This is Alan Pitt with Healthcare PittStop. I feel very fortunate today to have Dr. Richard Gunderman as my guest. Dr. Gunderman is the Chancellor’s Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy and Medical Humanities and Health Studies at Indiana University.
AP: I don’t feel worthy actually. You’ve been a contributor to The Atlantic Magazine. You’ve authored over 600 papers. You have several books including We Make a Life By What We Give as well as a new book, We Come to Life with Those we Serve. I feel very fortunate to have met you previously at a seminar you gave on physician burnout. On behalf of the medical staff here at Dignity Health, thank you very much for joining me today Richard.
RG: It’s a pleasure to be with you.
AP: As you know, I am a son of a physician and my daughter has just completed her third year of medical school, so we’re in the business of healthcare as a family. But many physicians I know are not really recommending medicine to their children. I was wondering if you have any comments about this. Do you think it’s a new phenomenon or is this something that’s been with us for a long time?
RG: I think it’s a relatively new phenomenon. I mean the old idea that a parent or grandparent would be proud to announce to family and friends that their son or grandson, daughter or granddaughter, had chosen a career in medicine is highly accurate—for much of the 20th century. But I do think in the last couple of decades of the 20th century and at least the first decade of the 21st, a lot of physicians became rather skeptical—maybe even cynical—about medicine as a career and started advising their children and grandchildren not to go to medical school. There’s good evidence of that. In one study roughly half of US primary care physicians said they would actually discourage their own children from pursuing a medical career.
AP: I know when my daughter told me she wanted to go to medical school I really challenged her. She ultimately turned to me and said, Dad, what do you want me to do? Do you want me to go to law school? To business school? You want me to get a Ph.D.? What is a good choice for my generation? At least as a physician, I’ll have a comfortable income and I’ll be doing something worthwhile. Give me some suggestions on what to do about this.
RG: I think one of my own children is pursuing a career in medicine. And I think in a way the challenges we face in medicine could be regarded as a blessing. What do I mean by that?
There was a period of time when you could come to work, take good care of your patients, and know you were more or less completely discharging your responsibility as a physician. Today we have a lot of challenges in the way healthcare is organized and financed, and the pressures that are brought to bear on individual physicians and the practice of medicine.
AP: I feel like today, more than perhaps 20 or 30 years ago, when we come to work as physicians we have a mission. We have a good fight to fight on behalf of the profession of medicine and the patients we serve.
RG: There are a lot of forces impinging on the work we do today that either distract us from what good medical care looks like or in some cases discourage and even penalize us doing what we know is in the best interests of our patients. That’s an unfortunate situation that can promote bad outcomes, like burnout. But on the other hand, we do have a fight worth engaging in, and I think that’s something to be grateful for.
AP: In my career, I’ve seen the business of medicine encroach on and change the practice dramatically. These transactional shiftwork kinds of things, hospitalists, even a new thing—nocturnalist—was not something I was familiar with. You worked 8, 10, 12 hours and then you were done. That’s been a real change. Any thoughts on how the individual physician can resist burnout? What they can do for themselves or how they can view their profession or even themselves differently?
RG: I think it’s a deep problem. And like all deep problems it calls for a deep solution. Superficial solutions might be to reduce the number of hours physicians have to work or find people on whom physicians could offload some of the responsibility for activities like record keeping that we’re not particularly good at. I don’t think it makes a big difference in patient care.
But, in fact, I think the problem goes much deeper than that. What we really need to figure out is how, as physicians, we cannot just “hold a job”—you know, that shift mentality. Yeah, I work Monday through Friday 8:00 a.m. to 6:00 p.m. Or I work the night shift five nights a week. We need to move away from the idea that the practice of medicine is just a job and try to regain the sense that it’s a profession and perhaps even a calling.
We are standing for something beyond our own convenience, beyond our own compensation packages and retirement benefits. We’re serving a purpose beyond ourselves. In a sense, when we come to work we are answering our calling to be there and make the most of our knowledge and talents and passion to make sure that our patients get the very best care we can provide.
AP: You and I had a meaningful dialogue when you came to visit about how there’s a distinction between how I see myself—who I am—and what I am. And when that’s separated, a lot of conflict is created. I think a lot of times we get lost in the business and forget some of the reasons we got into medical school in the first place. Any thoughts—if you were to start at the beginning—how we might help our medical students by integrating this into medical training, to account for this kind of evolving medical environment?
RG: I think one way is to engage medical stude
nts in conversation with people who are actually practicing medicine, hopefully self-reflective and to some degree rhetorically gifted physicians who can explain what it’s like to practice medicine today and to talk about the divided loyalties or the sense in which they feel pulled in multiple directions.
What it’s like to try to navigate that variety of compromises that needs to be made—to make sure that my employer generates all the revenue that this patient encounter provides. Am I here to make sure that my organization makes its quality metrics? Am I here to avoid getting sued? Am I here to make sure this patient gets the same kind of care that I would hope a colleague would provide to my parent or my spouse or my child?
Those aren’t necessarily mutually exclusive alternatives. But I think we’ve got the emphasis wrong, that our priorities are somewhat out of whack. And we need physicians to engage medical students—maybe not necessarily on day one but certainly in the first year—to alert them to the kind of tensions that exist in contemporary medical practice and get them thinking about what they aspire to as physicians. Do I want to generate as much revenue as possible? Do I want to provide the very best care I can to my patients? For most doctors there’s a tension between those two things, and we need to get clear on who we are as professionals and where our highest loyalties lie.
AP: Interesting. I watch my daughter and her peers. There’s such a heavy focus on acquiring the knowledge base, and we don’t spend enough time talking about true mentorship or all the other aspects that go into being a true he
RG: That is a great point Alan. I once had an associate dean of my medical school refer to the work my fellow educators and I do as content delivery. You know, the idea that there is this body of knowledge that currently resides in a full receptacle, and we want to download tha
t into the empty receptacles of the students. I think that’s an oversimplified and distorted notion of what it means to educate a physician.
A big part of becoming a good doc is not just knowledge transfer. It’s something like emulation. When I think about what had the biggest impact on me as a medical student or a resident, it wasn’t just the facts and textbooks. It was the physicians I worked with. I got to see them deal with bad outcomes, breaking bad news to patients, dealing with disappointment. I also got to see them rejoice. That taught me as much—and in point of fact more—about what it means to be a doctor than anything I heard in a lecture or read in a textbook.
AP: I’ve spent a lot of time in technology of late, and I’ve become kind of focused on this machine learning, artificial intelligence space. It seems to me at times technology—the EMR is perhaps the most obvious example—somehow displaces our humanity, our relationships with our patients.
And, you know, when I went to medical school, I was the owner of knowledge I acquired in books. I was tested on that knowledge that computers can do better than I can now. How do you see this playing out in terms of how our role as providers develops over the next five to 10 years?
RG: Well, one possible future is that depicted in the Star Wars films. If you watch those closely, you notice that essentially all the medical care is delivered by robots or androids. It’s like you don’t need a human touch in medicine. But all of us have been sick. We’ve had relatives or friends or loved ones who were sick. When you’re sick or you’re beside someone who’s sick, it means a great deal to you to know that you’re under the care of a human being who knows you and genuinely cares about you.
And I don’t think any computer algorithm or any robot is ever going to be able to supply that. Human life—including human health and disease and injury—they have human meaning. And just because a computer can formulate a diagnosis or select between several different treatment pathways, that’s not the same thing as being under the care of a human being who recognizes you as a human being and who cares about you as such.
AP: I completely agree with you. I can’t see people getting care from an ATM. A lot of venture capitalists think that you’re going to have this computer, you’re going to put in data, and the drawers open and there’s going to be your drugs. I don’t see that. I feel like I’m in the business—if you will—of reassurance many times, talking to another person, reassuring them that it’s going to be OK. Or if it’s not going to be OK, it’s going to be as good as we can possibly make it.
There’s a tendency for physicians to kind of lose their place in this. And one of the things that really gets my goat is this “CYA” medicine—”cover yourself” medicine. This seems to be an ever-present response in this current medical culture. Do you get a sense of how this fits into how we see ourselves as healers? Any thoughts for radiologists or other clinical folks around how they can resist the temptation to practice [this kind of] medicine?
RG: You know, you can approach medicine or any career doing everything you can to protect your job security, your income, your legal liability. That’s no way to practice medicine and frankly it’s no way to live.
What is called for in the practice of medicine—and human life in general—is courage. We’ve got to see clearly enough what’s going on, and we’ve got to care deeply enough about what needs to happen to be willing to stake our professional judgment, our careers, and even our lives on it. This risk aversion thing can get way out of hand.
And it produces not only meaningless patient charts, where we’re mentioning every conceivable diagnosis to make sure we can’t be accused of having omitted one, but we end up as cowards, being afraid to put what we know and believe in on the line. That’s not just a fearful way to practice medicine, that’s an impoverished way to go through life.
AP: You know, I don’t think it is the patient’s responsibility to have to consider all these pressures and concerns on providers. But do you have any suggestions on how patients—if they’re aware of some of these challenges on providers—might respond in a way to partner with their providers to get the answers that they need to move forward in the modern world of medicine?
RG: I think one thing patients can do is to try to understand. And by the way, we’re all patients. I mean, even physicians and nurses and health care administrators —all of us—will get some sick at some point. If you see medicine as a battle against mortality, we will all eventually lose. Death is as natural a part of life as birth. So we need to be aware that we’re human beings on both sides of the stethoscope or both sides of the CT scanner, that we’re both trying to manage uncertainty and anxiety and trying to do the best we can.
And I think patients should try to understand, as best we can, what good medical care looks like—what a good doctor looks like—and do our best, first, to select for good doctors and good medical care.
Secondly, to try to be the kind of patients that bring out the best in doctors, and that means to some degree being open and honest and vulnerable. You know, I’m not just going to walk into my doctor’s office and say, hey, I’ve spent a lot of time surfing the Internet and I’m pretty sure I know what I have and what you need to prescribe. But rather, here are the problems I’m having. I’ve got a hypothesis here, but what do you think?
We can build a much more collaborative relationship, where we can recognize that neither one of us is omniscient or omnipotent and we’re in this together, working together, so the patient gets the medical best medical care—but frankly also so that the doctor can be a good doctor. If we deprive doctors of the chance to be good doctors—to practice good medicine—it is inevitable that the good people in medicine will become discouraged and burnt out and perhaps leave the practice of medicine altogether.
AP: I do believe the relationship has to be somewhere in the middle. The paternalistic approach that has been so pervasive for many decades has to go away, and we have to ask our patients to really partner with us.
Richard I really appreciate the time today, and thank you so much.
RG: Thank you for the opportunity.