Five Ways Medical Culture Harms the Doctor-Patient Relationship

Mark Adams/123RF.com

"The culture of a workplace - an organization's values, norms, and practices - has a huge impact on our happiness and success" - Adam Grant.

Current medical culture has evolved over thousands of years. It dictates how we treat each other and ourselves. It's an insidious culture of self-neglect, unspoken hierarchies, jousting, and undervalued humanity.

As physicians, we are expected to establish rapport and trust with our patients while enmeshed in medical culture. Our "values, norms, and practices" are to care for patients as we would our own family members. The success we're striving for is to have best possible outcome for all of our patients.

But our goals and culture are antagonistic; good patient outcomes will occur despite medical culture, not because of it.

Below are just five ways medical culture undermines the efforts to establish a successful doctor-patient relationship.

If we can’t be sick, you can’t be sick

“Compassion for others begins with kindness for ourselves” -Pema Chödrön.

I was once working with a physician who was suffering with flu. I overheard him tell a patient “If you’re not at least as sick as me, you don’t get a work note.”

Medical culture is clear on this: Doctors may not miss work for sickness. If you must, you should try to get your shift covered.

I have personally seen physicians working with:

• Symptomatic brain masses
• Acute appendicitis (During his shift, he completed a work-up on himself and checked in to the hospital after consulting his own surgeon once the shift ended.)
• Ovarian cancer (Came to work, left for chemo, went back to work)
• Jaundice from advanced liver disease, on the transplant list.
• End-stage AIDS (Saw patients from a wheelchair, too weak to walk)
• Kidney stones, gallstones
• Countless cases of flu, colds, gastroenteritis, sinus infections
• Broken bones
• Contractions from pregnancy (“Meh?—?if I start to deliver, I’ll just go to L&D”)
• Sepsis from a urinary tract infection (to be fair, he had to leave his shift early to be admitted)

That's just the physical list. A list of psychological, emotional, spiritual or familial neglect would be even more robust.

We feel we can power through physical illness and conceal our emotional needs. We prioritize a career and sacrifice our lives to the detriment of our overall well-being.

When you treat yourself this way, it isn't surprising that you'd treat others similarly.

We define health by the absence of disease

A patient wants to feel better; a doctor wants to make sure you're not sick. If the patient is not objectively sick, the doctor is done.

Maybe the patient doesn't feel well, but there’s nothing objectively wrong. So, they’re healthy!

These are misaligned goals. It's hard to build an effective team when the members have different goals.

With misaligned goals, it's more likely that no goal will be achieved at all, or if it is, it won't be achieved well.

The life of a non-physician versus the life of a physician

If you follow a traditional course to becoming a doctor, you'll begin your education around age 18 and finish around 30. You'll spend the time in between obtaining your education. When you're done, you'll have a median annual income of about $290K where the median annual income in the US is about $60K.

There is a tremendous difference in those two lifestyles.

For a physician to understand patients, he/she has to understand the social determinants of their health: legal, psychological, social, familial or financial barriers to their care. Your patients are homeless, addicted, abused and abusive, psychologically ill, trafficked and impoverished. Understanding their lives is vastly different than reading about it - and understanding is critical to establishing a therapeutic relationship.

For a patient to understand a physician, they'd have to understand the unusually high degree of challenge, sacrifice, dedication, delayed gratification and achievement required to reach that goal. Physicians give up their twenties. They owe hundreds of thousands of dollars to get there. They have learned and been tested on libraries of information. They function at a very high level after not sleeping for days. They make life and death decisions.

Many patients would not identify with a physician’s life, and the physician would not identify with theirs.  Putting them on the same team without addressing this difference in backgrounds will only make identification and alignment of goals less likely to occur.

We're must be reminded to acknowledge life

“The Pause” is a relatively new concept. When a patient dies, the medical team caring for the patient can carry out a 45 second pause to acknowledge that patient’s life and death. There is no proselytizing, just a statement that The Pause is being carried out followed by a quiet period. If one doesn’t feel comfortable with it, they don’t have to do it.

I personally believe that this is a wonderful and powerful practice. I am in no way critical of The Pause itself. What amazes me is that as physicians, we have to be taught and reminded to acknowledge a life.

We need a reminder that our patient who had a life, had birthdays, first loves, children, pet peeves, made jokes and had good times? They had favorite foods and secrets. They were someone’s little boy or girl at one point.

We need to remember that they were alive.

The Pause being a relatively new initiative (and one that was developed by nurses) tells you a lot about where medical culture is and has been.

We depersonalize

“The good physician treats the disease; the great physician treats the patient who has the disease” - Sir William Osler.

We depersonalize when we don't call patients by their names  (“The appendix in bed five.”). We do it to members of our own team: "Where is my nurse/my resident?"

We do it every time we reduce the impact of diseases to the data associated with them: "There’s a 1/1000 chance that you’ll have a complication, that’s it!"

These are all dehumanizing experiences. They communicate one thing very clearly: We aren't connected to you; we're connected to the pathology.

This way of communicating is generally done for the sake of clarity and brevity. There are fourteen "Mr. Smith's" in the waiting room. There's only one with appendicitis.

But over time, this communication does a disservice to the patient and distances us from the patients we serve. Our communication becomes our thoughts, and our thoughts distance us from the patients we serve.

Tips On Transcending Medical Culture

The good news is that medical culture is still evolving. Real-life experiences are prioritized for medical school applicants and medical education is focusing on those trained in humanities. Wellness is being emphasized and work-life balance is more of an expectation for employment than ever. But changing medical culture is like turning around a barge?—?it’s not going to happen immediately.

Here are a few approaches to improve culture and in turn, start strengthening the doctor-patient relationship.

Put the patient in their frame, not yours

I start by thinking of one of my family members - one of my children for example.

I then think of the patient as I think of my child. They aren't “a patient”, but as “someone’s daughter” or "someone's mom."

This is someone’s child?—?at one time, this was someone’s newborn baby. This person brings joy to his/her family.

Thinking of patients that way helps you to identify with them. You understand them better. It lets you imagine your own mother coming home and talking about her doctor's appointment that day.

It puts the patients in the context of their life, not yours, and it humanizes them. When you do this, you start to think about caring for that patient as you’d want your own family member treated.

Avoid corporate buzzwords; be human instead

Be aware of corporate speak creeping into your practice. These are phrases and slogans designed to give patients the perception that they are having a good experience.

We're taught to use phrases like "I'm washing my hands now to keep you safe." or "I'm going to close your door to preserve your dignity."   Often, this is the same awkward phrasing used on patient satisfaction surveys, so when the patient is asked "Did the doctor do everything to preserve your dignity?" the patient will score it highly.

The benefit of using these phrases stops with metrics such as patient satisfaction. Patients are generally savvy enough to recognize them as inauthentic and doctors often feel disingenuous for using them.

These tactics are false dialogue - the doctors aren’t being themselves, and patients pick up on it. They don't foster meaningful relationships.

Find a shadow

Identify a colleague who can shadow you for a few patient encounters and give you honest feedback.

Let her observe you as you try to interact with patients as you typically do. Afterward, seek feedback on the human aspect of your care, not your clinical decision making. Asking her about your ability to establish rapport, ease a patient, answer questions, or your attitude can be helpful - we are often not perceived the way we feel we should be.

When you receive feedback, listen without interrupting.  Learn what the difference is between what you think is happening and what is perceived.

Use this information to improve your interactions.

Care for patients away from the bedside

There are a few ways to do this - call a patient at home to check on him/her. Or, assume a leadership role where you manage patient complaints.  It is impossible to do this and not gain a better perspective of the care you're delivering.

Hospitals have safety reviews for cases with bad outcomes. If you work in a hospital that has one, ensure that the patients and their families are invited to such a review. Regardless of what you think went wrong with a particular case, seeing it from the patient's side is a powerful experience. It will change the way you view patient encounters and soften your approach to people.

Medical culture is deeply ingrained and slow to change. Physicians need to hold their relationship with patients as a priority and maintain awareness of how that relationship is being undermined.