Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, December 21, 2006

Why Do We Really Do It

I just finished reading Sid Schwab's book, and -- among lots of other things in it -- I find that he brings up an interesting point. How do patients really know how good he is, when all his amazing work (which includes the "cognitive" aspects of what to do, what to do it to, and when and how to do it along with the purely technical aspects of "doing it") is hidden away behind neatly tied sutures? (He also addresses this in his blog from time to time.)

Sid is right. As he has said, the body is very forgiving, and even if a surgeon isn't quite as elegant as he is, the patients heal up fine and no one is the wiser. Lest he think he's all alone in his sense that no one really knows how good he is, allow me to assure him that he is not.

A deft turn of phrase in a patient interview that elicits the nuanced response that suggests what turns out to be the correct diagnosis is just as much a thing of beauty as an elegant dissection. Coming up with just the right words of comfort at just the right time; breaking bad news without breaking the spirit; the plain talk that cuts through the dense jargon to explain the everyday esoterica of medicine; these too must be appreciated for their own sakes, because no one else will ever know.

Ah, but the patient knows, you say. Your patients don't watch you operate (though there are nurses, sometimes assistants and anesthesiologists as occasional audiences.) While that may be true, I have to believe that the "better" surgery -- the one that causes the least necessary damage to the body -- is going to be easier to recover from. Although any given patient may not recognize that his recovery was marginally easier than his roommate's, I know that in the aggregate that kind of quality gets noticed. (Also, by definition, a given patient does not have the opportunity to compare how he feels recovering after the same surgery performed by two different surgeons.) Other physicians come to know that Dr. Schwab's patients get out of the hospital sooner, have fewer complications, and just seem to bounce back quicker that Dr. Schlub's. With the reputation comes the respect.

Then again, is that really the point? Certainly the respect and admiration of one's colleagues is an important reward; validation of ones' skills always feels good. But is that really why you do it?

I don't think it is. I think doing the right thing in the right way for its own sake is its own reward. (We sure as hell aren't in it for the money; right?)

We can brag to our staffs, to our families, to our colleagues. We can blog. We can even write books. We can enjoy our listings as Top Doctors in magazines; our nominations as Best New Blogs; perhaps even Doctor of the Year someday.

But ultimately, the only true satisfaction we are going to get is that which comes from knowing in our heart of hearts that we did a damn good job. If that's not good enough, we're in the wrong business.

(Postscript: I actually drafted this post before writing about my personal blogging rules. I just noticed that taking them together, they seem to be saying much the same thing.)


At Fri Dec 22, 12:23:00 AM, Anonymous Anonymous said...

That's true, but you omitted the other half of the coin - not only does the patient not notice whether or not your care was particularly spiffy, their opinion of you is usually based on your personality and/or ability to make chit chat. As far as FPs go, the practice I go to has a couple. One doesn't know his ass from a hole in the ground, but is young, goodlooking and excellent at flattering people. The other is really, really good, reads more literature than 99% of our colleagues and may secretly know more about my specialty than I do. But he has the personality of a cheese grater, so Dr. A is the one everyone wants to see. Ah, well. Such is life.

At Fri Dec 22, 01:14:00 PM, Blogger Sid Schwab said...

Good topic! (Gee, why would I say that...?) Anyhow, it's an interesting thing. Whereas I agree many docs did notice my patients seemed to do better, what many others noticed is that I wasn't as good an ass-kisser as some of my colleagues. WIth extremely rare exceptions, I was always (I must say. Because who else will?) nice to my patients. But I was sometimes less than charitable to... I'll let it go at that.) Affability; availability; ability -- in that order. It's been said before. The ways of the world are such that you are absolutely right: you must get your satisfaction from within. On the other hand, for a guy like me -- namely (not getting too detailed here) never satisfied, always unable to tell myself I did good, it means in fact it comes from nowhere. And whereas I've been known to brag about stuff (you pointed out mention in a book), in reality I realize that sort of thing is entirely meaningless. I used to think the best validation was surgery nurses coming to me as patients. Until a really excellent recovery room nurse told me who her OB/Gyn was: one of the most technically lousy and judgementally impaired I'd ever known.

At Sun Dec 24, 10:21:00 PM, Anonymous Anonymous said...

I should have added this, by way of concurrence with the thrust of your post: as a surgeon, I always took the most pride in the relationship I was able to establish with my patients; and the process of diagnosis and decision-making that made for the correct carrying out of care. The operation itself, while fun more often than not, was the mechanics. It's the relation with the patient from which the satisfaction really comes.


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