Angst-driven Medicine?
Department of Medicine, Kaplan Medical Centre, Rehovot and the Faculty of Medicine, the Hebrew University Hadassah Medical School, Jerusalem, Israel
Summary
Side-by-side with the quintessential scientific process and humanistic values, doctors' behavior and decisions in the clinical encounter are increasingly influenced by ‘foreign’ considerations that are little mentioned and seldom recognized as a significant force.
Many such issues can be identified in the literature. They include reactions to uncertainty and to fear of litigation or complaint; responses to pressures of managed care organizations; time constraints; avoidance of exposure to emotions and suffering; yielding to demands of patients or families; compromises made due to the presence of the computer as a third party in the encounter; and the accumulating effects of work-related stress.
All these varied factors, many of them new in the arena or increasing in importance in recent years, often cause angst in the clinician. Thus, they may skew the doctor's behavior and decisions away from ‘best’ evidence-based and compassionate medical practice towards less optimal, but angst-reducing solutions.
Several multifaceted approaches may prove useful in minimizing angst-driven medicine and its potential harm, thus improving the quality of care.
The problem defined
The clinical encounter between doctor and patient, whether it takes place in the hospital's ward, the doctor's office or the patient's home—remains the heart and soul of medical practice. It is the patient–physician encounter that provides the setting, and more importantly, the foundation of decision making, arguably the most crucial of all physicians' activities. As such, the clinical encounter should be based on a solid scientific process of data collection and interpretation and on humanistic values of compassion and commitment.
However, these are not the solitary players in the field. It has long been realized that alien non-biomedical variables (such as patients' characteristics) are important as well, affecting decision making by clinicians. We maintain that side by side with the pursuit of all laudable values of patient care, physicians are also often moved by a compelling need to ‘avoid’ certain issues which involve angst, stress and worry. Such ‘negative’ concerns often become a silent, unmentioned and ignoble partner to the scientific and humanistic considerations. They are increasingly present in today's practice of medicine and may lead physicians to a path of suboptimal decisions and behavior.
This almost subconscious inclusion in the encounter of ‘foreign’ motives aimed at reducing physicians’ angst and stress has far-reaching implications that have been little appreciated as a whole. We identify and discuss several strong and prevalent ‘negative’ concerns that arouse angst in clinicians and may act behind the scenes to skew clinicians’ actions and decisions. Important deleterious effects on the quality of care and on patient–physician relationship may ensue. Most of these issues are not new, yet their impact and cumulative adverse effects seem to be increasing and should be better recognized as one of the more threatening problems of modern medicine.
Its multiple causes
First, the reactions to uncertainty, which remains inherent and ubiquitous in clinical medicine. Contrary to all expectations, the spectacular advances in our knowledge and capabilities have not reduced uncertainty regarding the individual patient. The practice of medicine is not only becoming increasingly complex, but paradoxically, even more uncertain. Autopsy studies reveal that rates of misdiagnosis remain substantial and largely unchanged. Both uncertainty and doctors’ inability to handle it may result in substandard care. Reactions to uncertainty include concern about bad outcomes, anxiety and stress, lower scores of work-related satisfaction and frequent burnout. Besides the harmful effects on doctors, suboptimal patient care—even harm—may result. Physicians may react by indiscriminate ordering of tests and treatments to protect against the risk of failure; focusing on aspects most amenable to investigation or treatment to the exclusion of other significant problems, or withholding information from their patients.
Second, fear of litigation or complaint—a proliferating problem—is closely linked to uncertainty and acts similarly, promoting the notorious ‘defensive medicine’. Defensive practice is observed in many countries and across varied specialties and types of practice. Most practicing physicians appear to be susceptible. Thus, in the field, evidence-based medicine is often being replaced with over-ordering of tests (particularly, costly imaging studies) or diagnostic procedures, redundant followup or unnecessary admissions or referrals. Avoidance of certain procedures or particular patients also occurs. Such responses to the rapidly spreading ‘malpractice crisis’ are not that unexpected, given that over one-third of senior clinicians in one UK study had been involved in litigation and suffered from distress and anger as a result.
Third, the ascendance of managed care created the need to match performance to the expectations and demands of the organization (NHS, HMOs). Since the organization's chief concern is cost containment, doctors are constantly being pressured towards lesser utilization of health services, fewer referrals, cheaper medications and shorter hospital stays. Implementing incentives that reward physicians for providing fewer services and closely monitoring and harassing those who do not comply, underscores the multiple commitments physicians have nowadays. The physician's role as a gatekeeper, may lead to a confrontation with the patient or seriously undermine trust when needs are most intense. All this creates a continuous ethical dilemma for the doctor who finds it hard to cope with the conflicting loyalties.
Fourth, the increasing demands on physicians’ time. With older, more complex patients; polypharmacy; the needs to choose between a growing number of options and to inform patients and involve them in decisions; and diminishing continuity of care, the constraint on the relatively short consultations is steadily growing. The time allotted for the average medical encounter has not increased despite mounting obligations. To those must be added the task of searching the ever-increasing literature for the relevant evidence, choosing between the many new tests and medications now available and tailoring the information to the individual patient. Since clinical information is often missing (reported in nearly one in seven GP visits), the clinician's limited time resources are further jeopardized. Gazing at the computer screen and keyboarding may take up to 40% of the visit time and interfere with its desired content and quality. Time constraints are known to worsen cognitive performance, affect decision making and increase the risk of error. Harassed physicians may, therefore, curtail their ‘investment’ in their patients through fear of exceeding their time schedule and over-burdening their already highly strained timetable. No wonder that time-consuming history and examination tend to be replaced by ‘turfing’, referrals and more tests.
Fifth, fear of intimacy and emotional contents of the patient–physician encounter is only partly related to its time-consuming effects. Such issues may also be awkward, embarrassing and emotionally demanding for the physician whose training in this area may be insufficient. The fact remains that avoidance is very common and ‘sensitive’ personal issues are much more often missed than taken up, even when brought up by the patient. This attitude can be traced to perceived ‘risks of connexion’ and to the negligence of everything not biological throughout medical education. It results in much potential harm to the patient including missing important diagnoses, such as depression; undermining patient's trust, compliance and satisfaction; and sending patients into the arms of doubtful complementary and alternative medicine (CAM) ‘healers’.
Sixth, demanding patients were much less common when physicians were the only holders of knowledge and authority. With the departure from physician's paternalism to patient autonomy and from ignorance to widespread free online information—the doctor's image has undergone some devaluation and patients’ expectations have risen. Patients who insist on having a particular new imaging test or drug they had just read about —are no longer uncommon. The proportion of medical activities that stem from patients’ initiatives is not known but may be substantial. Even perceived patient pressure often leads to activities. Physicians who are unsure of themselves or afraid to lose time and calm in arguments or even lose their patient are particularly susceptible and may yield to their patient's demands even when they are unfounded.
Seventh, the interposition of the computer on the physician's desk, between doctor and patient may also have detrimental effects, besides its remarkable benefits. Physicians often remain absorbed in their screens and the interaction with the computer may detract from the essential eye, mind and heart contact with the patient. Accessing patient's previous data and the typing of new material takes considerable time, sets the pace of the encounter and may also dictate much of its content. Over 10 different prompts may appear ‘demanding’ the doctor's attention, sometimes at the threat of losing pay-for-performance or not being able to proceed or retain new material. ‘Shortcuts’, such as incomplete laconic notes or omitting to open mandatory windows are familiar to all. Computer-associated angst may be more common than realized.
Lastly, periods of work-related personal distress have been experienced by most doctors. Competence concerns and perceived medical errors; complaints or fear of them; demanding patients; overwork, tiredness and sleep deprivation are common. All have been strongly linked to physician irritability or anger, depression, anxiety and burnout. To avoid these negative feelings, physicians may opt to employ alternative paths, deviating from proper practice. A vicious cycle develops: once personal distress sets in, a significant decline in the quality of care provided occurs, as well as a sharp loss in the empathy towards patients. Overworked or stressed physicians also report high frustration with patients, while satisfied physicians breed satisfied patients. Physicians’ distress can, therefore, be regarded as a domain of its own.
Suggested remedies
Thus, ‘angst-driven medicine’ undermines the quality of care and needs to be attended to. Any attempt to correct its many negative consequences, however, must be founded on two assumptions. First, there is going to be no return to medicine as practiced 30 years ago. Second, the influence of ‘angst’ on decisions is ubiquitous and virtually impossible to eliminate. Nevertheless, much can be done to improve physicians’ adjustment to the new angst-laden arena and minimize its adverse effects.
Health organizations and policy makers could strive for continuity of care and reconsider the time allocated for a typical medical encounter to accommodate the changing scene. New techniques, such as telephone triage, e-consultations, improved electronic health record (EHR) and handy up-to-date online texts may reduce physicians’ workload, facilitate decisions and reduce angst. Excessive pressures to economize need to be counterbalanced. Health organizations should form active, authoritative and independent bodies to oversee policies and individual patient's cases. Physicians’ accountability complicated by financial incentives poses serious ethical dilemmas that need addressing and better developed guidelines.
Medical schools, residency and continuing Medical education programs have a crucial role in teaching time management skills and training for better listening and sensitivity to the patient's concerns and narrative. Much can be accomplished within the time currently allotted. Education must stress the enduring importance of the history and physical examination and provide physicians with knowledge on test characteristics, selection and interpretation using problem-based learning. These may improve untoward responses to uncertainty. The curriculum can be modified to include roots of work-related stress and coping skills, financial aspects of medical decisions and ethical guidelines in the era of managed care. Thus, physicians will hopefully acknowledge cost problems yet resist pressures to withhold necessary technology in providing professional care.
Physicians can become more proficient in recognizing and managing angst-generating issues. Becoming more cognizant of angst in medical practice (to which this article may contribute) may well be an important initial step. One of the best techniques to combat angst seems to be able to involve patients in these issues. Neither uncertainty nor conflicts of interest are taboo and could be discussed with patients in a way that would not harm their confidence. Involvement of patients in decision making and collaborative reading of the EHR, are to be encouraged. Instead of the often harassed practitioner distanced behind the computer, a more communicative, caring and confident clinician may develop.
Final summary
In conclusion, despite the meagre attention they get, negative concerns of physicians in everyday clinical encounters are very common in both ambulatory care and hospital settings. They may affect many daily decisions and deviate doctors from the defined dimensions of professional competence. Thus, medical decisions are not purely the result of rational clinical reasoning and evidence and humanistic endeavor, but may be tainted by physicians’ angst and their constant effort to evade several prevalent and pressing concerns. Their cumulative impact needs to be further studied and effective multifaceted ways to overcome these barriers and improve clinical decisions and patient–physician relationship can then be developed. Recognizing ‘angst-driven’ medicine, its prevalence and its causes—is a mandatory first step.
Conflict of interest: none declared.
Note: Full references can be obtained from Professor Schattner upon request.
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