Inching our way forward into medical care that is truly collaborative, we face many challenges.

The first is internal: our medical training (pretty much no matter when we trained) reflects a very long history of “doctor knows best”– not because doctors have an ingrained desire to be seen as superior, but because they like to be seen as heroes. War has been described as “long periods of boredom punctuated by moments of sheer terror,” and this could, in some ways, describe the life of a practicing physician as well. Most doctors see patients for long stretches with everyday complaints: headache, nasal congestion, insomnia, anxiety, cough, constipation… you get the idea. The child who comes to her/his pediatrician and “codes” (i.e collapses) in the waiting room, or the busy businessman who has a heart attack while waiting to be seen, is very rare– and yet our training is heavily weighted towards being able to deal with these rare but frightening events. Our training is all about recognizing “zebras,” not “horses,” even though horses are what we are likely to see in our country. Patients expect a doctor to be able to recognize dangerous conditions no matter how rare (brain tumor, leukemia, schizophrenia, abdominal aortic aneurysm).  What use is a doctor who cannot save your life or that of your child?

In the United States, the completion of medical school is in no way sufficient to practice even the most general branch of medicine; the four years of medical school must be followed by a period of internship and residency. Residencies are largely completed in the inpatient (hospital) setting, and are spent diagnosing and treating things a doctor likely will never see again (hemorrhage from esophageal varices, cardiac arrest from cardiac tamponade, respiratory arrest from epiglottitis), but are expected to be able to manage nonetheless. In my own residency, we had to complete a certain number of intubations, spinal taps, blood draws and cardiac resuscitations in order to graduate, although we would never again be required to perform them. This was in addition to the considerable reading, studying and exam taking, all of which can lead a doctor to believe that their opinion on a medical subject should probably carry more weight than the opinion of a lay person.

Residents are poorly paid, and so a doctor (and their family, if they have one) will have endured a minimum of seven years of relative poverty and (probably) considerable debt– which goes doubly and triply for the surgical specialties, whose training is harsher and longer. By the time a young doctor is able to practice in this country they both need and expect to earn enough money to make up for this. They are also typically sleep deprived and used to “giving orders” all day.

In many ways, life in the hospital for doctors and nurses resembles the military. It is a  stressful, life-and-death, strictly hierarchical, highly protocol-driven universe, where orders are not challenged and a very high level of performance and sacrifice is expected. Not a recipe for collaborative decision making, humility or creative thinking. I have suffered, thinks a doctor to themselves, and I deserve respect for that.  I have gone through all of this to be able to give you advice about your health. Why won’t you take it?

Imagine, for example, life as a pediatrician: you are seeing a little boy with bad daily headaches, who has never had immunizations and who has multiple food allergies, according to his mother. On today’s visit, she is terrified that her son has a brain tumor (like his paternal grandfather) and arrives with several articles about undiagnosed tumors and alternative treatments. She wants you to read them and get back to her. She will not accept your assessment that the headaches could be stress related. She tells you that her two former pediatricians regularly blew off her concerns. She says her mother is a nurse and agrees with her. There are eight more patients waiting for you before lunch. You were on call last night and, as it is winter, took 18 calls about sick kids and slept for three hours on the living room sofa in order not to wake your family. See where I’m going with this? This scenario pretty much hits all the doctor’s buttons. In this setting, interest in collaboration is hard to sustain.

Some of the challenges to collaborative medicine are external as well, the threat of litigation featuring prominently among them. If the doctor has to accept complete medical responsibility for outcome and practice standards, why should he/she allow you or me to “dictate” which labs they should order or which medications they prescribe? Such collaboration would be of lopsided advantage if only the doctor was held responsible for decisions the family was also making.

And yet, only a young and inexperienced pediatrician refuses to listen to mothers and “blows off” their concerns. If you do this routinely, you will miss something. Such as a brain tumor.

Back to the mother who wants me to reassure her that her son does not have a brain tumor as the origin of his headaches. She declined the offer of a CT scan suggested by the emergency room physician they saw last week. “Too much radiation,” she told him. “Can’t we just get an MRI?” she asks me.

I find myself caught between rational objections to the MRI and objections based on annoyance that she is “telling me what to do,” “doesn’t trust my judgment,” and is “operating out of her depth.” She is a school teacher, darn it, not a scientist.

But you know, she is right about the CT scan. They do include “too much radiation” and it’s about time we (doctors) realized and acted on this knowledge. But another piece of residency training kicks in to cloud my judgment: in residency, there is a certain “cool” way for doctors to behave. That way is to never be caught “over-reacting” to a patient’s complaints.

Over-treating, over-diagnosing and ordering too many labs and tests is the ultimate un-cool way for young doctors to act. The joke during residency is that while running a code (someone’s heart has stopped and you must intervene to save them), you should check your own pulse: the “coolest” intern is the one whose own heart rate has not gone up. Doctors don’t respect other doctors who overreact.

And then there’s the insurance. This mother has state sponsored insurance, which we are taught, “we all pay for.” So am I being profligate by ordering an MRI (thousands of dollars) for a headache that is very unlikely to be a brain tumor?  By acquiescing to her request despite my own “better judgment”, am I part of what is driving health care costs up?

In the old-fashioned days (as my granddaughter calls them), the doctor would be able to soothe a worried mother with his voice, setting her mind at ease with his superior knowledge and experience. Mother would have been primed by a paternalistic society to accept his counsel and not to appear to question it. She would not dream of demanding a collaborative decision.

But those days are well and truly gone. And we are left with an opportunity to put aside our resentment at being challenged and carve a new medicine where we are “all in it together,” even as we play different roles and have differing backgrounds in the science.

Help me understand that we are all in it together.

Help me understand that patients come to me for my best advice and counsel, but are not obligated to accept it.

Help me understand that they are not diminished by going their own way.

Help me understand that wisdom comes in many guises.

Help me overcome my own training, even as I must reference it.

That would be my prayer for the future of collaborative medicine.