The Doctor’s Apparent Ineptitude

via Steve Kay@Flickr (by-nc-nd license)

As a fun project, I’ve decided to frame this post as an abstract.

AIMS/OBJECTIVES:

To elucidate factors influencing perceived incompetence on the part of the doctor by the layman/patient/patient’s caregiver.

MATERIALS & METHODS:

Arm-chair pontification and a little gedankenexperiment based on prior experience with patients as a medical trainee.

RESULTS:

Preliminary analyses indicate widespread suspicions among patients on the ineptitude of doctors no matter what the level of training. This is amply demonstrated in the following figure:

As one can see, perceived ineptitude forms a wide spectrum – from most severe (med student) to least severe (attending). The underlying perceptions of incompetence do not seem to abate at any level however, and eyewitness testimonies include phrases such as ‘all doctors are inept; some more so than others’. At the med student level, exhausted patients find their anxious questions being greeted with a variety of responses ranging from the dumb ‘I don’t know’, to the dumber ‘well, I’m not the attending’, to the dumbest ‘uhh…mmmm..hmmm <eyes glazed over, pupils dilated>’. Escape routes will be meticulously planned in advance both by patients and more importantly by med students to avert catastrophe.

As for more senior medics such as attendings, evasion seems to be just a matter of hiding behind statistics. A gedankenexperiment was conducted to demonstrate this. The settings were two patients A and B, undergoing a certain surgical procedure and their respective caregivers, C-A and C-B.

Patient A

Consent & Pre-op

C-A: (anxious), Hey doc, ya think he’s gonna make it?

Doc: It’s difficult to say and I don’t know that at the moment. There are studies indicating that 95% live and 5% die during the procedure though.

C-A: ohhh kay (slightly confused) (murmuring)…’All this stuff about knowing medicine. What does he know? One simple question and he gives me this? What the heck has this guy spent all these years studying for?!’

Post-op & Recovery

C-A: Ah, I just heard! He made it! Thank you doctor!

Doc: You’re welcome (smug, god-complex)! See, I told ya 95% live. There was no reason for you to worry!

C-A: (sarcastic murmur) ‘Yeah, right. Let him go through the pain of not knowing and he’ll see. Look at him, so full of himself – as if he did something special; luck was on our side anyway. Heights of incompetence!’

Patient B

Consent & Pre-op

C-B: (anxious) Hey doc, ya think he’s gonna make it?

Doc: It’s difficult to say and I don’t know that at the moment. There are studies indicating that 95% live and 5% die during the procedure though.

C-B: ohhh kay (slightly confused) (murmuring)…’All this stuff about knowing medicine. What does he know? One simple question and he gives me this? What the heck has this guy spent all these years studying for?!’

Post-op & Recovery

C-B: (angry, shouting numerous explicatives) What?! He died on the table?!

Doc: Well, I did mention that there was a 5% death rate.

C-B: (angry, shouting numerous explicatives).. You (more explicatives) incompetent quack! (murmuring) “How convenient! A lawsuit should fix him for good!”

The Doctor’s Coping Strategy

Although numerous psychology models can be applied to understand physician behavior, the Freudian model reveals some interesting material. Common defense strategies that help doctors include:

Isolation of affect: eg. Resident tells Fellow, “you know that patient with the …well, she had a massive MI and went into VFib..died despite ACLS..poor soul…so hey, I hear they’re serving pizza today at the conference…(the conference about commercializing healthcare and increasing physician pay-grades for ‘a better  and healthier tomorrow’)”

Intellectualization: eg. Attending tells Fellow, “so you understand why that particular patient bled to death? Yeah it was DIC in the setting of septic shock….plus he had a prior MI with an Ejection Fraction of 33% so there was that component as well..but we couldn’t really figure out why the antibiotics didn’t work as expected…ID gave clearance….(ad infinitum)…so let’s present this at our M&M conference this week..”

Displacement: eg. Caregiver yells at Fellow, “<explicatives>”. Fellow yells at intern, “You knew that this was a case that I had a special interest in and yet you didn’t bother to page me? Unacceptable!…” Intern then yells at med student, “Go <explicatives> disimpact Mr. X’s bowels…if I don’t see that done within the next 15 minutes, you’re in for a class! Go go go…clock’s ticking…tck tck tck!”

We believe there are other coping mechanisms that are important too, but in our observations these appear to be the most common. Of the uncommon ones, we think med students as a group in particular, are the most vulnerable to Regression & Dissociation, duly accounting for confounding factors.

All of these form a systematic ego-syntonic pattern of behavior, but for reasons we are still exploring, is not included in the DSM-IV manual’s section on Personality Disorders.

CONCLUSIONS:

Patients and their caregivers seem to think that ALL doctors are fundamentally inept, period. Ineptitude follows a wide spectrum however – ranging from the bizarre to the mundane. Further studies (including but not limited to arm-chair pontification) need to be carried out to corroborate these startling results and the factors that we have reported. Other studies need to elucidate remedial measures that can be employed to save the doctor-patient relationship.

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NOTE: I wrote this piece as a reminder of how the doctor-patient relationship is experienced from the patient’s side. In our business-as-usual frenzy, we as medics often don’t think about these things. And these things often DO matter a LOT to our patients!

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