfilling career with meaningful relationships with patients is a job like any other job, with paperwork, procedures, and a way of relating that has been described as emotional labor. Emotional labor is a term used in the service industry when, for instance, flight attendants must mask emotions they feel and portray emotions they don’t feel. It’s fake relating to meet the expectations of the customer and employer.
Not everyone enters medicine looking for fulfillment through healing relationships with patients. Some are attracted to the high earning potential, the status, or simply job security. But even among the materially minded, many desire to have a positive impact. I remember that my classmates who sought careers in surgery said that for them, the reward would be “going in there and fixing the problem.” Inpatient medicine, in contrast, with its endless rounds and stream of patients with progressive, chronic conditions cycling in and out of the hospital, struck them as hopelessly ungratifying. Outpatient medicine, with its “worried well,” would be a waste of time or more of the same. I recall thinking that it was difficult to argue with them.
Only years later have I come to appreciate the fallacy. First, surgery doesn’t necessarily fix things. What it does is slice someone open, with the potential to do irreversible harm. Tens of thousands of people have had their backs or their prostates operated on with no gain, or with devastating consequences. Some have benefited greatly. So, the premise that a career in surgery will spare the physician the messy uncertainties of trying to help people whose bodies are still largely a mystery to the medical profession is false. It reflects a desire to cling to an expectation of perfection that characterizes many who want to become doctors and who are able to make it into and through medical school.
Second, caring for patients with chronic conditions, or simply the vagaries of old age, isn’t just about ordering lab tests, CT scans, and pills while watching them slowly recede toward death. It’s about helping people cope with and adapt to what’s happening to their bodies as they live their lives. But to serve patients in that way requires emotional and cognitive capabilities that aren’t discussed in medical school and are rarely modeled by faculty. With that piece missing, the perception of those heading into surgery that medicine is a Sisyphean task isn’t far off the mark. Internal medicine and primary care really are demoralizing if you think of patients as walking checklists of tasks to complete each time you see them.
What I’ve observed is that surgeons run from human engagement but can’t hide from it, whereas medicine doctors are drawn to it but are unprepared for what comes their way. These are generalizations, of course, that apply to many but certainly not to all. Among all types of physicians are those who do in fact openly and fully engage. To those who wonder where they fall, I pose the following question: Do you find interactions with your patients nourishing, and leading over time to a sense of attachment? That’s what engagement feels like. Those who answer “yes” are fortunate to have a personally and professionally rewarding career, and their patients—whether they appreciate it or not—are cared for by a healer. While healers appreciate being appreciated, it’s not what makes their work fulfilling, and its absence doesn’t diminish their sense of fulfillment.
The problem is that too few physicians find patient interactions nourishing, likely because they have been unable to retain the curiosity and openness to engage that they exhibited in their early lives. As discussed, there are many pressures to become less open and accessible to others, and to prioritize conforming over questioning as we grow up. The consequences for physicians and their patients are mutually adverse. Many physicians slog on, unfulfilled in their work, in the same manner that many people accommodate unfulfilling marriages. The connections are not there. Patients may or may not know what they’re missing. They often expect surprisingly little from their doctors other than technical competence and amicability. But, unfortunately, this often means settling for less than they need. There is relatively little in medicine that is so cut and dried that a lack of engagement isn’t consequential.
It is a paradox that we are prone to pass on to the next generation the destructive behaviors of those who hurt us. One study showed that pediatricians who were spanked by their parents were more likely to endorse spanking, despite seeing the research evidence that it teaches kids that violence solves problems and doesn’t lead to better behavior. As adults, we often repackage our trauma and inflict it on others in a modified form. It can be quite subtle. In my early 20s and 30s I could put others down when I felt insecure to show that I knew more than they did. Simon—who knew my mom well—would say, “You come by it honestly.”
Many people, if not most, experience enough micro-trauma to hold others at a distance. The commonality that I’ve observed frequently in relationships characterized by power imbalances—employer/employee, teacher/student, and parent/child—is capricious heavy-handedness. The parent or teacher or employer seems caring and supportive, leading the child, student, or employee to open up, to begin to relax and trust, and then, bam! They unexpectedly cut them down to size. Such impulses are born out of insecurity expressed as showing who’s in charge.
Simon guided me through reframing: A few years into my job as the director of a residency training program, when I was just a few years older than the physicians I supervised, I got irritated by a resident who used to e-mail me with the salutation “Hey, Saul . . .” rather than the more customary “Dear Dr. Weiner . . .” or “Dear Saul . . .” I felt I was not being respected. When I asked Simon what he thought I should do, he replied, “What’s disrespectful about how she’s addressing you? It’s informal and probably means she’s comfortable with you. However, I do think you should let her know that while it’s fine for her to address you that way, you want to be sure she’s aware to be cautious about such informality with future employers.” Rather than chiding her, he guided me to educate her in a manner that was no longer about me. When I talked with her, she seemed appreciative and relaxed. Had I reprimanded her, I could have undermined our relationship. I would have passed on that same capricious heavy-handedness.
Parents have the biggest impact because they create the world we inhabit in our early, most impressionable, years, at a time when we have no points of reference. They also shape how we behave years later when we have some power. I recall the terror I would feel when I said something my mother perceived as “being fresh” and her face would go dark with rage. By the time I realized what I had done, it was too late. Yet her reaction indicated she thought I was intentionally provoking her. Without the mentorship I got from Simon, I may have repeated the same behavior.
Similarly, I’ve learned that my physician colleagues who complain about patients who “never listen,” or who “are never satisfied no matter what I do” have a worldview that they likely “came by honestly.” They take things personally that have nothing to do with them. Preoccupied with their own emotional response, they react to angry patients with defensiveness rather than openness to understanding what they are observing. They do their best to conceal their feelings, of course, and act as if they are above the fray, which can seem patronizing. Instead, they could be asking what is going on when a patient’s behavior seems irrational or counterproductive: Why are patient and doctor so not on the same page? Why might the patient seem so chronically dissatisfied, and what’s the therapeutic response? If the doctor is preoccupied with how they are treated—if, in other words, it’s about them and not the patient—such questions are likely overlooked. Overlooking them not only compromises patient care but diminishes both parties. The individuality of the patient has not been acknowledged, and the physician is living in self-imposed solitary confinement, having cut themselves off from meaningful interaction. Medicine gets dull fast when it’s just about knowing what pills to prescribe or tests to order. The richness comes from real human connection.
To engage, you must regard your patient as an equal, despite differences in your medical knowledge or overall education. It may help to remember, for instance, that a homeless man or woman living on the streets in the dead of winter has survival skills you’d sorely need were you to land in their situation. An openness to engage comes out of an appreciation for the universality of the human experience and an understanding that differences are due to chance. If you can acknowledge that we all sometimes smell bad, look bad, and end up in really embarrassing situations, it’s easy to be responsive to a patient’s needs, as they cease to be “other.” After doing a foot exam you might offer to put a sock back on as a patient struggles to bend over, or after completing a rectal exam, you could ask the patient if they would like you to wipe the sticky gel from their behind rather than just handing them tissue paper to do it themselves.
Unexpected small gestures such as these can have a lasting effect. When I was sixteen, I stayed with Simon for a week at his home in Washington, DC. As I already aspired to be a physician, he invited me to the medical school to sit in on a class he taught. He woke me by gently knocking on the door at 6:00 a.m. and entering with a glass of freshly squeezed orange juice on a tray. No one had ever done anything like that for me, and it seemed a bit odd. However, over time I came to appreciate that such graciousness is characteristic of how he relates to everyone, regardless of their status, education, or responsibilities relative to his.
How we are treated greatly shapes how we treat others. Many of us have little experience with unconditional caring and respect. Patients come to expect and accept a low bar for how they’re treated by their doctors because they don’t know anything different. They acquiesce to physicians who do most of the talking and rarely ask questions, because what other options do they have? Nevertheless, they want to believe their doctor is great, as reflected in national patient satisfaction data that show how few doctors get less than a four- or five-star rating. Such expectations extend beyond health care: Students look up to teachers who spoon-feed them information and don’t like to be challenged, both because it feels familiar and because they don’t know what they are missing. And we all too often pick life partners ignoring—or perhaps embracing—the familiar feeling of not being treated well. Our expectations are set by the formative relationships we have when we are young, starting with our parents. And for many the bar stays low. That is unless we have the good fortune to have someone in our lives who shows us what a high bar looks like.
Unfortunately, medical school faculty who teach physician-patient communication rarely model open and full engagement. Instead, students are taught to navigate the doctor-patient relationship through practiced behaviors. They take classes on topics such as “giving bad news” and “communicating empathy.” While well intentioned, the training nevertheless orients them to “do something” to people, rather than to make a genuine human connection. They become proficient technicians rather than healing professionals.
Questions for Reflection and Discussion
1. When you reflect on how you practice medicine, do you think you are functioning mainly as a technician, or is your decision making taking into account particulars of each patient’s unique situation and preferences? If the latter, what are some examples?
2. When you are with a patient who has, say, poorly controlled diabetes, how far do you think you should go toward understanding what is going on? Are you likely just to ask if they are taking their current medications correctly and then adjust them as needed? Or are you the doctor who figures out that their vision has been failing so they can’t read the insulin syringe reliably, they’ve become fearful of injecting themselves regularly, and that what they really need now is both an ophthamology referral and prefilled syringes?
3. If you’re the second kind of doctor in the example above who gets to the bottom of things going on in your patients’ lives that affect their care, do you find this detective work exasperating, rewarding, or something else? Do you think it’s your job, or are you going beyond what’s expected of a physician practicing competently?
4. How has your training enhanced or impeded your functioning at a level above that of a technician who provides technically competent care that looks correct if you examine the chart, but is probably not ideal if you know what’s going on with the patient?