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Ann Thorac Surg 2002;73:11-14
© 2002 The Society of Thoracic Surgeons
a Department of Surgery, St. John’s Mercy Medical Center, St. Louis, Missouri, USA
* Address reprint requests to Dr Sasser, 621 South New Ballas Rd, St. Louis, MO 63141, USA
Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
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Introduction |
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As I embarked on this process, I read many news stories about the state of medicine. A New York Times article titled "Doctors sue health plans over coverage" said 7,000 physicians in Connecticut were suing six HMOs for denying coverage and withholding payments to doctors [1].
The chairman of the AMA’s board of trustees says in this article, "Physicians throughout the country have been pushed to the breaking point."
Another article titled "Feds fear physicians are making a living" was written by fellow thoracic surgeon Noel Raskin, MD [2]. It is a cynical account of the government’s efforts to seek and prosecute physicians committing Medicare fraud. I also read an article titled "Many doctors calling it quits earlier than planned" [3]. It reported on a survey conducted by a Dallas-based health-care recruiting firm [4]. The survey found that nearly half of physicians 50 or older plan to leave medicine within 3 years. Another 28% plan either to refuse to accept new patients or to otherwise limit the amount of time they devote to medicine. Managed care is the single greatest source of professional frustration for these doctors. In fact, for 9 out of 10, managed care is at least one factor if not the only factor causing them to make a change. The dissatisfaction, according to this survey, is so extreme that doctors are questioning their career choice. Only 4 of 10 of the surveyed physicians said they would encourage their children to seek a career in medicine.
This is no surprise to me, and I am sure not to you either. In fact, this dissatisfaction is beginning to impact the number of young doctors we are recruiting into thoracic surgery fellowships. During the last 3 years, we have not filled all the fellowship positions.
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Rediscovering a surgeon’s satisfaction |
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TopIntroductionRediscovering a surgeon’s...Doctor-patient relationships in...How do surgeons compare?One surgeon’s bedside...References |
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Yet, despite these challenges, we continue to deliver exceptional medical care. And, personally, I still find great satisfaction in taking care of people.
I always have thought that without my relationships with patients, this would just be another job. After reading stories like the ones I referred to earlier, I wonder if I am one of the few doctors still content at the end of the day. What is it that keeps me coming back? The answer is simple. Like you, I am passionate about helping the patients and their families who seek my care.
This passion for taking care of people is what I want to talk about today. It may sound simple, but in this turbulent era of medicine, I believe by rediscovering our roots we can nurture our passion to heal.
If I had to summarize my career succinctly, I would say this: I have helped many people wage battles against disease. We won some battles, and we lost others. One of the most important jobs in each of these battles was to inspire hope and to be a friend. With this philosophy, my relationships with patients and families have persevered. These relationships are the cornerstone of my practice.
Patient-doctor relationships often are a topic of discussion for our colleagues in internal medicine. But these relationships have been critically important to me as a successful, content thoracic surgeon. In fact, the bond we surgeons have with our patients is fundamentally critical. Patients place their full confidence in us as we enter their bodies with our surgical instruments.
I started my career in St. Louis in 1968 when you either joined the faculty at Washington University or St. Louis University or entered private practice. Choosing private practice, I became what was referred to as a circuit rider. This was a normal choice for a young thoracic surgeon. I was on the staff of nine hospitals scattered throughout metropolitan St. Louis. In my second year of practice, I put 24,000 miles on my car. Now, I practice only at one hospital—St. John’s Mercy Medical Center—and the only miles I put on my car are between my home and the hospital. Much has changed since I opened my office doors. Through it all, I have remained a solo practitioner, which certainly is not normal or typical in this age of medicine. A report by the AMA says between 1980 and 1999 the number of solo practitioners increased by only 16% while the number of doctors in group practice increased 158% [6].
As we all know, the demise of solo practitioners is the result of many events, including the emergence of managed care, the consolidation of hospitals into health systems, and the experiment with capitation. Somehow, through all of these changes, I have remained a solo practitioner. The changes in health care certainly have affected my practice, not to mention my income. Yet, the relationships I have with my patients and their families have endured and remained constant.
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Doctor-patient relationships in the wired world |
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We are all familiar with the increasing pressures we face for proving our competence, especially since the Institute of Medicine’s report on medical errors. Our patients are demanding more and more proof that we are capable of treating them. Medical associations throughout the country, including the American Board of Surgery and the American College of Surgeons, are examining how best to determine competence. I encourage each of you to become involved in this dialog. We are asking, "What is the best way to measure our abilities as doctors?" We do not yet have the answers, but we will. We must. The patients of this century will demand it.
Wallace Ritchie, MD, executive director and secretary-treasurer of the American Board of Surgery, wrote in a recent issue of the Bulletin of the American College of Surgeons: "It is the hope of the board that diplomates and Fellows [of the College] will see value in the exercise [of determining how to measure competence] and will endorse it because of pride in their profession and pride in themselves" [7].
As our patients and their family members search the press and Internet, they are looking for information about us specifically, or possibly about the hospital where they will receive treatment or maybe about the latest experimental therapies available for their disease. As the doctors of this century, we have the opportunity to develop meaningful partnerships—not just relationships—with today’s informed patients. After all, we still are the most trusted sources for health information.
David Dranove, PhD, a professor of management and strategy and health services management at Northwestern University’s Kellogg Graduate School of Management, explains in his recent book about health-care economics that patients still shop for their health-care services by asking friends, family, and physicians for referrals [8]. The rankings and quality indexes published in the press and available on the Internet are secondary to these personal referrals.
Mike Magee, MD, with the Pfizer Medical Humanities Initiative, has been actively researching and writing about the current state of doctor-patient relationships [9]. The research has found that approximately 60% of patients are extremely or very satisfied with such factors as physician communication, accessibility, and follow-up after office visits. Less than 15% of patients surveyed were dissatisfied with their doctor’s performance in these areas of communication and accessibility.
Physicians were not as optimistic. When patients evaluated how their doctors communicated with them, 64% said they were very or extremely satisfied. Only 46% of physicians thought their patients would respond that favorably. This means about half of the surveyed physicians thought their patients would either be neutral or negative about their doctor’s communication skills. It seems to me our patients give us more credit than we give ourselves.
Magee’s work also recognizes the changing nature of doctor-patient relationships. A significant number of patients and doctors—9 of 10—prefer a mutual partnership in which both parties make medical decisions. Doctors and patients agree that the relationships of the past, in which doctors served as authority figures, are no longer relevant. In fact, nearly 90% of both doctors and patients believe it is very important for patients to be active in their health care beyond just complying with medical advice.
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How do surgeons compare? |
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One surgeon’s bedside manner |
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TopIntroductionRediscovering a surgeon’s...Doctor-patient relationships in...How do surgeons compare?One surgeon’s bedside...References |
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As my first commandment I want my patients to believe that their problems are the only problems I am facing that day. I make every attempt not to appear rushed. When I enter the hospital room of one of my patients, I take time to sit down, if just for a minute. This lets a patient know that I have time to listen.
I also respect my patients’ anxieties about surgery and their prognosis. I make sure all my patients’ questions are answered before their procedures. I visit with them the day of their operations, after they wake up to review what happened in the operating room, and to discuss what they can expect next. If tests or x-rays have been ordered, I make sure I discuss the results with my patients before leaving the hospital that evening.
When dealing with particularly frightening diseases, a surgeon must not remove a patient’s hope. I consider this my greatest responsibility, next to technical perfection during a surgery or procedure. Even if death is imminent, I must not remove hope for one more year, one more month or one more day of life.
In that same vein, I promise to never abandon a patient no matter how dire his or her prognosis. I tell myself that despite the disease this patient is still the same person. He or she is still someone’s spouse, maybe someone’s parent or someone’s child. This person still deserves my best.
My next commandment comes from a lesson I learned early in my career. Once, at the request of a patient’s wife, I did not tell the patient, who was dying, the truth about his prognosis. His wife begged me not to tell him. She thought it would threaten his will to fight. On his deathbed, the patient looked me in the eyes and said, "You lied to me." I had to tell him that yes, I had. That was probably 25 years ago. It was the first and last time I lied to a patient. Since then, I have made it a rule to never let the family know something that the patient does not know. By holding myself to this, I stay true to my commitment to be honest with my patients. As a cancer patient said in the movie The Doctor, "Don’t ever lie to me. I don’t have time for lies."
And, as my last commandment, I never discuss money with my patients. This is the job of my office manager. I want my patients to know that my only concern is their health. Regardless of their financial situations or insurance carriers, I provide all of my patients the same level of care. I believe all physicians have a responsibility to take care of the underprivileged at some level. It helps us stay connected to our commitment to serve others.
These are just some of the ways in which I conduct myself to develop and preserve gratifying relationships with my patients. Without these tenets, I may very well have been one of those doctors who called it quits early. But, my passion to heal has kept me engaged in what has proven to be a satisfying profession. It is my hope that physicians of all generations who may be discouraged will rediscover the roots of our life work: the relationship between patient and physician. Within these relationships we can find no greater satisfaction.
A former lung cancer patient at the Massachusetts General Hospital wrote: "I have learned that medicine is not merely about performing tests or surgeries, or administering drugs. These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness" [12].
... "a human being, not just an illness." Friends, it is that simple. I thank you again for allowing me to serve you this past year. It has been an honor.
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References |
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TopIntroductionRediscovering a surgeon’s...Doctor-patient relationships in...How do surgeons compare?One surgeon’s bedside...References |
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