In numerous writings and venues regarding physician practice, the claim is made that “physician education is lacking in nutrition, geriatrics, care for non-cisgender people, relating to patients in general, cultural respect, equitable treatment, etc.” While all of these suggestions have merit, to what extent would they lengthen the already most extended medical school curriculum among developed countries? Or would those who advocate for these additions propose that they replace parts of the current curriculum? If so, what present courses could be eliminated? Alternatively, these topics could be offered as fourth-year electives.
Although all of the proposed areas of knowledge are essential, some may be best taught through clinical rounds with actual patients, through instructors modeling and discussing positive behaviors, as shown in recent studies. Others would be more suitable for a classroom. Additionally, some topics, such as nutrition, may be less relevant for students considering specialties like surgery, where physicians serve as consultants and interact with patients only briefly. Conversely, this knowledge would be essential for primary care providers, cardiologists, or endocrinologists.
It is questionable how well these extras will integrate into the current realities of medical practice, where most physicians have limited time for patient interaction, as their for-profit employers require a certain number of patients to be seen per hour. This is partly necessitated by the continual decrease in reimbursements for clinical services. Additionally, while primary care practitioners (PCPs) could perform many basic procedures (i.e., splinter removal), they are reimbursed less for them than specialists, and it is economically sensible to refer them, despite this reducing the time that could be used to establish and maintain a relationship.
Let us assume that physicians, especially PCPs, are provided with all the additional information everyone thinks they should have and that they have all the time necessary to impart this information, as needed, to every patient they treat. Would this result in the joint patient-provider decision-making touted as the “gold standard” of medical care? Likely not! To receive information, a patient must be both motivated and capable of learning, and far too often, they are neither. How frequently has a patient been prepared to take notes or asked to borrow a pen and paper to do this?
It frustrates me when experts and organizations preach this ideal but always fault the physician if the relationship falls short of this goal. However, a joint activity requires that both parties share equal responsibility for it to function effectively. Through observing patient-clinician interactions, I have found that the patient half of the dyad is frequently deficient, rather than the physician!
As I have written, at least half of the patients queried prefer their physicians to make decisions on their behalf and not be involved in the medical aspects of their care. Those who wish to make decisions may be unable to participate due to limited literacy (at or below the eighth-grade level), diminished motivation resulting from prior experiences, an inability to reason rationally and neutrally, or a combination of these factors.
My predoctoral internship included time in a high-risk pregnancy clinic for women who, for a variety of reasons, had an increased possibility of a medical complication that could endanger their lives and/or that of their fetuses. A physician examined each woman, and then she attended a class on strategies for maintaining her health and supporting a healthy pregnancy, ideally to term. During the examination, the importance of the subsequent class material was emphasized.
The class instructor was an uninspiring speaker, but the information was vital and should have been inherently motivating. Nonetheless, every attendee expressed utter boredom. The provided booklets, which were colorful and basically written, were not even opened but were discarded in the trash can outside the classroom door, and some students lit cigarettes as soon as they exited the building.
How are patients like these supposed to be equal partners in their care? Some non-medical experts criticize physicians, who, at times, are less than courteous. They should experience the frustration when one of these patients arrives at the hospital in a critical condition (i.e., eclampsia) that might have been avoided if she had followed the provided advice, especially when the physician is exhausted and is now responsible for attempting to save both!
“I did not know where to find any information” is a frequent comment heard by researchers in many fields when people are queried about their inaction. Recently, some researchers have suggested that this was an excuse for a lack of motivation. Patients can obtain accurate and reliable information for themselves, written simply on the Internet. According to recent data, at least 96 percent of adults have internet access through a computer or cell phone.
Although this leaves approximately 8 million adults who are unable to do so, they are not bereft of options. As I have previously noted, they can access publicly available computers at local libraries. Additionally, public schools, particularly in rural areas, often have computers available for use after hours, provided that prior arrangements have been made. Even hospitals have library computers that can be accessed by appointment. In all instances, assistance in how to search would be available. If she inquires, internet access may even be possible in her clinician’s office!
M. Bennet Broner is a medical ethicist.
