"An ounce of humility is worth more than a ton of arrogance." -- Jack Coulehan, M.D.
I am a physician, and I don't think I am more arrogant than non-physicians. While patients and media frequently accuse us of behaving arrogantly or poorly, I'm not sure these are fair generalizations. In addition to my long career in medicine, my family and I just spent four months intimately involved with physicians and the health care system. Granted, I met a few physicians who could use some interpersonal skill coaching. But, for the most part, they were caring, "normal" people. I am not convinced that, as a group, physicians are any more arrogant than lawyers, business men and women, politicians or university professors.
So, why the bad rap? A recent Gallup poll found that people still routinely rank physicians amongst the top three most respected professions. If this is the case, what is it about the health care system and the experience with a physician that brings out negative feelings?
Just to be clear, I fully expect many of you to disagree with me and I welcome your comments.
The Doctor-Patient Relationship
You have just arrived in the emergency room with crushing chest pain and now find yourself flanked by an emergency room doctor and a cardiologist, neither of whom you have met before. What qualities would you like to believe that they possess? Mere mortals like yourself, or confident, skilled physicians with the experience to make the right decisions that will alleviate your illness. Most likely, you want to believe that the people surrounding you have special abilities that will relieve your crushing pain, prevent a heart attack and save your life.
In 1980, Dr. Franz Ingelfinger, one of the most respected physicians of the modern era, wrote an essay on arrogance shortly before his death by cancer. He believed that the patient must see their physician as a benevolent authoritarian figure with the experience and competence to recommend advice they will accept. "I want to believe that my physician is acting under higher moral principles and intellectual powers than a used-car dealer," he said.
Now, before you get all red in the face and upset, stick with me just a little longer. I recently went through the ups and downs of the health care system with my wife, who was critically ill. We were dealing with numerous variables and options. Although I am a physician who understands all the fancy words and jargon, I still wanted someone who I felt would make the best decisions. We all purportedly desire to actively participate in our care, but I don't think this means that we want a physician who will serve us a cafeteria line of options and tell us to take our pick. Of course I want to hear the options, but then I want my physician to recommend the course of action that he or she thinks will prove most effective. It is not arrogance -- it is confidence. Dr. Ingelfinger called this sort of interaction "beneficially arrogant." He contrasts this with "destructively arrogant," which he defines as an attitude that lacks empathy and reeks of insolence and vanity. While some physicians may still behave poorly, I believe that physicians are no more vain or insolent than any other group of people.
This does not discount many of the complaints of arrogance, nor does it imply that there is no room for improvement. The current health care system depersonalizes the doctor-patient relationship and "created a kind of 'system arrogance' in which the patient is seen not as a person but merely as a job to be done cost effectively." Getting to know a patient on a personal level today may prove just as difficult as containing medical costs. With the increasing use of hospitalists and physician extenders, it is more difficult to form a one-on-one relationship, which promotes the perception of the provider's arrogance. Thirty years ago, Dr. Ingelfinger wrote, "Efficient medical practice, I fear, may not be empathic medical practice, and it fosters, if not arrogance, at least the appearance of arrogance."
Is it Confidence or Arrogance?
The physician's knowledge of the body and ailments places them in a potential position of dominance. Once a physician recognizes this, he or she may become arrogant. That arrogance may manifest itself as:
- A failure to listen to a patient's and family's problems
- A lack of respect and good manners towards staff and patients
- Abusive or critical comments
- Boastfulness and exaggeration of one's abilities
- An unwillingness to be questioned
- Blaming others for mistakes or omissions made by the physician
I think we have all recognized these negative traits in some physicians. Where do they come from? Is the behavior hard wired or is it learned from the wrong type of role models during training?
In his article "On Humility," Dr. John Coulehan states that, "Today, I suspect that few students regard character formation as part of their medical education at all and even fewer consider humility an ingredient." There is no question that the 10 or more years of training can wring the compassion out of students and residents.
Role models are critical to maintain a healthy attitude during training, and I was fortunate to have two spectacular role models early in my medical education. Reflecting back on my long career, I don't think I ever met an arrogant pediatrician. However, some specialties are another story. Although medical schools are placing greater emphasis on teaching empathy, I like Dr. Ingelfinger's process for screening applicants -- "That only those who have been hospitalized during their adolescence or adult years be admitted to medical school. Such a practice would not only increase the number of empathic doctors; it would also permit the whole elaborate system of medical school admissions to be jettisoned."
Of course, should that system fail, we could fall back on my long-held belief that every medical and nursing student should be forcibly constipated for three days. They would immediately develop compassion and empathy for the patient who refuses to go to therapy until their problem is relieved.
A Little Humility, Please!
Perhaps I am wrong. I guess I do know more than a few arrogant physicians. Medical culture can encourage assertive behavior, arrogance and a sense of entitlement. Edmund Pellegrino, in his chapter on human dignity, pointed out that "indifference, ineptitude and arrogance are transmissible." These are learned behaviors during the long period of training that we can pass onto other members of the health care team. We must speak up whenever we witness arrogance in medicine and other aspects of our life. Why do we pay any attention to people who behave like Donald Trump? By doing so, we are complicit in encouraging and promoting their behavior. At the start of this new year we should try on a little bit of humility.
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