By the fourth sentence of the preface to The Silent World of Doctor and Patient, Jay Katz has quietly issued a startling challenge to a fundamental principle of the doctor-patient relationship. He writes:--Michael Millenson at the Health Affairs Blog. Times obituary of Jay Katz here.
It took time before I appreciated fully the oddity of physicians’ insistence that patients follow doctors’ orders. During my socialization as a physician I had been taught to accept the idea of doctors’ Aesculapian authority over patients. When I began to doubt this authority, that was the moment when the book began to take shape in my mind.
“The oddity of physicians’ insistence that patients follow doctors’ orders” – the phrase brings you to an abrupt halt. Jay Katz, who wrote those words in his landmark book published nearly a quarter of a century ago, died in late November at the age of 86.
But I can't help myself. Why is Yiddish a "venerable tongue" in the headline? Surely the language is no older than English? And why is it called "the 1,000-year-old amalgam of Hebrew, German and assorted European dialects that was once the lingua franca of Europe’s Jews"?
Amalgam? (You mean, perhaps "language"?) Assorted European dialects? (Maybe "languages"?) Lingua franca? (Rather, "first language"?)
It's almost as if the reporter knew nothing about the topic she was writing on!
"Iz er a yid?" (Is he Jewish?)
"Avade iz er a yid." (Of course he's Jewish.)
What was next said, as I first heard it:
"Er kikt oys vi a narisher." (He looks like an idiot.)
I said "Vos?" (What?)
"Ir kikt oys vi an arisher." (You look like an Aryan[?].)
"Vi an arisher!"
Oh! I get it. Like an "ayrisher" ("Irisher" in non-"YIVO" Yiddish, Irlender in standard Yiddish), in the speaker's pronunciation - "arisher."
Thus was I saved from getting in a fight with two older men on the Lower East Side (probably avoiding a beating in the process).
Ultimately, because of vast historical and social forces, physicians by and large remain oriented towards an unattainable and inappropriate positivist ideal, and thereby severely compromise the deeper values of their own moral agenda. This choice—encouraged by the professionalization process—largely explains why medical ethics serves such a minor role in medical education; why complaints of medicine’s dehumanization are rampant; and why myriad studies, surveys, and testimonies attest to the lack of physician empathy. Indeed, if medicine aspires to an objective ideal at the expense of its unique value-laden agenda, the profession will be hounded by complaints that it has forsaken its ancient calling for a Faustian pact.--Alfred I. Tauber, Medicine and the Call for a Moral Epistemology, Part II: Constructing a Synthesis of Values. Perspectives in Biology & Medicine Summer 2008; 51(3).
A self-conscious moral epistemology—an epistemology that remains aware of its ongoing negotiation of competing values and construction of its interpretative knowledge—provides a philosophy of medicine for the doctor’s diverse roles and activities. On this view, a philosophy for medicine must acknowledge the multidimensional character of medical thinking that utilizes values spanning the ideals of laboratory science to the empathetic response of humane care. But more, this philosophy must recognize a fundamental difference between the scientist’s search for the real and the physician’s pursuit of the therapeutic.
Medicine requires more than “true” outcomes (as in scientific truth-seeking); physicians embrace “best” results for the care of their patients. While seeking the “true,” patients and their caregivers are often satisfied with something else (for example, the effective intervention may be a sham treatment or a placebo). “Truth” directs clinical science, and clinical science directs itself to good outcomes, but in the hierarchy of medicine’s philosophy, it is ethics of care that directs the physician’s science and ultimately determines clinical choices.
Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it's nap time.Solomont doesn't know that surgeons often must hand off care during a long procedure (colectomies can last forever)?
The Royal College of Surgeons (one of the organizations named by Solomont as opposing stricter work-hour regulations) provides a summary of their recommendations regarding training modifications. After a thorough review of work patterns in the context of impending regulations (or after they had already been instituted; it's not clear to me), the following findings became (magically?) apparent:
- a significant reduction in the need for acute surgical intervention (except for life- or limb-threatening conditions) between 22.00 and 08.00
- the majority of work undertaken by surgical staff during this period relates to the management of medical co-morbidities
The report also mentions a number of possible solutions. Leaving off for a snooze during the middle of a heart bypass is not mentioned, but scheduling innovations are.
Surgery and medicine training programs are naturally going to squawk at work hour regulations, and it's a tradeoff between continuity of care and well-rested residents. But it's also a myth that every hour of time spent at the hospital means another hour spent in quality medical education. Hiring physician extenders doesn't mean depriving housestaff of the opportunity to see interesting patients and learn necessary procedures. Often just the opposite is the case.
Speaking of naps, many sleepless surgeons have already taken a few - but in the OR, browning out over the field, not at home. Which would Solomont prefer?
Greed vs. Greens, or In Which Righteous Quasitarian Anger is Cooled by Spicy-Hot Chili Sauce on Falafel
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A pity that Google Maps' streetview is not festooned with the For Rent banners I saw today on the building at 34 Union Square East. I didn't take a photo, since I was stunned simultaneously with grief, schadenfreude, schaden-anger [Schadenzorn?], and...
...the happy thought that Maoz Vegetarian is just down the block.
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Yummy, and much cheaper than Zen Palate Usq ever was. Maybe I'm not so mad after all.
Define quality for me. Then show me a system in which there won't be as many winners as losers--how else do you save 30%? Then I will show you a real health care policy debate and we will see how much consensus we have.Wellness? Wellness programs today look an awful lot like the voluntary education oriented wellness programs we were selling in 1988 and things are far worse. Prevention? Most of the commonsense steps in prevention were available to us years ago.We have been avoiding the heavy lifting in health care reform for 16 years. For me, all of these new ideas aren't so much new ideas as one more "Ground Hog day" in the long-running health care debate.