The public voice of doctors

One of the selfish reasons I love being a physician is the honor of being included in such a respectable group. Doctors are good people, smart people, dedicated people. These are my colleagues, my mates, my fraternity.

This attachment to the honor of doctoring is why it pains me when we hurt ourselves with our words. When the public voice of doctors lacks grace or empathy or even a modicum of self-awareness, the profession, the group as a whole, is diminished. The digital age cuts both ways. On the one hand, its democracy gives regular doctors a voice, but on the other, it amplifies and makes permanent our missteps.

A recent op-ed in the Wall Street Journal stirred me to think about the responsibility physicians incur when they reach out publicly. Dr. Daniel F. Craviotto Jr is an orthopedic surgeon who submitted an essay to the editors of the WSJ. His Declaration of Independence piece, which urged doctors to defy health-care mandates issued by bureaucrats not in the healing profession, addressed many of the challenges in US healthcare delivery. Craviotto brought attention to intrusions to the patient-doctor relationship, the awfulness that is modern-day electronic health records, and declining reimbursement for doctors. All important issues for sure.

Yet, his essay, or perhaps one could call it a sophisticated rant, served to diminish the dignity of his colleagues, his fraternity, his team. Let me explain. It will take a few paragraphs.

Malcolm Gladwell recently advised doctors to tell their stories. In a Forbes interview, he said doctors should “help people understand what it is really like to be a physician.” The thesis is that health reform might improve if both the public, and reformers, understood the perspective of real doctors. Gladwell’s command of the obvious is striking. “You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”

I agree with this idea. It’s one of the reasons I write about doctoring, and health policy, and it’s why I advocate that other doctors do the same. I’m no negotiator or problem-solver but it’s clear that seeing problems from others’ perspectives improves the odds for conflict resolution.

Consider, for instance, the specific conflict we are in with US healthcare. Here, I’d argue that the dearth of real-world physician voices has impeded progress. I regret waiting so long to engage in the conversation. I suffered from the bystander effect–my colleagues will keep up the advocacy; I’ll just keep ablating arrhythmia. I was too interested in doctor-specific outcomes, which is, in fact, part of the problem with healthcare delivery. (But that’s another topic.)

The thing about being a doctor and joining the public conversation is that it’s serious. Three sobering facts are true when a doctor reaches out publicly: 1) He or she represents the dignity of the profession, 2) People will listen, and 3) People will form intuitive perceptions. And you know the rule about perceptions.

Since we are talking about doctors and their public voice, it seems a good place to review word definitions. One of the definitions of grace is courteous goodwill. Tone is the general character or attitude of a piece of writing. Self-awareness is a noun for conscious knowledge of one’s own character, feelings, motives, and desires.

One of the things I’m most squeamish about is looking back at my early writings. (The truth is I’ve taken down a few of my previous posts, and I’ve edited others.) Why? The answer is that some of my words were tone-deaf, hyperbolic, and, when read from the perspective of others, devoid of self-awareness. A couple of hard lessons I have learned about self-awareness: I write often about health and the value of exercise. Readers quickly pointed to my luck in being gifted healthy lungs, legs and mitochondria. Endurance sports come naturally to me. I’ve taken that for granted. Another example comes when I’ve expressed opinion on declining reimbursement for what I see as valuable clinical skills. Again, readers taught me to consider doctors’ pay in relative terms. Simply said, we are compensated well, not only in dollars, but in self-esteem and public respect. It’s easy to forget that most sub-specialists are paid more in salary than the president of the United States.

Some might quarrel with where I’m going with this. “Hey, Mandrola, you have said that a doctor’s public voice should be candid and real and honest. Then you get sideways about an orthopedic surgeon who does just that in the pages of the Wall Street Journal.”

Perhaps I’m naive but I don’t think candor and honesty are opposing forces of grace and self-awareness. It’s just harder to write that way. Yet if we want to move health care in the right direction while maintaining the dignity of our profession, doctors who engage in the public conversation must be mindful to do both.

We won’t be perfect. We never are. But surely we must think hard about our words before hitting the send or publish button. I think my grandmother taught me that a long time ago.

JMM

Indiana University pediatrician and uber-explainer Dr. Aaron Carroll details the many flaws in Dr. Craviotto’s Declaration of Independence.

Update: Shortly after I published this post, my colleague in medicine and social media, Dr. Jordan Grumet, wrote this opposing view, Why I don’t agree with @aaroncarroll. Dr. G dissents, but in doing so with grace and self-awareness, he emphasizes my point.

Comments

  1. says

    Thanks for this post John. Unfortunately the article in the WSJ is simply either a prolonged venting session – or a rant – depending on your viewpoint.

    It is repeated examples of blame, justify and complain and 100% maintenance of victim mode on the behalf of Dr. Craviotto. Then he mistakes magical thinking for a “Declaration of Independence.”

    It is a poorly written article with flawed logic that does not propose a real solution.

    I suggest we not get too excited about it – or wish for a more enlightened physician voice on the internet or feel that this taints the opinion of all doctors.

    I think most people can see this as simple frustration from someone who would quit … if their actions were consistent with their words. I think he should walk away and take back his independence.

    Your thoughts?

    Dike
    Dike Drummond MD
    http://www.TheHappyMD.com

    • says

      Thanks Dike. I have two thoughts:

      1) Your comment about the WSJ essay being poorly-written with flawed logic makes me wonder about newspaper editors. I can’t help but put myself in the meeting room at a newspaper when these letters/essays from doctors are discussed. What is said, or thought, at these gatherings of people who well understand the written word? Based on what (many) newspapers publish from doctors, one could surmise that editors don’t have the best interest of our profession in mind. Our local paper publishes awful stuff from doctors–misspelling, grammar mistakes, and outlandish views, words, which clearly do not represent the mainstream of our profession. Yet this stuff gets in the paper–in this case, the WSJ no less.

      2) Since you are the Happy-MD, the other thing that pops into my head is the notion of contentment and managing gracefully. I don’t write much about the value of buying small cars, living in modest houses, and embracing the many beautiful victories in medicine, because it comes off as paternalistic and self-righteous. I keep Sylvia Boorstein’s It’s Easier than You Think, by my desk–I read it often. I talk to myself most mornings on the way to work–“Manage gracefully today, John.” I fail at this a lot, but it’s a work in progress.

  2. says

    Working as both a software engineer in the nuclear field and a 911 paramedic, I enjoy hearing about the “regulatory struggles” the healthcare profession has.

    If we had the lackadaisical oversight found in the healthcare side of the house, my goodness would things be different in the nuclear industry. However, we’re considered safety related. Very safety related. People worry about what could go wrong, and rightfully demand that we hold ourselves to a very high standard. The crazy thing is, the nuclear industry is extremely unlikely to harm or kill you. In comparison, your healthcare practitioner is quite likely to kill you.

    To hear a physician lament that he’s just now moving to electronic records and that he’s just now having to deal with “onerous” oversight seems quaint. I was fairly surprised to find he was only 58 years old. Usually folks crowing about electronic medical records are much older. He at least had access to computers when he was in college (they were much larger then).

    Welcome to the real world Dr. Craviotto Jr, where you’re expected to keep up with the times and when in a position to have an impact on the health and safety of humans you will enjoy some regulatory oversight.

    Could these be done better? Always.

    Did these all of a sudden become problems? No.

    • says

      Thanks Christopher, I’m reading Kahneman’s Thinking, Fast and slow, and he is teaching me about how we think about risk and benefit. Clearly, the nuclear field takes a unique view of regulatory safety, and perhaps this is why, statistically speaking, humans face more danger from their doctors than they do nuclear power. I often tell patients that arrhythmia gets most dangerous when doctors get involved. I don’t mean this as a knock against doctors. Instead, what I aim for is to get all involved to consider the harms from things, be they nuclear power, or anti-arrhythmic procedures, as an anchoring point.

  3. Steve Bornfeld says

    I agree–Dr. Craviotto’s essay was tone deaf (and I agree as well with Dr. Carroll’s assessment).
    But more, I’m not sure what Craviotto is angling for.
    Having no first-hand experience as a physician, I’m not sure I understand this “circle the wagons” mentality. Even if it is understandable, that does not make it justifiable. I know I can’t read the comments on “KevinMD” anymore–not good for my blood pressure.

    • says

      Thanks SB. I, too, have noticed the degradation of comments–not just on Kevin’s site but on many web portals. I’m worried about it. Our family watched an hour-long conversation with Alain De Botton last night. Of the many issues he discussed, the one that struck me most was how tenuous the glue is that binds humans together. He asked us to think what any of us would be capable of if life’s comforts were removed.

      As for my comments here, I’ve been lucky; most who comment do so without vitriol. That said, I had to begin moderating all comments because of a couple of outliers.

  4. John C. Key MD says

    I enjoy your writings, both clinical and medico-economic and have followed you ever since I found out of your writing existence.

    The role of the polemicist can be important and I believe Dr. Craviotto’s piece in the WSJ fulfilled this role. To be sure, I wouldn’t have expressed it his way myself, nor would you or obviously Dr. Carroll. I don’t think that
    Craviotto in any way “diminished” his colleagues by what he wrote, nor, I think, did you succeed at all in explaining why his remarks were wrong. Liberal lions like Harry Reid, Patrick Leahy and Ted Kennedy have been praised and supported by their colleagues for “being willing to say outlandish things that gets the party’s point across” and allow others to he wallflowers. Why not acknowledge the value of our orthopedic colleague’s polemical contribution?

    Organized Medicine has los every battle it has fought since the 1960’s. Let’s not be hasty to condemn a physician who had the courage to “grow a pair” and explain the prevailing conditions on the ground from a doc’s standpoint.

    Again, thanks for your writings and I will remain a regular reader,

    John C. Key MD
    Retired General Surgeon and current Direct Pay General Practitioner
    Kerrville, Texas

    • says

      Thank you Doctor Key, for the kind and supportive words, but also for making me think about an angle I had not considered previously. Dr Howard Luks Tweeted yesterday that an orthopedist was the pot-stirrer. You call him a polemicist. Okay. That’s a good point. But then, even though you somewhat disagree with me — Craviotto did not diminish his profession — you made your points with honesty and candor AND grace and self-awareness. This is what I mean. As for having the courage to say outlandish things, I’m not sure doctors would garner the public respect they do if they behaved like outspoken politicians. Our public respect, the self-esteem it brings–this is a sort of compensation, isn’t it? You are Doctor Key. I am Doctor Mandrola. This still counts for something, I think?

  5. Jay Schloss says

    Wonderful dialogue here free of all extremism and rhetoric. What can we do to get all you folks to Washington for an audience with the Powers-that-be?

    You’d never know it from watching mainstream media, but folks with disagreements can find middle ground.