Barriers to bedside relationships: training and modern day medicine

Issue: August 2006

ByRoderick H. Tung, MD

We all start out our medical careers with hopeful, naive, and fresh perspectives, but inevitably we all lose some of our innocence and humanistic idealism along the long training route.

One of the major reasons that I chose a career in medicine is for the unique interpersonal relationships, trust, and longitudinal care that are inherent to doctoring. Unfortunately, as I have progressed in medical education, I find myself quite different from the bright-eyed third year medical student that wished to “befriend” every patient I encountered. Don’t get me wrong, the most rewarding moments as a physician to me are still the ones in which a deep personal connection exists; I just feel that they are few and farther between in the latter stages of my training. Why is this the case?

Training days

Roderick H. Tung, MD [photo]
Roderick Tung

Exhaustion through hunger and extreme sleep deprivation have long been used as methods of torture in times of war. In the same vein, going through long and busy call nights without time to eat or sleep and taking a full 24 hours to recover the following day leaves little time to “enjoy life” as a human in a 48-hour period. My experience has always been that the day following the post-call day is when I feel most fatigued, which basically meant that almost half the week was devoted to the call experience, including the aftermath. There is no doubt that better interactions with health care professionals (ie, nursing staff and especially patients) result from a well-rested, peaceful mind and body. Over time, as many are subspecializing, the duration of training is increasing and inherent to that is further wear-and-tear on the psyche.

Furthermore, in rigorous training programs, there is always a supply-demand mismatch in patient care. Clinical volume should be high to ensure diverse exposure to the full spectrum of disease entities, but can be overwhelming as time is limited. I can distinctly remember during residency how morale would take a downward slide for the entire team when we had to finish rounds at the expense of missing the food at noon conference. The time pressure imposed on physicians in the clinic setting, in which only 15 minutes are allotted for a follow-up visit, also forces us to be “short” with our patients. As a medical student, I was assigned to only one or two patients at a time, affording me the opportunity to form personal connections by making multiple visits throughout the day. As a resident, I quickly became responsible for the “big-picture” issues for 20 to 30 patients and simply didn’t have the time. As a fellow, the clinical volume is less than during my residency and I have enjoyed having fewer time constraints.

Lastly, the lack of continuity for any given patient in a training program is a barrier toward developing fulfilling and long-lasting relationships. It feels gratifying when a patient remembers you and your name and exactly what you did for them. Too often, patients in teaching hospitals remark that they have seen so many doctors that they just can’t keep them straight, which can be dehumanizing for both patients and doctors-in-training.

Specializing: organ caregiver

In modern day medicine, there is a strong trend toward subspecialization. As a subspecialist, there is an inherent tendency to limit one’s focus to a specific disease entity, rather than caring for the entire patient. As an electrophysiologist, the clinical scenario often reduces a patient to merely a delta wave and short PR from a left lateral accessory pathway. I often hear patients say about their cardiologist, “He doesn’t care about that, he’s a heart guy,” when referring to their extracardiac symptoms. It is rare for a subspecialist to have as strong of a relationship with a patient as their primary care physician. I miss the expectations from patients in which I am there to take care of them rather than a body part.

Technology

Technology has destroyed the old-fashioned bedside relationship between doctor and patient. Gone are the days when a clinician can spend an hour at the bedside learning about a patient in hopes of making a diagnosis through a thorough history and physical. We no longer spend time at the bedside debating if a triple ripple at the apex is felt waiting for post-PVC accentuation of a murmur, when the diagnosis of hypertrophic obstructive cardiomyopathy is easily apparent on an echocardiogram performed by a technician. With the popularization of electronic medical record keeping, one can know almost everything clinically necessary about a patient before even seeing him or her, with the exception of a physical exam, which is being replaced by imaging modalities. In our hospital, we can see live waveforms including real-time vitals, arterial line tracings, and telemetry on all patients in the ICU from any computer. These technologies, although improving the availability and tracking of data, are enabling us to spend less and less time at the bedside getting to know our patients.

At the end of the day, we should reexamine why we chose our profession and reflect on how our individual attitudes have changed during the training process. In doing so, I realized that many of the barriers to optimizing doctor-patient relationships are unique to medical training — and I look forward to the return to humanism after completion of fellowship.

Roderick H. Tung, MD, is a fellow at Cedars-Sinai and is a member of Cardiology Today’s Fellows Advisory Board.