Wednesday, May 8, 2013

Healer or Master Mechanic: The Future of the Servant Leader Physician

I will be giving Grand Rounds on health reform to an academic department of Obstetrics and Gynecology at a major teaching hospital next week.  The audience will include young physicians in training, eager to learn their new craft and excited about the skills they are developing.  I prepare my slides on the new laws and the forces that now face every practicing doctor and have to wonder whether those young physicians will be trained to be master mechanics of the human body, or holistic physicians treating all aspects of a person.  Will they be leaders of medicine or technical experts of pathophysiology?  For people in the field of Obstetrics, will they see helping a woman bring a new life into this world as a lofty endeavor that is a privilege, or just see the technical difficulties of the high risk pregnancy and the challenging delivery?  Will they be artists, scientists or the traditional combination of both that makes medicine a calling as well as a career. 

In health policy articles, doctors are often described more as expensive resources that must be carefully managed so that they stay focused on diagnosing and treating patients while maintaining productivity than as holistic healers.  Systems to prevent them from straying too far from normative algorithms rather than staying true to the science of evidence based guidelines are described as critical to good care. In that framework, the best physician is one who follows the scientific guidelines most carefully and accurately.   But evidence based guidelines alone do not reflect the context of a patient who may have family problems, financial difficulties and emotional issues that impact the diagnosis and treatment that is the core of the art of medical practice.  Will the guidelines and productivity measures allow young doctors coming up through the system to take the time to get to know their patients in such a way so they understand that context and that person who has the disease (or the pregnancy in the case of Obstetrics)? Will the new career of medicine allow the artistry of medicine to flourish while still maintaining the strong foundation in science? 

The current model for health care is also a team model.  That change from the solitary general practitioner is a strong positive however the risk of a team is that sometimes no one professional takes ownership of the entire patient and the entire situation.  There is no leader.  When we deal in a world of doctors as purely diagnostic and therapeutic specialists we risk the physician focusing on the pathophysiology of the disease and forgetting the entire person in which it resides.  The traditional doctor’s role as the leader of a team falls to the wayside.  The diffusion of the ownership of a relationship can leave a patient feeling abandoned by a complex system that only seems to acknowledge the “science” while letting the whole person fend for his or herself.  The art of getting to know a patient and their family so that the therapy can become a true partnership and a true healing is at risk of being lost. 

There is also an emphasis on a patient’s participation in their own care.  This is also a strong positive as good care should be a partnership.  However much of the writing on patient participation is focused on the patient’s access to Internet based tools and apps and is more about “self-service” medicine than it is about partnership with their health professionals. 

What will I tell these young physicians who are starting their careers and their lives as physicians?  I have to tell them of the challenges ahead.  The challenge of taking time to get to know your patients when you are an expensive resource and you will be judged on your productivity.  The challenge of honing the skills you will need in order to interact with patients as people and not only collections of symptoms.  Those are skills to be learned and practiced over years.  That is why medical training is a hands-on mentoring model that gradually allows the resident in training to take on responsibility in small pieces as they develop those skills.  The skills are not only intellectual but interactive.  Just how do you tell a new mother that the child she has just delivered, following the totally normal pregnancy, has a genetic illness that will eliminate the possibility of watching that child grow to independence?  How does a resident learn to diagnose and treat and also learn how to stay with a person as they are leaving this life with a terminal illness?  On a more mundane level, how does that doctor, or nurse practitioner, help the person with a “minor” self-limited illness who is frightened and struggling to get through the day, convinced that the illness is more significant and more life threatening than the science reveals it to be?  How do we, as a nation, encourage this art through our health policies and teach this art to young physicians and other young health professionals?  How do we teach them the privilege that we have in helping people on a daily basis, using the communication, empathy, and caring arts that we have learned from those who taught us as well as the science that we now focus on in our education?

Traditionally, doctors and other health professionals were trained to be “servant-leaders” and the history of medicine began with a religious framework.  In my religion, Judaism, Maimonides, one of the greatest Jewish thinkers, was a physician and a healer and his code of medical ethics, written in the 12th century is still used today.  One line of the oath says, "May I never see in the patient anything but a fellow creature in pain."  In Christianity Jesus is traditionally seen as a healer. In Islam, Ishāq ibn ʻAlī al-Ruhāwī wrote in the 9th century, that physicians must be "guardians of souls and bodies".

The concept of the servant healer which was described in our current era by Robert Greenleaf in 1970 in his landmark essay “The Servant as Leader” is based on religious and philosophical thought.  That concept has been embraced and developed even more by Christian writers who have described Jesus as the model for servant leadership. 

Greenleaf wrote,

"The servant-leader is servant first... Becoming a servant-leader begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first... The difference manifests itself in the care taken by the servant first to make sure that other people's highest priority needs are being served. The best test, and the most difficult to administer, is this: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?"

 Medical training used to stress living with patients, and learning their lives and their experiences in order to better understand what they are going through so as to be a better servant.  Go into any old, established medical center that was founded in the early 1900s and you will see lists of names of doctors and nurses who died from infectious diseases as they fearlessly took care of their patients while living with them in the hospital.  Those people were trained to be servants, artists, and yes even spiritual guides through an illness.  They were taught to be leaders in the best tradition of servant leaders.  Has the arrogance of science removed some of the caring and serving that characterized medicine in the past? 

In the Talmud, in Judaism, there is a passage that says, “The best of the doctors are bound for gehinom (hell)”.   This is baffling however Dr. Daniel Eisenberg of Thomas Jefferson University School of Medicine gives two interpretations.  One explanation is that the physician is always at risk to make a preventable error that would result in death or injury giving them criminal responsibility.  The second explanation is that the physician must be humble and the doctor who sees himself or herself as the “best” may not recognize the need to see himself as an intermediary and a partner in healing rather than the source of healing.  This too, will lead to “gehonim”.

At these Grand Rounds, I need to communicate the choices they will have.  Will they be healers or master mechanics?  Will they take time with patients or be “productive” in diagnosing and treating?  Will they be teammates focusing on their narrow area or servant leaders?  I pose these questions and hope to challenge them to be the servant-leaders, the healers, to continue in the ancient tradition of our craft. How they answer those questions will be up to them.