The culture of American medicine is a culture of contradictions.
On the one hand, healthcare professionals are culturally predisposed to put the lives of patients before their own, especially in times of crisis, as we have seen throughout the Covid-19 pandemic. The qualities of bravery and altruism are part of the physician’s value system, a system that is firmly anchored in the culture of medicine.
On the flip side, the same cultural principles that turn doctors into heroes can also take victims into patients.
To better understand this strange paradox, consider how physicians use language to express their common values while hiding or ignoring the true meaning of their words.
The mysterious language of doctors
When looking for my new book “Carefree: How the culture of medicine is killing doctors and patients, “I have asked thousands of physicians to shed light on the secrets of medical culture, including the language, symbols and codes that physicians use to communicate with each other and relate to the world around them.
Particularly powerful insight came from a former colleague, who sent me this memory early in his career. Here he describes the process of ‘logging out’, when one resident’s shift ends and another begins:
As a rule, there were outings in the evening to inform residents or interns about the night watch of our patients. Often added to the medical information was “a good person with serious illness” or something similar. I have always found it interesting, because [if] one can be a “bad person with a good disease” or a “bad person with a bad disease” or a “good person with a good disease”.
I knew exactly what he was talking about. As a surgeon, I had heard this expression dozens of times. Although doctors always pronounce it with good intentions, it has an unspoken meaning that has dangerous consequences for patients.
Who is a “good person with a bad disease”?
I will never forget a gunshot victim I treated during my surgical residency – a young man with a gaping hole in his chest.
As we ran from the ER to the operating room, my colleague kept constant pressure on the patient’s chest to prevent exsanguination (bleeding). Under the white glow of the operating room lights, I gathered the clamps, suction, and sutures needed to control the geyser of blood that would erupt as soon as my colleague removed his hand from the wound. A nurse stood with a pair of scissors and, three in number, removed the patient’s t-shirt with a skillful slice of the fabric. There on the patient’s chest, under the blood, was a horrific sight: a large swastika tattoo with hate words that I will not repeat.
At times like this, doctors remember that all patients deserve good care. Even him. That day, we did our job and saved his life.
When logging out that evening, my co-residents and I did not call the man a “bad person.” But we didn’t call him “a good person” either.
This label, “a good person with serious illness”, is reserved for patients who doctors say deserve the most sympathy and special attention. It’s a term used to describe a mother of two young boys who just found out she has terminal breast cancer. It’s a term of tenderness for the charming old prankster down the hall who dies of lung disease. It is intended for the adolescent with an aggressive bone tumor and an early interest in medicine.
They are all “good patients”. Their charming dispositions and tragic circumstances make doctors want to help in any way they can. For these patients, well-meaning physicians implore their colleagues to devote an extra 15 minutes to comfort them, alleviate their suffering, and demonstrate the kind of compassion that represents the highest virtues of medical culture. I have never seen a doctor refuse such a request.
However, these good intentions and acts of benevolence cover up an ugly and unspoken truth in American health care. Because there is never enough time in a physician’s day, the extra attention given to “good patients” is attention to “other” patients.
Who are the “other” patients?
As my former colleague pointed out in his email to me, there are no objective or exact criteria for determining which patients to qualify as “good”. Doctors are human, and like all humans, they are more attracted to some people than others.
But how do they choose? There is a large body of research showing that the people we love the most tend to be the people who are most like us (“birds of a feather” as they say).
Brett Pelham, professor of psychology at Montgomery College in Maryland, calls it “implicit selfishness.” On the popular podcast Hidden brain, Pelham explains, “We tend to focus on people who are more like us, who speak our language, who speak our idiom, who look like us, who worship like us. And we pay much less attention, unfortunately, to the issues of people who don’t.
Put differently, when a doctor expresses empathy and “feels the pain” of a particular patient, that person is very likely to look like a friend, family member, or someone who does. already part of the very united network of this doctor.
And in American medicine – a profession historically and still predominantly made up of Anglo-Saxon white men – physicians often fail to understand the suffering of those who look or speak differently from them. These individuals are the “others”.
Despite good intentions, white doctors literally don’t feel the pain of their black or Spanish-speaking patients, at least not as intensely as the suffering of patients who share the same skin color, language, and life experiences.
The impact of physician bias
Out of the more than 10,000 physicians I have known as colleagues, I have not met any who I would describe as openly hateful or prejudiced. This is because the culture of medicine frowns on physicians who consciously discriminate against patients. This would constitute a flagrant violation of the fundamental principle of the profession: Primum non nocere, or “first, do no harm”.
Any doctor found guilty of intentionally harming a patient would be looked down upon by his colleagues and probably punished. But, of course, doctors don’t see themselves as being overtly or implicitly biased. Most doctors would vehemently reject the idea that they discriminate against certain patients. But they do.
Last month, President Biden named the week of April 11 in honor of Black Maternity Health. He did this by acknowledging that black mothers die three times more than white women.
Many of these deaths occur after childbirth due to unrecognized bleeding and untreated high blood pressure. Doctors and policy experts attribute these tragic consequences to black women to differences in health insurance coverage, socio-economics, and other environmental factors such as diet and education level. These factors exist but do not explain why the difference in mortality between black and white patients disappears when the attending physician is black.
No one has quantified the amount of postpartum attention given to women of different races and ethnicities, but it makes sense to expect “good patients” to receive more attention than those who are omitted. of this club.
How the language of medicine protects the doctor’s ego
The truth is, this familiar phrase about “good” people makes doctors feel virtuous. They go home at night feeling good about themselves for showing sympathy and kindness.
They never consider the likelihood that the “good” patients will be unconsciously selected for special treatment because of their skin color, ethnic background, or position in society. They never want people to get substandard care, but it does.
The expression “a good patient with a bad disease” can sometimes express empathy. But too often it turns out to be biased, racist and harmful.
In medicine, ambiguous language helps resolve the conflict between what doctors say they do and what they actually do. The words they use and the culture they foster protect them from feelings of shame or embarrassment. They never wonder if they have fulfilled their “do no harm” oath. But damage has been done. Medical culture is the anesthetic that masks the harm inflicted.
The culture of medicine is not taught in a classroom or in textbooks. He is experienced in medical school and absorbed during residency training. After a decade of watching senior physicians and listening to their stories, young physicians are adopting the same standards and role models when interacting with patients and colleagues.
Over time, all physicians have mastered the language of medicine – both life-saving terms and life-threatening code phrases.