Doctors in a Changing World

In 1174, Maimonides was appointed court physician to the rulers of Egypt and spent most of his days at the palace. Concerning his arrival home each day, he wrote: “I partake of some light refreshment, the only meal I eat in twenty-four hours. Then I go to attend to my patients and write prescriptions and directions for their ailments. Patients go in and out until nightfall, and sometimes . . . I am so exhausted I can hardly speak.”

BEING a doctor has always required self-sacrifice. But the world in which doctors practice today is rapidly changing. Their work schedule can still be just as exhausting as that of Maimonides. But are they respected as much as doctors used to be? How have new circumstances affected the doctor’s way of life? And how have recent developments changed the doctor-patient relationship?

A Changed Relationship

Some can still remember the time when a doctor could carry all his remedies in his black bag. There were mixed feelings about doctors in those days, just as there are now. Most were revered for their ability, respected for their rank, and admired for their ethics. At the same time, however, they could be criticized for their fees, berated for their failures, and denounced for their seeming lack of compassion.

Still, many doctors derived deep satisfaction from helping the same family for generations. They used to make numerous house calls, and in country areas they sometimes stayed for a meal or even spent the night when delivering a baby. Many doctors personally made up prescriptions of medicine for their patients. Unselfish physicians provided free treatment for those of little means and were available 24 hours a day, 7 days a week.

Of course, some physicians still work that way, but in many places the nature of the doctor-patient relationship has probably changed more in the past few decades than it has in many centuries. How have these changes come about? Let us look first at the home visit.

What Happened to House Calls?

Visiting patients in their homes used to be the accepted way to practice medicine, and in some lands it still is. But worldwide the custom has been in decline. The Times of India said: “The family doctor with his reassuring bedside manner, intimate knowledge of the family and willingness to make house calls whenever required, is becoming an extinct species in an age of specialists and superspecialists.”

Because of the explosion of medical knowledge, many physicians have specialized and work as part of a group, with the result that patients may see a different doctor each time they are sick. Consequently, many doctors cannot enjoy the long-term relationship with families that they used to have.

The move away from visiting patients at home began a century ago, when doctors started to make greater use of laboratory analysis and diagnostic equipment. In many places health agencies came to see house visits as an inefficient way to use physicians’ time. Today most patients are able to get transportation to visit a doctor’s office. Also, auxiliary and emergency medical services now do work previously handled by doctors.

Changed Status

In today’s world fewer doctors are independent. Medical services are more often provided by government agencies or health-care companies that employ doctors. Many doctors, however, dislike having a third party in the doctor-patient relationship. Such agencies often require doctors to see more patients in less time. “I have to see a patient every seven to ten minutes,” says Dr. Sheila Perkins, a general practitioner in Britain. “And I have to spend much of that time entering information into the computer. There’s little time left to build a relationship with the patient. It can be very frustrating.”

The changing world in which doctors practice is one in which patients have gained more power. At one time the “doctor’s orders” were unchallengeable. But in many lands today, doctors are obliged to inform the patient about treatment options and possible outcomes so that the patient can give informed consent to the treatment. The balance of the doctor-patient relationship has changed. In the eyes of some, the doctor’s image has been reduced to that of a technician.

In our rapidly changing society, a large proportion of physicians are women. Female doctors are often more popular because they are seen as better listeners. So their influence on the profession seems to be to make it more compassionate.

Most people appreciate a doctor who understands patients’ feelings and the stress they live with. But it is reasonable to ask, How many patients understand their doctor’s feelings and the stress he lives with? Doing so could surely improve doctor-patient relationships. The following article may help.

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Maimonides

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Brown Brothers

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In the past, doctors often made house calls

Doctors Under Stress

“A young couple came to me full of hope that I could do something for their newborn baby. As I examined him, my heart sank. His condition was incurable. Can you imagine my feelings when I told these new parents that their son would never see? As I dismissed them from my office, I felt overwhelmed with emotion. But a moment later my next patient was upon me expecting a welcoming smile! That’s what I find stressful.”​—An ophthalmic surgeon in South America.

PATIENTS don’t usually visit consulting rooms to consider their doctor’s problems. A patient’s mind is filled with his own need for help. Consequently, few people realize how much stress doctors live with.

Of course, everyone has to cope with stress, and the medical profession is not the only stressful occupation. However, since nearly everyone becomes involved in doctor-patient relationships in one way or another, understanding the stress doctors live with and the effects it can have on them is worthwhile.

Doctors start learning to live with stress early in life as they struggle for a place in medical school. But when medical training starts, it is usually an unforgettable jolt to the emotions. It is the beginning of a process that can change the medical student’s feelings, his very character.

Medical Training​—A Shocking Experience

The traumatic first visit to the dissecting room can be as early as the first week of medical studies. Many students may not have seen a corpse before. The sight of naked, shriveled bodies in different stages of being cut open to reveal the anatomy can be quite repulsive. Students have to learn strategies to cope with their emotions. Often they resort to humor, giving each cadaver a funny name. What seems appallingly callous and disrespectful to an outsider is necessary to students who are trying not to think of the person that the body used to be.

Then comes clinical training in a hospital. Most people are not forced into contemplating life’s brevity until perhaps middle age. But medical students come face-to-face with incurable disease and death in their youth. One described his first experiences in the hospital as “disgusting to the point of revulsion.” It can also be quite shocking to students in both rich and poor countries when they first realize how often patients are denied needed treatment because there is not enough money.

How do newly qualified doctors cope with the stress? Medical staff often have to distance themselves emotionally from patients by depersonalizing them. Instead of referring to the person needing attention, the staff may say, “Doctor, there’s a broken leg in cubicle two.” This may sound comical if you don’t understand the reason for such a description.

Compassion Fatigue

Doctors are trained as scientists, but for many the greater part of their work consists of talking to patients. Some physicians feel unprepared for the emotion of doctor-patient relationships. As noted in the introduction, one of the most difficult situations for a doctor is breaking bad news. Some have to do it daily. People in crisis often need to give vent to their anguish, and physicians are expected to listen. Dealing with anxious, frightened people can be so tiring that some physicians suffer a type of burnout now called compassion fatigue.

Recalling his early years, a family practitioner in Canada wrote: “Work was flooding me: needy people wanting my time; distressed people wanting to off-load their distress; ill people needing my action; manipulative people pushing and pulling; people coming to see me; people pressing for me to go to them; people coming down the telephone wires into my own home​—and even my bedroom. People, people, people. I wanted to be of use, but this was madness.”​—A Doctor’s Dilemma, by John W. Holland.

Does the stress ease with the passing of years? Seniority usually brings more responsibility. Often life-and-death decisions have to be made instantly, perhaps on the basis of inadequate information. “When I was young, it didn’t worry me,” explains a British doctor, “just as it doesn’t worry youngsters to drive dangerously. But with age, you value life more dearly. Now, treatment decisions make me more anxious than ever.”

How does stress affect doctors? The habit of distancing oneself emotionally from patients can carry over into family relationships. Avoiding that tendency can be challenging. Some physicians are outstandingly compassionate in helping patients with their feelings. But how far can they go without suffering compassion fatigue? This is the doctor’s dilemma.

Coping With Difficult Patients

When asked about the stress of doctor-patient relationships, doctors often start by describing difficult patients. Perhaps you recognize some of the following types.

First, there is the patient who wastes the doctor’s time by rambling on without coming to the point and explaining what his problem is. Then, there is the demanding patient who calls the doctor at night or on weekends for nonemergencies or demands treatment the doctor would prefer not to recommend. Also there is the distrustful patient. Some people research useful information about their condition, perhaps by Internet, and this can be helpful. But such research may lead them to lose confidence in the medical expert they have come to consult. A doctor may not have time to debate the pros and cons of everything that such research turns up. It is frustrating for a doctor when distrust makes his patient incompliant. Finally, there is the impatient patient. He abandons the treatment before it has time to take effect, perhaps seeking advice elsewhere.

In some parts of the world, however, the major source of stress for doctors is not the patient but the lawyer.

Defensive Medicine

Many countries report a surge in the number of malpractice suits against doctors. Some lawyers make frivolous claims to win riches. “They are sending medical liability insurance premiums soaring,” explained the president of the American Medical Association. “These lawsuits lead to other agonies as well. For a physician, a wrongful suit can cause great harm​—embarrassment, loss of time, . . . stress and anxiety.” Some doctors have even been driven to suicide.

As a result, many physicians feel obligated to practice “defensive medicine,” making decisions based on the possible need to defend them in court rather than on what is best for the patient. “Practicing medicine from the position of covering one’s back is now a way of life,” said Physician’s News Digest.

As pressures on doctors continue to mount, many of them wonder what the future holds. Many patients have the same question, as they observe increased suffering from some diseases despite advances in medical science. The following article presents a realistic view of the future for both physicians and patients.

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COOPERATING WITH YOUR DOCTOR

 1. Make the most of your time with your doctor by preparing how you will explain your problem fully but concisely, starting with your foremost concern

 2. Avoid calling your doctor at times outside of office hours for nonemergencies

 3. Be patient. Proper diagnosis and treatment take time

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‘EVEN ROUTINE CASES CAN BRING SATISFACTION’

“The gulf between medical practice here and in more developed regions is huge. Here, learning a profession is viewed as a way to escape poverty, and so studying medicine is popular. But there are many doctors and few jobs. As a result, doctors are paid very little. Few people can afford to see a doctor as a private, paying patient. I work in an obsolete hospital with a leaking roof and only the most basic equipment. Our staff consists of two doctors and five nursing assistants. We serve 14,000 people.

“Sometimes patients think I don’t examine them adequately, but when you have 25 patients waiting, you can’t afford lengthy consultations. Still, treating patients brings me satisfaction, even routine cases. For example, mothers often bring in their undernourished, dehydrated children who have diarrhea. They have lackluster eyes and anxious faces. I just have to tell the mother how to use rehydration salts, parasite medicine, and antibiotics. Once these take effect, the child starts eating again. A week later he or she looks like a different child​—bright-eyed, smiling, and playful. The prospect of enjoying such experiences made me want to be a doctor.

“Beginning in childhood, I dreamed of relieving sick people. But medical training changed me in a way that I did not expect. I saw people die for lack of even the small amounts of money they needed for lifesaving treatment. I had to make myself unfeeling so as not to be affected by the sadness. Only when the cause of suffering was shown to me in the Bible did I understand God’s compassion and regain my ability to feel for others. I was then able to cry again.”

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Dr. Marco Villegas works in an isolated Amazonian town in Bolivia