Skeptical and Compassionate

Reminder: On this site, the use of the word ‘doctor’ should be thought of as a flexible short-hand for an informed health care provider.

Why are We Doctors?

Why are we doctors? No doubt, there are many reasons.

Some pursue a career in medicine for less-than-humanitarian reasons. Perhaps they seek financial reward. Perhaps they seek prestige. Perhaps they seek the approval of family members. Many were encouraged early on by influential role models. On some level, these reasons are fine but never sufficient.

Would-be doctors may seek the profession because they enjoy the technical side of medicine. They enjoy the process of pondering evidence, diagnosing conditions, testing their hypotheses, and managing medical problems. The challenge can be frustrating and fun all at once. One would be hard pressed to think of a better application of the scientific method.

Most of us also care about science itself. Readers of this site likely care a great deal about science. Here, we have dealt with the merger of science and health care by starting at the foundation of the philosophy of science and building the case for science as an ever evolving model of reality that can be used to inform our decisions. We learned the scientific meaning of the kinds of scientific of knowledge, such as such as theories, laws and facts. We learned how to differentiate science from pseudoscience and logic from logical fallacies. For all practical purposes, scientific knowledge gives us the most reliable picture of reality. To care about science is to care about reality. Doctors are the ones who should understand the relevant science -- who should understand the relevant reality -- and use this understanding to inform their practice in the care of people.

Whether you are an M.D., D.O., D.D.S., D.P.M., PhD, P.A., N.P., R.N., M.A., L.P.C., R.P., or another professional designation, your practice should be informed by the best model of reality possible.The job description of a doctor calls for the caring of patients; for the caring of people. Those who seek to become doctors should do so because, at the most important level, they should care about people.

Who is Unhappy?

Consumer Reports surveyed nearly 49,000 of its readers regarding their experiences with their doctors: 660 primary care doctors were surveyed as well.

About 75% of the respondents stated that, while they were mostly satisfied with their doctors, they had a variety of complaints about the experience (long waits topped the list). Unhappy patients tended to complain about a lack of quality time with their doctors, as well as a perceived lack of compassion by doctors who dismissed their complaints or seemed too quick to prescribe medication. Patients were also dubious about the fact that most doctors are seen talking to (and taking ‘freebies’ from) pharmaceutical sales representatives, thus supporting the notion that their doctor’s opinions are being influenced by ‘big pharma’.

This is a valid point. The Consumer Reports study states, “The majority of doctors we surveyed said that pharmaceutical company representatives contacted them more than 10 times a month. Thirty-six percent were contacted more than 20 times a month. On average doctors said they spend a few hours a week dealing with pharmaceutical salespeople.”

“Patients were less satisfied when they thought their doctors relied too much on prescription drugs and were unwilling to consider nontraditional or non-drug treatments. More than one-quarter of patients indicated some level of discomfort with their doctors' inclination to prescribe drugs.”

There were many unhappy doctors as well. Their number one complaint was the burdensome amount of insurance company paperwork and restrictions that decreased their ability to practice good medicine. Next on the list was financial pressures that force doctors to see more patients and therefore spend less time with individual patients.

Doctors commonly complained that their patients do not follow their advice and do not take their medications.

Doctors and patients alike are frustrated with the bureaucracy of medicine. Patients suspect doctors of over- prescribing medications and doctors complain that patients often do not take their medications. Clearly, both sides have valid points. Doctors are influenced by pharmaceutical companies. Doctors do prescribe treatments that are unnecessary. Although it does not follow that all of mainstream medicine should be the subject of denialism, we can get an idea of where such denial comes from. We can see why many people seek ‘alternatives’.

The Reality of Modern Medicine

Idealistic motivations of the student frequently give way to the harsh reality of the competitive training process.

Medical schools and other medical professional training programs weed out applicants primarily by test scores and grades. Their experience with candidates as human beings comes mainly from an interview and letters of recommendation. Much of medical school is crammed with the learning of basic science and pathophysiology. We learn diseases. We learn that patients are the ones with the diseases. We learn how to interview patients in detail about their lives to consider how to manage diseases.

At this stage of the process, we first have a taste of the connection with our patients. Then, we go to the hospitals where we are told to take a “focused” history, one that is pertinent to the disease or symptom in question. In other words, “Hurry up ‘cause we have a lot more diseases patients to see!"

We become hardened as the patients and their illnesses come and go. As students, there are always senior residents and attendings to impress with your knowledge of disease. There are other students with whom you are competing for class rank and residency positions. Then in residency, it’s out of the frying pan and into the fryer. Work loads increase as well as the number of patients. Although the process is a bit better with the elimination of the 36 hour ‘on-call’ shifts, the principles are the same. For those wishing to specialize (most docs these days), residents feel an added layer of competition as they vie for fellowship spots.

The focus of medical training is directed at self-interest much of the time. We are judged on the number of patients we see and the efficiency with which we see them. Patients may begin to seem like necessary parts in this process rather than the true focus of medical practice.

Preventative medicine (much of primary care) is based on guidelines aimed at the reduction of death and disease across large populations. Not that this is wrong. Epidemiology-based recommendations provide guidance for managing large populations and significantly decreasing death and disease rates within those populations. But people want to feel as if they are being treated as individuals, not statistics.

Patients feel this. CAM providers know this.

“CAM” and Individualism

In the Alternative Medicine section, we explored the reasons that people gave for choosing CAM. A large percentage believe that CAM allows them to have a more active role in their own health and like how CAM emphasizes caring for the "whole person". They also report dissatisfaction with mainstream medicine, mainly due to poor communication with doctors, concern about side-effects and the feeling that mainstream medicine is too limited in that it is ineffective for their problems.

It is no wonder that practitioners in the CAM world market themselves as “caring for the whole patient”, or taking a “holistic” approach. People are not the sum of their illnesses. CAM providers seem to have picked up on the fact that patients feel like numbers. They promise to focus on “wellness” instead of disease.

Science-based doctors are frequently perplexed at the implied idea that we do not care for the "whole person". "Of course we do!" exclaim most doctors. However, scientific training is often portrayed as reductionist. We learn about disease down to the cellular level. Doctors care about the whole person, but we do take a reductionist approach. This is actually good. But to those who are ideologically predisposed to viewing the body in terms of spirit and 'energy', and to those either unfamiliar or intimidated by science, reductionism seems cold and impersonal. Our bureaucratic process of delivering medicine does not help.

Many CAM providers have not been through the academically-charged training of science-based medicine. Those that have been through it (but left) probably take solace in getting out of the production-line-style of practice. CAM providers are not beholden to scientific evidence as science-based professionals are. They are not judged on their ‘numbers’. They focus on patients’ emotions. Patients who seek CAM seek the warmth of a provider’s attention and affirmation that they are not just a number. In the process, patients are told that they can ‘heal themselves’, that they are being treated with ancient wisdom, ‘naturally’ and with ‘energy’. Their pills and nostrums are not ‘drugs’, but natural ‘supplements’. CAM providers walk the line of promising to provide treatments without the coldness of science, yet presenting them with the authority of science. CAM providers are embraced as ‘experts’ in their fields. They and their patients believe in CAM despite (or in spite of) the objections of science-based doctors, due to lack of evidence.

The ‘evidence’ for CAM is ‘experienced-based’. Patients embrace it due to the positive emotional experience they have with the practitioner. The particular practice (homeopathy, acupuncture, chiropractic, reiki, etc) does not matter as much as the emotional experiences and connections they develop with the provider.

Again, we form our beliefs first, then we rationalize them. When faced with evidence against the belief, cognitive dissonance can kick in and cause us to embrace the belief with even more conviction.

Thus, by utilizing ‘experience-based medicine’ over science-based medicine, CAM providers and seekers may begin to feel like brave mavericks in a hostile world of closed-minded doctors.

Caving to Popularity: Integrative Medicine

Health care has become very competitive. Insurance companies compete for patients by promising quality care for low costs. Hospital systems do the same. Insurance companies and hospital systems find themselves walking the line between providing the best science-based care, and giving people what they think is best.

‘Evidence Based Medicine’ has become the motto in today’s world of health care. However, as we have seen, evidence based medicine is not necessarily science based medicine when it comes to implausible claims. Ultimately, our care has become driven by market demands and popularity, rather than sensible science. As a result, academic centers and insurers offer bizarre hybrids of science based medicine and non-science based belief systems under the politically correct title of ‘Integrative Medicine’.

Departments of integrative medicine have sprung up throughout the healthcare landscape, even at top-ranked academic centers like Harvard. When a regional system develops and markets such a department, competing systems follow suit. On one level, integrative medicine departments may dissuade some from seeking care from independent, unregulated CAM providers who may discourage science-based care to patients with serious health conditions (such as denial of vaccines, AIDS and chemotherapy). This may be a potential benefit. On the other hand, ‘integrating’ falsly provides non-science-based belief systems with the status of science. In this regard, we are being disingenuous.

Cognitive dissonance theory predicts that the leaders of these academic centers will recognize the conflict at a base level, but then will actually change their ideas about science and evidence in order to honestly promote such ‘integration’. They will come to absolutely believe that the marketing of CAM within their system is driven by open-mindedness and compassion, rather than by economically driven market forces.

Richard Feynman is credited for saying, “Keep an open mind, but not so open that your brains fall out.” By legitimizing CAM in our academic centers, we are legitimizing implausible and unsubstantiated notions such as meridians, qi, subluxations, innate intelligence, the “law” of infinitesimals, and the naturalistic fallacy. When reasonable people promote these practices, dissonance leads them to rationalize them with arguments built from logical fallacies.

It appears that cognitive dissonance theory is being confirmed yet again.

Legitimizing Pseudoscience to Appear Compassionate

Our health care system bends to economic forces. Integrative Medicine departments are the direct result of such forces. But what drives the demand? Do patients consciously crave treatments that would have to violate laws of science in order to be true? It is likely that they do not. It is more likely that patients demand a system of care that validates their feelings; one that makes them feel like an important individual, rather than a statistic. They are demanding a more humanistic system.

For the most part, people seem to have a baseline respect for science. However, most have a very poor baseline understanding of science. The mass media doesn’t help. The competitive race to report the ‘news’ leads to conflicting headlines about the results of small studies, even before they are published (let alone put into context). Single studies contribute to science but do not define it. Pseudoscientists, denialists and CAM providers use this to their advantage by dressing up their arguments in scientific terminology and then presenting them to the public (and to hospital administrators). When called out on such practices, claims of persecution, closed-mindedness, conspiracy, and naturalistic fallacies are often heard. These are typically followed with the argument that science is not able to measure their claims. Thus pseudoscientists try to have it both ways.

People generally are not equipped to tell the difference between science and pseudoscience. People can be convinced by scientific sounding language when presented well, but are quickly turned off and intimidated when the presenter lacks the compassion to interact with them on a personal level.

People trust caring people, not data. They trust providers’ opinions if they are likable and caring. This trust translates into patients believing the claims of the caregiver. The beliefs form due to emotional reasons.

People have a natural tendency to be swayed by the naturalistic fallacy. Products and treatments that are sold as being “natural” seem much more inviting than chemically-derived, mass produced pharmaceuticals with unpronounceable names.

Patients (rightfully) demand to be listened to compassionately. They demand healthcare providers that (appear to) have expertise and confidence in the care they provide. They demand to be treated in a way that makes them feel like the important people that they are.

Why can’t practitioners of scientific medicine meet this demand? Of course, many science-based doctors already do this by way of a caring bedside manner, a true ability to non-dismissively listen to patients and validate people’s feelings, teaching proper information in layman's terms, and by spending enough time with them. But why are there so many that do not? The answer is not simple.

Perhaps these deficiencies lead mainstream healthcare systems to promote and legitimize pseudoscientific practices to capitalize on the demand for compassion.

Barriers to Compassionate Doctor-Patient Relationships

Skeptical doctors should realize that part of the lure toward so-called alternative medicine is the generally positive emotional response that many have to it. Quasi-objective reasoning comes after the fact. Perhaps science-based health care could provide such a positive appeal.

For purposes of discussion, we will focus on primary care (Internal Medicine, Family Practice and Pediatrics), but much applies to specialists as well. Let’s just refer to this broad category as ‘medicine’. The Consumer Reports polling data, discussed above, defined the perceived barriers to meaningful doctor-patient relationships. But what are the origins of these barriers?

Doctors are schooled and trained to be scientific and analytic. There is little training given in communication and debate skills and almost no training given in business skills. Doctors, like scientists, feel that communicating information simply means telling people facts (provided the doctor actually knows the facts). This will work for some patients, but it will not work for people with preexisting biases and beliefs that run contrary to what the doctor states.

Medicine is a business unlike most. In most businesses, the provider is paid for services or products by the customer. But in medicine, who is the customer? The simple answer is the patient. But, for the most part, the patient is not the one who pays the provider. Third party insurance companies pay the provider. In some cases, the patient pays the third party, however, in today’s American system, it is usually the patient’s employer that pays the insurance company. So if we follow the money, the ‘customer’ is nebulous. The customer is not the patient, but an amorphous entity consisting of the patient, a third party payer and an employer. Each part of this ‘customer’ has an agenda. These agendas often conflict.

The insurer / customer has the power of negotiation over the physician. This customer dictates its agenda through contractual agreements designed to achieve evidence-based results as applied to large populations at nominal costs. Standardized practices are required to achieve this. From the perspective of a population, this is a good thing. In response, doctors join forces by forming large groups (physician organizations, or P.O.’s). P.O.’s in turn negotiate with insurers for payment schedules based on measurable goals. They put pressure on their doctor-members to meet these benchmarks so that they can bring quality data to the negotiating table. Thus, the doctor must focus much of the appointment time on meeting these benchmarks. Thus, an office visit is often perceived as an ‘assembly line’ process by both the patient and the doctor.

The employer / customer negotiates with the insurer to provide care for its employees as a benefit designed to attract and keep valuable workers. Employers want happy, healthy employees, but they naturally do not wish to pay more than is necessary. Thus, employers make insurers compete for business. This leads to multiple, complex ‘plans’ that are offered to employees (patients) as products in lieu of pay. These plans, and their limitations, are rarely understood by the patient, thus setting up potential conflict and red tape between what the patient wants and what the doctor is able to provide.

In each visit, doctors must address the patients’ concerns, address the benchmarks for which they will be judged by their P.O.’s, document according to the rules of E&M coding, order appropriate testing, prescribe treatments (hopefully in a responsible, cost-effective way) and wrap up the visit in a timely fashion. It is easy to see where compassion may get left behind.

There must be a way to meet the demands of all three customers, especially the most important one -- the patient.

Where Do We Go From Here? Eliminating Barriers

Our system of health care has dropped the ball. We have let bureaucracy and big business undermine our judgement and the ‘art of medicine’. Earlier on this site, we learned that the philosophy is informed by science. The art of medicine is informed by the science of medicine. Skeptical doctors need to find a way to deliver quality care at both the population level and the individual level. We need to address the defined barriers to meaningful doctor-patient relationships. This means knowing the science and knowing people.

- Wasted Time

The Consumer Reports survey indicates that much of patient complaints are related to time. WebMD summarized the time related complaints as follows:

Patients' top complaint about doctors was time spent in the waiting room. Nearly one in four patients (24%) said they waited 30 minutes or longer.

Other complaints from patents were:

• Couldn't schedule an appointment within a week: 19%

• Spent too little time with me: 9%

• Didn't provide test results promptly: 7%

• Didn't respond to my phone calls promptly: 6%

The time issue also encompasses the time spent on redundant bureaucracy, such as filling out forms to provide data that has already been given (insurance information, demographics, etc.). Time also is wasted when office staff (including doctors) are inefficient at managing the bureaucracy. Doctors have no formal expertise in reducing these burdens and we should acknowledge this fact. We can decrease wasteful time and increase quality time by making an investment in hiring an expert to help, thereby increasing both the satisfaction of the patient and the doctor. Other businesses are using evidence based models to increase efficiency. These models can be adapted to medical practices. An example of such a process has become known as “Lean”.

Time also becomes tight due to the benchmarks that doctors must meet as defined by their insurance contracts. Many good doctors meet these benchmarks, but do not have an efficient way of collecting and reporting the data. They are being paid less for doing the same or more work than in the past, and are therefore less satisfied with practice. This dissatisfaction likely interferes with effective patient care. Benchmark requirements are here to stay and will likely become more burdensome. Skeptical doctors should embrace and adopt systems that decrease redundancy and streamline bureaucratic requirements (eg. through electronic technology and efficient business practices).

The time issue causes patients to develop negative attitudes toward their doctor even before the appointment takes place. Unless this is addressed, other factors may be a bit moot.

- Communication

Beyond the time issue, communication is a commonly identified barrier to patient satisfaction. The 2008 BMC Complimentary and Alternative Medicine article reports that in 2005, up to 40% of CAM users identified poor communication with doctors as a reason to seek CAM.

By definition, communication is at least a two-way street. Patients want to have their concerns heard, validated and addressed. They wish to be involved in the decision-making process, but because they lack expertise, also want the doctor to guide them confidently. Effective communication skills are essential for science-based medicine.

Listening to and validating the patient’s concerns are identified as extremely valuable skills for doctors. Studies have shown that doctors tend to interrupt their patients after only 14 to 23 seconds. After a frustrating bureaucratic experience getting into the exam room, patients’ attitudes toward their doctors will immediately turn negative if they feel dismissed in the exam room.

Patient-Physician Communication: Why and How is a review article that lists 9 reminders for doctors.

The first two involve determining what knowledge the patient already has and what knowledge the patient is seeking. Some patients have higher levels of knowledge. Some have high levels of misinformation. Some wish the doctor to explain things in detail; others do not.

The authors emphasize the importance of empathy and slowing down. Empathy is nearly impossible if you are rushed and checking the clock. Again, time is a barrier to communication.

“Allowing this time for silence, tears, and questions can be essential.”

Telling the truth is essential. A patient’s trust is dependent on the doctor’s trustworthiness. Being honest with patients, especially about bad news, is important. Equally important is being honest about unknowns. We all will feel driven to provide definite answers, however when uncertain, being honest means being certain about the uncertainty. Honest does not mean emotionally cold. Empathy is a big part of honesty. We must also provide hopefulness without making misleading claims.

Keeping the conversation simple means explaining things in terms that the patient can understand. Patients appreciate doctors who have enough insight into their level of knowledge that the doctors do not talk down to them, yet they do not hide behind technical jargon.

The compassionate doctor should react to patients’ responses and adjust the communication level accordingly. Such a dynamic skill must be developed. On a busy schedule, most patients are in different moods and have different levels of concern. We must adjust quickly and accordingly.

- Beware of Behavior that Drives Mistrust

The Consumer Reports study revealed that patients are weary of doctors’ biases toward drug therapy.

Patients regularly see doctors devoting time to the sales pitches of pharmaceutical company sales representatives. They also see doctors accepting gifts in the form of food, gadgets and samples. Doctors are people and are therefore subject to the same personal motivations as the rest of us. Most doctors underestimate the influence that ‘drug reps’ have on them. Cognitive dissonance theory predicts that doctors who accept gifts and sales pitches will counter the dissonance by rationalizing all kinds of positive benefits from the interaction.

Patients with a (justified) baseline suspicion of ‘big pharma’ will likely become immediately suspicious of the influence that such interactions have over their care. 12% of information given to doctors by drug reps was found to be inaccurate.

It is revealed that patients are turned off by doctors who are quick to prescribe medications for any and all ailments. This is a shortcut to effective care. We have seen that many medications that are commonly prescribed have no benefit over placebo. It takes more time to discuss a condition and to try to get the patient to understand its natural history than it does to prescribe a pill. However, by carefully explaining the benefits and the limitations of certain treatments, most patients will feel validated and empowered by the extra effort.

- Be Sensitive to Beliefs

Science trained doctors have been known to be dismissive of patients’ beliefs when it comes to alternative medicine. Remember, forms of CAM such as acupuncture stem from belief systems. People react with strong negative emotions when their beliefs are dismissed. A patient will not change a belief simply because a doctor says that their belief is false. Indeed, most beliefs are held not because of reason, but because of emotion and biases. People ‘know’ that these treatments work because of the many psychological reasons that we covered in the sections on cognitive biases, the placebo effect, logical fallacies and alternative medicine. Beliefs are enforced and defended by emotions, not reason.

Skeptical doctors may have an emotional response to the notion of alternative medicine that is as strongly negative as the patient’s is strongly positive. Important and bond-building discussions can be had between patients and doctors when a positive and respectful relationship exists. Such a relationship cannot form when patients feel that their beliefs have been dismissed as ‘dumb’. Such patients may view the world in terms of things to believe or disbelieve. If dismissed, they will quickly defend themselves with mechanisms such as the ad hominem tu quoque (they will quickly find fault with the doctor’s ‘beliefs’ such as the prescription drugs that they are quick to prescribe after accepting gifts from sales reps). Relationships thus quickly dissolve as patients seek CAM providers who confirm their beliefs and treat them nicely.

Skeptical doctors must be aware of this. Many of us have found this out the hard way.

We must pick our battles. We should be quick to point out behaviors that are dangerous, such as declining life-saving treatments in favor of CAM. However, the discussion should come out of the doctor’s true concern for the patient’s health. The associated emotion must be positive. We cannot expect a belief to be reversed with reason, at least not in one visit. Skeptical doctors who are familiar with the fallacies and biases that led to the belief can use similar strategies to turn the patient toward practices that have been shown to actually work beyond placebo effects, especially when dealing with life-threatening problems. This can be done with integrity and compassion.

Practices that are relatively innocuous such as Reiki should not be attacked directly unless a patient is refusing important treatments in favor of it. Once trust is established between the patient and doctor, seeds of reason can be planted during the relationship. People often become interested in how the skeptical doctor decides what to ‘believe’ and not ‘believe’. This takes time.

The Reductionist’s Science of Compassion

We are a social species. We emotionally bond with others to form trust. We emotionally reject others when hurt. Our relationships are not really based on reason or logic; however we may rationalize reasons for them after the fact. Patients form relationships with their doctors based on their emotional responses to their interactions.

Science is uncovering the neuroendocrine pathways of these emotional responses so that they can be understood and used to make predictions in experimental situations. Skeptical doctors can use this knowledge to inform their approach to patient interaction in ways that are emotionally satisfying for both patient and doctor.

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