In the movie Edge of Darkness, Mel Gibson plays a cop whose daughter was murdered in front of him. During the movie, he uncovers the conspiracy that led to her murder and he discovers that one of his closest and oldest friends, Bill, a fellow cop, was in on it. In a dramatic scene in his kitchen, Bill comes to visit him just before Mel Gibson’s character is finally betrayed. It is a Judas moment and Gibson’s character knows that he will die soon. With a now full awareness of everything, Gibson’s character says to Bill:
You know, Bill, no one expects you to be perfect. But there’s just a few basic things you gotta get right. Always do the best you can by your family. Go to work every day. Always speak your mind. Never hurt anyone that doesn’t deserve it, and never take anything from the bad guys.
It’s a powerful moment in the movie. The words remind me, unfortunately, of many of my fellow physicians. They aren’t perfect and no one expects them to be, but there are just a few things they’ve got to get right.
If you’ve been with howardisms for very long, you know that I really just write about one thing: how to be a good doctor. It comes in different forms: how to understand and interpret medical literature, how to be technically competent, how to think correctly and free of bias, etc. I get upset, too, when I see medicine done poorly; sometimes my writing reflects that frustration. This is one of those times.
I always think to myself: What’s the one thing – the most important thing – the one thing I would talk about to any physician, resident, or medical student, that would make them a better physician? What’s the best piece of advice?
Here it is:
Let’s break that down, though.
Medical ethics are quite simple:
- Beneficence: Always act in the best interest of the patient (not in your best interest or your employer’s best interest);
- Nonmaleficence: Don’t be the source of harm to your patient (or if you are, make sure it’s worth it – make sure the benefit outweighs the risk);
- Autonomy: Let the patient decide the best course of action given her wishes and personal values (and remember, you have autonomy, too, in the physician-patient dyad);
- Justice: treat all patients equitably and consider the economic impact of how you treat an individual patient in terms of how it impacts your ability to treat others (when you overspend resources on one patient you are harming other patients by making those resources unavailable).
I have written before about applying ethics to how we treat patients; in fact, this post is the most popular howardism ever that doesn’t have the word vaccine in it. But, every day, I see a healthcare system that is almost entirely devoid of ethics. Hospitals, doctors, midlevel providers, pharmaceutical companies, insurance companies, government agencies, and every other person who has their hands in the multi-trillion dollar cookie jar that is the US Healthcare system, almost exclusively operate out of self-interest while wearing a cloak of moral superiority or altruism; I call this exploitation.
So, here are some explicit rules that will ensure that you aren’t perverting medical ethics for your own goals. These are the few basic things you’ve got to get right.
- Follow science-based guidelines. I’ve written about this extensively before in the post I referenced above. Guidelines are the best that we, as a group, know. They are not always right and they are often changed. Some guidelines contradict others. I take issue with many of them. But your personal opinions and experiences cannot negate them. If you disagree with a guideline, work to change and influence it, don’t just ignore it. A famous anti-vaccine doctor in California was just this week placed on probation by the state medical board for his unethical treatment of patients that deviated from science-based guidelines. He has a right to disagree and be skeptical, but he doesn’t have a right to make-up his own nonsense and call it medicine (at least he doesn’t have the right to do that under the auspices of a board certified and duly licensed medical doctor). Yes, guidelines should sometimes be deviated from. I would guess that about 5% of patients require significant deviation from guidelines. When this occurs, the reasons should be explicitly documented. But, in the real world, guidelines and evidence-based medical recommendations are not followed in around 80% of medical encounters. When a gynecologist deviates from pap smear guidelines or a cardiologist deviates from coronary stent guidelines, they are guilty of the exact same thing as Dr. Sears when he deviated from vaccination guidelines. Worse, the reason for the deviation is often self-interest and economic. Fewer pap smears mean less money for the practice; fewer mammograms mean less money for the hospital, etc. Following guidelines and evidence-based practice recommendations usually involves doing less, and doing less means making less money for you and your employer. Evidence-based practice guidelines help you provide the best mix of beneficence, nonmaleficence, and justice for your patients. They are an ethical must.
- Fully inform patients. Far too often, autonomy is invoked as the reason for deviation from guidelines or best practices. But, it is unusual that fully-informed patients make poor decisions. It is rare that a patient who truly knew that one treatment pathway was better for them would choose the alternate pathway. For example, does it make sense that a fully informed patient would choose a birth control pill over an IUD if her goal was to remain unpregnant for a number of years? Over five years, a hormonal IUD will be 22 times less likely to kill her, 420 times more likely to keep her unpregnant, less likely for her to have an ectopic pregnancy, make her 140 times less likely to have an unwanted surgical procedure, make her more likely to have periods she likes, etc. It sounds like a no-brainer, and it is. That’s why every important health organization recommends IUDs over birth control pills as first-line contraception. Yet, over 85% of women don’t get one (and most of those women aren’t even given the choice). I could write a paragraph like this about dozens – hundreds – of things in medicine. If you are doing lots of elective Cesareans, I suspect your patients aren’t fully informed. If your patients are getting robotic hysterectomies, they are not fully informed. If your patients are choosing yearly pap smears or mammography at age 40, they are probably not fully informed. Autonomy without complete and accurate information is not autonomy but coercion and exploitation. Or, if you give them antibiotics when they aren’t indicated or other interventions just because they ask for them, you may be negating your own autonomy. Your autonomy counts too.
- Don’t waste resources. It is estimated that we waste more money on unindicated labs and imaging tests each year in the US than we spend on the entirety of K-12 education. Add to this cost all the unnecessary procedures and surgeries, plus the unnecessary prescribing of unneeded drugs (or using a branded drug when a generic drug will do), and one realizes quickly that as much as half of US healthcare expenses are wasted. This over-utilization of resources actually leads to worse outcomes and this paradox is generally well-known; we spend about double the amount per patient in the US for inferior outcomes compared to other first-world nations like Finland. This is one way that the ethical principle of justice is subverted. But there is another, more insidious way as well. Sometimes we spend money and resources on patients and we do achieve better outcomes for the expense, but those resources might still have been better spent elsewhere. We spend an incredible amount of money on patients in the last year of life, where the cost per quality year of life is excessively high; when we do, that is money we are not spending on other patients where the cost per quality year of life is much lower. We must focus on high impact interventions and make sure everyone benefits from these. When an elderly patient with a terminal disease consumes millions of dollars of resources to extend his life by a few months (and miserable, poor quality months at that), we have taken away resources that might have been used to add quality years of life to other patients. Healthcare resources are scarce and finite; it is our duty, through public policy and guideline development, to distribute them as evenly as possible; but this duty also occurs on an individual basis, every day. When you prescribe a branded birth control pill that costs a $140 per month when a generic pill costing $8 per month would have sufficed, you stole birth control from 17 other women. When you do an unnecessary hysterectomy that costs the healthcare system $20,000 dollars, you deprived 200 women of a year’s supply of birth control. When you check a CBC or BMP on a healthy 30-year-old patient at her yearly preventative visit – or get a lipid panel or TSH or Vitamin D level – you wasted precious money that could have provided needed services to someone else. I’m sure you can come up with your examples. Who benefits? Not the patient, but the drug company, the doctor and hospital, and the laboratory company. This is the definition of exploitation.
- Don’t give bad advice. Physicians often do more harm with their mouths than with their pens or scalpels. Patients look up to physicians and trust that what they are told is important and factual. We ask patients to change their lives based on our advice, and they pay us for that advice. Patients are incredibly vulnerable in our presence and we wield enormous power over them. But much of the advice that physicians give to patients isn’t evidence-based. Don’t tell patients anything that isn’t clearly based on good science. It seems like 99% of the health information patients read on the internet is false; but one of the reasons that this erroneous information has digital legs is because somewhere, some irresponsible doctor told a patient that false information. It is your responsibility and ethical duty to know that what you tell patients is supported by current, replicated, quality scientific data. This means things like don’t tell people to participate in dieting fads; don’t recommend bed-rest to pregnant women; don’t recommend alternative medical interventions that are unscientific, etc.
- Be educated. A corrollary to the first four points is that you must be educated. Patients are spending their money on you and entrusting their lives to you because they assume that you are up-to-date and that you are treating them based upon the latest scientific evidence. Clearly, physicians are not commonly doing this (as evidenced by how few physicians follow evidence-based practice recommendations). Your one job is to stay up-to-date and educated about the conditions within your scope of practice. It is not optional. You are not allowed to do things because you have always done them that way or because “that’s how I was trained.” I went to medical school 18 years ago and I often reflect that virtually nothing in medicine is treated the same way now as it was then, at least not in the hands of competent doctors. Even ten years is an eternity. Since I graduated residency in Obstetrics, we have dramatically changed our labor management guidelines, our fetal heart rate monitoring definitions and algorithms, our Cesarean delivery technique, the methods of neonatal resuscitation, we have introduced delayed cord clamping as standard practice, revised the GBS management guidelines, made breakthroughs in the most effective methods of induction and augmentation of labor, etc. In short, if I practiced Obstetrics the same way today as I did when I graduated residency, I would call myself a bad doctor. Education doesn’t come in the form of detailing from drug or product reps, industry-sponsored dinners, or golf get-aways dressed up as CME conferences. You are paid a lot of money to read a couple of magazines a month (and change your practice accordingly).
- Don’t make medicine a business. I fear that this is one of the biggest impediments to ethical medical practice. Are you worried about how changing your practice pattern will affect your bottom line? As I said before, there are economic consequences of doing fewer paps, mammograms, and hysterectomies. There are economic consequences of doing fewer colonoscopies, echocardiograms, coronary stents, CT scans, bone density scans, obstetric and gynecologic ultrasounds, cystoscopies, urodynamic studies, first-trimester genetic screens, back surgeries, etc. But forget about not doing unnecessary surgeries and tests for a minute; it gets worse. Have you ever attended a workshop or conference to learn how to monetize your practice? Do you offer boutique services to make cash? Do you prescribe hCG injections or phentermine for weight loss despite both practices lacking data that say they are effective? Do you sell vitamins or cosmetics or offer a variety of ineffective laser treatments? Are you practicing cosmetic dermatology or do cosmetic plastics procedures even though you weren’t adequately trained to do them and those things are beyond your scope of practice? Maybe you don’t. But do you have patients come back to the office for lab follow-ups when a phone call would have worked? Do you have patients routinely come back after starting a new medicine like birth control just to see how they are doing when you could have just told them to call or make an appointment if they have any problems? Those are all ways of monetizing your practice. If I leave the day and feel like people came to see me for no reason other than for me to bill a 99213, I feel like a complete failure. What sick people didn’t have a chance to see me that day? Who couldn’t afford insurance that year because we, as a profession, waste so many resources that we have doubled their insurance premiums?
- Stand up for what’s right. There is a lot wrong with medicine and healthcare. Most incentives that affect how we act are perverse. I will write elsewhere about the Quadruple Aim, but let it suffice to say here that everything we do should serve to improve patient outcomes, improve patient experiences, lower costs of healthcare, and improve the physician/provider experience. Believe it or not, those four aims work together seamlessly and beautifully. It requires integrity to make those aims (and, indeed, the patient) the center of everything you do. It often requires that you go against what might seem to be in your or your institution’s best economic interest. Stop making excuses. If physicians want to be respected, they must have this integrity. We must police ourselves against those who pervert our ethical standards. You have an opportunity to stand up for what’s right in every patient encounter, every committee meeting, every conference, etc. Do it.
- Stand up for yourself. We used to talk about the Triple Aim, but now we talk about the Quadruple Aim; the new aim is that we should seek to improve the physician experience as well as the patient experience. Patients cannot get better without us. We need to be healthy, both physically and psychologically, to provide effective care to patients. In an age where we spend 2/3 of our time doing paperwork or other nonclinical activities, where we worry about our financial futures, where we suffer for years with too-rampant litigation, etc., our patients are the ones who suffer. Medicine, despite it all, is still a physician-led enterprise. Don’t cede your power to others. Stand up for yourself and your profession.
One of my dear friends recently asked me, “How can I do academic medicine the right way?” The answer to this question is what I have just written. But I’ll add a few more points for consideration
- Fight for change. There’s a lot of orthodoxy and establishmentism in academic medicine; a lot of lickspittles and sycophantry too. Yet medicine and science are constantly changing and evolving. If you or your department is not, it’s time for a change. Promote an environment of intellectual curiosity and progress. Encourage change for change’s sake even. Look hard at any practice that has persisted for more than five years. Be skeptical. If something works and is supported by evidence, keep doing it. Teach it. Preach it. At the same time, remember that there are no sacred cows, even if the chair thinks there are.
- Don’t be a pseudo-intellectual. Let’s be honest, most people in academic medicine aren’t particularly gifted and most don’t understand how to conduct or interpret research correctly. Don’t be that guy. Realize that 80% of papers published each year contain false conclusions. While challenging the status quo and being innovative, take a conservative approach with novel findings in papers, especially those which have not been replicated and which contradict other, more established findings. Don’t be a fool for P-values. Learn how to use and apply Bayesian statistical techniques in conducting and interpreting research.
- Learn how to teach. This should go without saying, but it needs to be said. Most physicians in academic programs have received no education or training in pedagogical techniques. Worse, many of them have no interest in teaching. If you are going into academic medicine, accept the responsibility and take the initiative to develop those skills. Ask for feedback and accept it. Work on it everyday. Decide if the first ‘g’ in pedagogy is hard or soft. No one teaches well by accident. You can start with reading my book on vaginal hysterectomy and the appendix on teaching residents and then dedicate a few hundred more hours to reading and practicing.
- Stop the cycle of workplace violence and abuse. Yes, I’m sure your medical school and residency training were tough. Yes, I know, your generation worked harder and longer hours than these youngsters these days. Yes, the new generation just doesn’t get it and they need to learn the hard way. If you believe any of that, please resign your position today. You are the problem. You know nothing about education. You know nothing about yourself. Just because you were abused in residency doesn’t mean you should abuse your residents. Just because you were abused as a junior faculty member doesn’t mean you should abuse and bully your junior faculty members. You don’t get to pay your dues and then take advantage of others after a few years. You aren’t special just because you became an attending physician, a division chief, or a department chair. Check your arrogance at the door. Treat your colleagues as colleagues, with respect, honesty, and dignity. Treat your students and residents as your future colleagues and always want the best for them. If you don’t believe that your students and residents will someday be a better doctor than you, please resign immediately.
- Know what the **** you’re talking about. One of the most frustrating things for learners is when they realize that their attending physician is clueless. It happens every day. Worse, though, is when the learner doesn’t realize it. It is heartbreaking when I see the blind leading the blind. Academic physicians have an even greater responsibility than physicians-at-large to be educated and know what they are talking about. Yet, too often they show up and give the same lecture to students and residents that they have given for the last 10 or 15 years; they don’t stay up-to-date; they use their academic perch as an excuse or justification to do whatever they want despite its opposition to current evidence or guidelines. Don’t teach a single thing ever that you don’t fully understand. You should be able to answer any question raised in detail. It is your responsibility. Don’t talk about stuff you don’t know about.
- Don’t teach your opinions. This is an extension of the last point. You are going to have opinions and they are sometimes valuable, but you aren’t allowed to teach them as truth. Share them if you must but clearly state that they are merely an opinion not supported by scientific evidence. Warn your residents and students against using anecdotal evidence to determine practice patterns. Show them examples of where you disagree with guidelines but follow them anyway. Yes, I’m serious. Sorry, but your learners don’t care how you like to do something; they care what the evidence says. Hopefully, those two things are in agreement.
- Admit your weaknesses. This day (June 30) has always amazed me. Somewhere today, a resident will become an attending at the stroke of midnight. One day, she was calling her attending with every patient and every decision and she constantly questioned her abilities; the very next day, she is the one being called by that ill-confident resident. There was no magic at the stroke of midnight. She wasn’t suddenly infused with the knowledge, skill, and wisdom she lacked mere minutes before. Yet, too often, an unbreachable arrogance sets in. I hear people say, “Fake it until you make it.” No. Admit your weaknesses. Be honest with your residents. Model for them the correct behavior of identifying knowledge gaps and searching for the information needed to make the right decisions. I spend an hour or two on PubMed every day and I am a content expert in my field. Indeed, the most valuable skill any attending can teach a resident is to know his limitations and weaknesses and how to address them on a daily basis.
- Don’t go along to get along. I mentioned sycophantry already. I mentioned fighting for change. But let me be more emphatic: academic medicine is about challenging beliefs and practices, being skeptical and inquisitive, making others defend their beliefs and you defending your own. Mix it up; be the gadfly; be the skeptic. If someone doesn’t, then things won’t get any better.