IAN WEBSTER. The retreat from patients, a letter to young doctors

Feb 27, 2020

The idea that the pressures of patient care cause doctors to withdraw from direct clinical work has been in the background of my observations of my colleagues and their work since the 1970s.

Dear colleague,

Through your career you will interact with patients and you will see through them, however manifest, a troubled world in microcosm. Their burdens and joys buffeted by an economy and politics indifferent to their predicaments. There is much to learn about our society from them – its values and life-experiences.

You will be asked to deal with problems not resolvable with the skill-set taught in med school or in postgraduate training. The – facts, the pattern, the diagnosis – will be inadequate for the life problems of so many who will present for care. The ever-changing health problems of today are not encompassed by the way medical diagnoses and disciplines have become split into so many discrete fragments.

The eminent sociologist, Richard Sennett, after studying the British NHS, said,

“Doctors’ and nurses’ attitudes to patients are innately craftsman-like, driven by curiosity, investigating slowly, retaining an ability to “learn from ambiguity” and the “interplay between tacit knowledge and self-conscious awareness”.

These are the skills which can make the clinical task so rewarding, if you are prepared to allow them to do so. The insights gained, honed by experience and learned by doing, are to treasured. Think of the surgeon coping with an emergency, or the physician unravelling a patient’s breathlessness and distress, or the conversation at life’s end for the desperately ill.

You will continually need to defend the time you spend with patients against the pressure to take shortcuts in a time-urgent, risk averse environment of high patient loads and quantitative healthcare targets. Richard Sennett, quoted above, said,

“These special skills have been eroded by quantitative healthcare targets. No place for the craftsman’s subtle and practised “interplay between tacit knowledge and self-conscious awareness” in the brutal Fordism of the health service.”

Dealing with the problems of the mind and body can pose existential questions, especially when physical and mental problems occur together, and expose our inability to intervene effectively. It can be painful – distressing – in dealing with problems of this kind. The medical underground speaks of “heart sink” patients – those with intractable, unsolvable dilemmas and social predicaments. These patients have the same rights and entitlement to the level of interest and care as for an acutely ill young person, a trauma victim or patient in heart failure.

A recent large study of US physicians, showed that they experienced high bureaucratic demands (55%), frustration with computerization (30%) and a loss of medical

autonomy (24%) and ‘burn out’. And the ways they dealt with ‘burn out’ were often pretty unhelpful – isolating themselves, exercise (probably OK), excessive sleep and in 24% of instances – alcohol. It is this sense of inadequacy and failure which can drive the ‘burn out’ that you or some of your colleagues may experience.

While I was working in an inner-city community health centre, a colleague gave me a paper to read, “The retreat from patients”. It was written by a leading psychoanalyst, Lawrence Kubie, and published in the Archives of General Psychiatry in 1971. He despaired at what was happening as psychiatrists retreated from patient care in the US.

Kubie was concerned about the shift from office practice to full-time salaried positions and the downgrading of clinical skills to the rewards of academia and to monetary and in-kind benefits, as he saw them. That was 50 years ago. Today psychiatrists are fleeing the stress of public psychiatry, from the heavy-lifting of great suffering, to the environments of private offices in suburbs with compatible patients – once characterised as the ‘worried well’. These movements not only afflict psychiatry but can be seen in almost every branch of medicine.

It does not have to be that way; there is real satisfaction from sharing the innermost struggles against illness and in being prepared walk the journey with patients.

As Kim Oates said in Pearls and Irritations, 12th February, 2020,

“…there is good evidence for better outcomes when patients are partners in their own care”.

This can be the well-spring for your future in medicine.

Ian Webster AO is Emeritus Professor of Public Health and Community Medicine, UNSW and physician to the homeless at the Exodus Foundation, Ashfield, NSW.

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