Do I Want A Philosopher As My Surgeon?

I recently stumbled upon an article describing upcoming changes to the Medical College Admissions Test.  Also known as the MCAT, this is the exam that strikes fear into the hearts of pre-med students nationwide, due to its rigorous assessment of all the hard sciences that we despised in college.  The MCAT can make or break someone’s application to a prestigious medical school, and in a very real way, it can be the deciding factor as to whether someone even becomes a doctor at all.

According to the article, the AAMC—the organization which administers the MCAT—will “stop focusing solely on biology, physics, statistics, and chemistry, and also will begin asking questions on psychology, ethics, cultural studies, and philosophy.”  The article goes on to say that questions will ask about such topics as “behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”

Response has been understandably mixed.  On at least two online physician discussion groups, doctors are denouncing the change.  Medicine is based in science, they argue, and the proposed changes simply encourage mediocrity and “beat the drum for socialized medicine.”  Others express frustration that this shift rewards not those who can practice good medicine, but rather those who can increase “patient satisfaction” scores.  Still others believe the new MCAT is just a way to recruit a new generation of liberal-minded, government-employed docs (or, excuse me, “providers”) just in time for the roll-out of Obamacare.

I must admit that I can understand the resistance from the older generation of physicians.  In the interest of full disclosure, I was trained under the traditional medical model.  I learned anatomy, biochemistry, pathology, microbiology, etc., independently, and then had to synthesize the material myself, rather than through the “problem-based learning” format of today’s medical schools.  I also have an advanced degree in neuroscience, so I’m inclined to think mechanistically, to be critical of experimental designs, and always to search for alternate explanations of what I observe.

In spite of my own training, however, I think I might actually support the new MCAT format.  Medicine is different today.  Driven by factors that are beyond the control of the average physician, diagnostic tools are becoming more automated and treatment protocols more streamlined, even incorporated into our EMRs.  In today’s medicine, the doctor is no longer an independent, objective authority, but rather someone hired to follow a set of rules or guidelines.  We’re rapidly losing sight of (1) who the patient is, (2) what the patient wants, and (3) what unique skills we can provide to that patient.

Some examples:  The scientifically minded physician sees the middle-aged obese male with diabetes and hypertension as a guy with three separate diseases, each requiring its own treatment, often driven by guidelines that result in disorganized, fractured care.  He sees the 90 year-old woman with kidney failure, brittle osteoporosis, and congestive heart failure as a candidate for nephrology, orthopedics, and cardiology consults, exacerbating cost and the likelihood of iatrogenic injury.  In reality, the best care might come from, in the first example, a family doc with an emphasis on lifestyle change, and in the second example, a geriatrician who understands the woman’s resources, needs, and support system.

Psychiatry presents its own unique challenges.  Personally, I believe we psychiatrists have been overzealous in our redefinition of the wide range of abnormal human behaviors as “illnesses” requiring treatment.  It would be refreshing to have an economist work in a community mental health clinic, helping to redirect scarce resources away from expensive antipsychotics or wasteful “disability” programs and towards job-training or housing services instead.  Maybe a sociologist would be less likely to see an HMO patient as “depressed” and needing meds, but enduring complicated relationship problems amenable to therapy and to a reassessment of what she aspires to achieve in her life.

This may sound “touchy-feely” to some.  Trust me, ten years ago—at the peak of my enthusiasm for biological psychiatry—I would have said the same thing, and not in a kind way.  But I’ve since learned that psychiatry is touchy-feely.  And in their own unique ways, all specialties of medicine require a sophisticated understanding of human behavior, psychology, and the socioeconomic realities of the world in which we live and practice.  What medicine truly needs is that rare combination of someone who can not only describe Friedel-Crafts alkylation and define Hardy Weinberg equilibrium, but who can also understand human learning and motivation or describe—even in a very rough way—what the heck “Obamacare” is all about anyway.

If I needed cardiac bypass surgery, would I want a philosophy major as my surgeon?  I honestly don’t care, as long as he or she has the requisite technical skill to put me under the knife.  But perhaps a philosopher would be just as well—or better—prepared to judge whether I needed the operation in the first place, how to evaluate my other options (if any), and—if I undergo the surgery—how to change my behavior so that I won’t need another one.  Better yet, maybe that philosopher would also want to change conditions so that fewer people suffer from coronary artery disease, or to determine a more equitable way to ensure that anyone who needs such a procedure can get it.

If we doctors continue to see ourselves as scientists first and foremost, we’ll be ordering tests and prescribing meds until we’re bankrupt.  At the other extreme, if we’re too people-friendly, patients will certainly like us, but we may have no impact on their long-term health.  Maybe the new MCAT is a way to encourage docs to bridge this gap, to make decisions based on everything that matters, even those factors that today’s medicine tends to ignore.  It’s not clear whether this will succeed, but it’s worth a try.

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19 Responses to Do I Want A Philosopher As My Surgeon?

  1. Hawkeye says:

    “The scientifically minded physician sees the middle-aged obese male with diabetes and hypertension as a guy with three separate diseases, each requiring its own treatment, often driven by guidelines that result in disorganized, fractured care.”

    With respect, what you are saying here is dangerous trash. Scientifically trained people integrate treatment as a matter of course, and see disparate symptoms as manifestation of common phenomena.

    I am a mathematics professor at the University of Iowa and no one has ever trained me to “teach the whole student.” I do that as a matter of course. I am well aware that my 18 year olds are discovering sex and booze along with mathematics, and I make jokes about it.

    Many lives have been destroyed by muddle headed thugs who think Occam’s razor is a product made by Shick. Every scientifically minded psychiatrist knows that the disparate symptoms, metabolic, pain and mood, are somehow united. How? They are working on that.

    Nassir Ghaemi worte “The Rise and Fall of the Biopshycosocial Model for a Reason.” He had to. I used to teach Calculus to premeds, and prepharms. I used to joke that I expected the pharmacists to do better because the subject was more scientific and more difficult than medicine. I wasn’t kidding. There is a reason why the histrionic and undisciplined Rob Whittier is right about so much—and wrong about so much also. Psychiatrists are not terrible psychologists, they are terrible neurologists.
    Victor Camillo
    Professor of Mathematics
    University of Iowa

    • stevebMD says:

      Hawkeye,

      Of course it’s “dangerous trash” for a physician to see his/her patients this way. And I don’t mean to imply that a good physician– scientifically trained or not– looks at people through such a narrow lens.

      But there’s no doubt that the increasing specialization of medical professionals (often driven by the science) means that it’s harder and harder to “integrate treatment.” And even those who are supposed to be the “master integrators”– ie, the primary care providers– are being asked to do more with less. EMRs and insurance reimbursement don’t make it any easier to “treat the whole patient,” either.

      I agree that disparate symptoms are usually manifestations of common phenomena, and that we sometimes fail to see this. I’m just thinking that maybe the philosophy grad (who’s more likely to have heard of William of Occam than your pre-med calculus students) may do a better job of it.

      • Hawkeye says:

        Steve,
        I got a little over the top, sorry. I think the debate you are initiating is very important. The best math students are wonderful integrators, there are only two ideas in calculus and about ten techniques and 10,000 problems. They don’t need a philosopher to be effective. But a scientist without soul is dangerous—useless.

        A good model is maybe Yuri Zhivago, “Poetry, like good health, is not a vocation.” Zhivago practices medicine with a scientist’s mind and a poet’s soul. I don’t know how to teach that. Who would the teacher be?

        Isn’t humanism best taught by mentoring? I’ll bet you are a great mentor!!!

        In any case as you point out, Doctors, however are under ridiculous pressure, to be people, let alone healers. The fifteen minute med check is preposterous. At least we can say this to obese, patients with cardiac problems and incipient diabetes who are depressed:”If you can walk three miles a day……..”

        How much fun it is to exchange comments and avoid work. I am trying to referee a paper that is late, the editor is really mad, and I don’t know what I am doing and I have to do it today. Same as a patient you have not been able to help much who is about to walk out the door. I need a philosopher.

  2. Rob Lindeman says:

    Steve, the phenomenon you identify in the blog and in your response to Victor Camillo has been going on since the dawn of specialization over 100 years ago.

    Medicine IS different, for many reasons including our tendency to view people as so many organ systems, rather than as people.

    Perhaps the proposed changes to MCAS are an attempt at a remedy. If so, it is a ham-handed, silly remedy.

  3. Jackie says:

    “The article goes on to say that questions will ask about such topics as “behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”

    The problem here is that there is “no right answer” for any of these topics. They can — and therefore will –all be politicized. Pity the poor MCAT test-taker whose views on cultural matters differ from the establishment’s in any way. That might be enough to bar entry to medical school for that person.

    My son remembers taking a high school standardized test with these instructions: “Read the following paragraph and then check the answer that best describes how it made you feel”. Now, he’s a bit of a smart-ass, so he added a new box and wrote, “It makes me feel hungry.”

    So, I say that the MCAT should be about science.

  4. Mara says:

    Hmmmm. I think I like that idea of making the MCAT more diverse in subject matter. Especially because I don’t think medicine is just about medicine. How a doctor views you has an effect on treatment. There are a lot of anecdotes I could put down, especially ones that have been told to me by single moms on MediCal (doctor’s will look down on them when they see there lack of wedding rings, etc). Doctors are not just making decisions based on science. They have hangups and they don’t provide the same kind of care to people they don’t like. No joke, a close friend of mine, a single mom, delivered her second child at a hospital. Her firstborn child was there with her. The nurses then called social services. A social worker showed up and said my friend was in trouble because her firstborn child was not on MediCal. My friend then had to explain that the first child’s father has really good insurance and only her second child (by another man) needed to be on MediCal. The nurses had seen that her new baby was on MediCal, but the older child was not on it (I have no clue why they would check up on that), so they reported it to social services. That sounds like harrasment to me! I think they were just pissed a single mom was having her second child out of wedlock and so they wanted to make a statement.

    And I get why you would be turned off by increasingly fractured care, but I really believe that psychiatry is so incredibly different from the rest of medicine that it should be very separate. I don’t think other doctors should attempt to play psychiatrist. Personally, I have had severe physical problems with my gallbladder (not rooted in mental illness) that doctors tried to chalk up to anxiety. And it really freaks me out that there are so many stories people share on the internet about how a psychiatric diagnosis nearly killed them, because no doctor would take them seriously after that. Especially people with stomach issues. One woman with an anxiety disorder was saying that she showed up to an ER because her stomach was killing her and she begged them for some Xanax. They sent her to the psychiatric unit. When she woke up later down there, the PSYCHIATRIST told her he thought there was actually something wrong with her. She ended up getting her gallbladder removed.

    What freaks me out is that it was not the internal medicine doctors at the ER that diagnosed gallbladder disease. It was a psychiatrist. I feel like doctors who are NOT psychiatrists keep trying to play psychiatrist and diagnose psychiatric disorders WITHOUT consulting a psychiatrist to verify this. Doctors who do not specialize in psychiatry, imo, should not attempt to diagnose a somotoform disorder, conversion disorder, whatever, unless they are willing to back it up with the opinion of a psychiatrist. I believe their job should be to look for physical causes. I don’t even think they should be allowed to diagnose IBS unless they are willing to refer out to a psychiatrist. But that is just my humble opinion on the matter.

  5. Carol Levy says:

    What is missing is that being able to think in these other ways, outside the scientific model, allows a doctor to also think outside the box in respect to his patients and the problems they present, as well as possibilities.
    I do not know if my one neurosurgeon was different then all the rest in how he was trained (he was from Italy, isschool somewhat different there or school all along th way?) but all was lost, nothing else to be done, even he had given up. And then one day he came to me and said “I have an idea” He did an experimental brain implant in an area of my brain only done 12 times before in world and for thalamic pain as opposed to my area of neuropathic pain. It helped for quite some time.
    No one else ever thought to offer me anything other then what was in the known armamentarium (their word). Because of a new problem with this experimental one I am hoping he, and maybe somje other creative not oly scientifically oriented doc, can think of something new for me.
    Don’t throw out the scientific model but don’t be too quick to naysay about the other world of thought too.

  6. Ideally the MCAT would include sections on psychology, ethics, cultural studies, and philosophy — as a supplementary or secondary score. Facility with scientific concepts and techniques is more fundamental and necessary than facility with the social sciences and humanities. The public complains that we doctors know our scientific medicine but we don’t treat people as people. Let’s improve the latter without sacrificing an ounce of the former. There are enough med school applicants that we can admit those with no-compromise, high scores on the science portion of the MCAT, and who also show abilities in areas currently perceived as lacking.

    It’s a bit of a tempest in a teapot, though. Med schools already look for well-rounded applicants, and philosophy-psychology majors are already seen as an asset by many med schools. While the risk of politicizing non-science MCAT questions is very real, this concern overlooks the possibility that political bias (from the left OR the right) may already take place informally in the evaluation of application essays and interviews — and that science questions can be asked in a politicized way as well.

    • Hawkeye says:

      NO. NO. NO.
      A quick google search suggests that emotional intelligence is very important to success, once substantial standards for professional success are established. A transparently intelligent physician who tells me directly the why’s of diagnostic and treatment options as she sees them is expressing empathy.

      • I’m not sure what your loud disagreement refers to. We seem to agree that substantial (scientific?) standards come first, but that “emotional intelligence” is very important too. Perhaps you believe empathy equals “transparent intelligence” plus direct communication. You’ll find that equation wanting if your oncologist ever says: “Hate to break it to you, but your cancer has a 40% five-year survival rate, even with our best chemotherapy. I suggest you have that chemo, but I still wouldn’t buy any green bananas, if you get my drift.”

        Empathy is more than being smart and blunt. But the MCAT proposal isn’t about empathy, or even emotional intelligence. It’s about recognizing an ethical issue exists when it’s right in your face, realizing that cultural differences may affect how patients take their meds, or knowing that chemotherapy may be unaffordable. Important stuff, if not quite as important as knowing which chemo to order in the first place.

  7. Hawkeye says:

    I do think the thrust of the reforms is quite broad and equally broadly an attempt to increase empathy. The department I work for won a national award for fostering diversity and no one ever told us how to do it. If you’re from upper Manhattan and you can’t figure out how to talk to a working class African American from rural Louisiana then maybe you just wasted a Harvard education.

    I apologize for that, a bit humorously. I have a bias; my family was profoundly damaged by an abundance of empathy disguising an abundance of scientific ignorance. I am concerned that “I feel your pain” can be, and often is used, to cover up ineptitude. Choose the best of the best to practice any profession and teach empathy by mentoring and example. I assume that if a senior physician tells a resident sternly, “Don’t talk to patients that way.” A lesson will be learned.

    In a previous post someone suggested that there is a problem but we are not looking at the solution.

  8. Mariam Cohen, MD says:

    Another side to the problem of the specialization of medicine. I’m a psychiatrist (and got into medical school with a liberal arts degree!), and I see in my practice from time to time those well-trained scientific doctors who have no idea what they are going to do when they don’t do medicine and get depressed when they have to quit for any reason. They did pre-med and had great MCAT scores and have done great work for their patients for years and now in their 70’s (or even 80’s), they cannot quit working because they have nothing else to live for.
    Medical school is a trade school, and a well-rounded education before trade school is a great foundation for living, not just working. (Me, I’m working half time while pursuing an academic degree and career in something totally unrelated to medicine — and traveling, and weaving, and taking photographs, and . . . .)

    Mariam Cohen, MD

  9. Anonymouus says:

    I can not, nor will not, accept the premise of being an excellent doctor, while not going hand-in-hand, with being a well rounded, cultured, curious and intelligent human being. In any field, you bring to the table your life’s experiences. This is not singular to your profession and there are those who excel and those who will remain mediocre. And, as Dr. Steve said, I am not too sure i would like to discuss Satre should I have a cardiac problem. As pychaitrists, I think you have the singular and enviable position of bringing many of your assets to your patients and the more life experiece in your educational process, the better. On the otherhand, they should be rather extracurricular and not mandated. You can not mandate nor fakely cultivate empathy or curiosity. The work is brutal and expensive in the process of making doctors and, I can imagine, it is difficult to pursue other outlets.

    I have MD friends that are great musicians, artists, parents, and pursue their many interests and this is to be commended, I would love to be able to sing, this will never happen as I have no talent, but it does not take away the joy it brings me in others. I know the pursuit of a medical profession is enough and the science alone astounds me, yet, one can not be taught curiosity and desire. This is a wonderful asset to anyone and makes for better doctors and their personal lives. Think about it and sometimes it will be there for you when other of life’s challenges do not fulfill all of your patients needs but may fufill yours..

    • Hawkeye says:

      I sent this to a thoughtbroadcast fan, also a very experienced clinical psychologist:

      “To clarify further, and not to try to please you, I much like the idea of experienced psychologists who have seen lots and lots of patients advising doctors. I am not comfortable with pointed headed intellectuals doing so.”:

  10. Dr. D says:

    I would argue that the best surgeons are the thoughtful ones who take a philosophic view of things, and recognize not just the science, but also the art in what they do. See: Richard Seltzer, Sherwin Nuland, Atul Gawande.

  11. Nathan says:

    Just a peeve I guess, but I get irked when people describe medicine as an art and a science or good doctors as knowing science and having artistry in what they do. I feel like describing medicine as such, and I know it is very common, shows a poor understanding of both art and science. My understanding of medicine, is a practiced skill, involving the translation of medical research into beneficial heath outcomes.

    Many doctors ignore or disregard the growing evidence base for medical practice while relying on their own opinions, experiences, peer expectations, etc. This certainly isn’t using science to inform practice. While doctors may have studied life and physical sciences to some degree, the science that they purport to use, applied medical sciences, is not followed.

    As for art, I think it is just a lazy term for to describe things that doctors do when they are not informed by science. When things work out, they retroactively rationalize their creativity and ability to perceive/synthesize. When they don’t, there is nothing that could have been done differently.

    Practiced skills, including applying research findings to practice, engaging people, diagnostics, surgery, etc. are not science or art in themselves. They are informed by science and may be complex and require creativity/experience/thoughtfulness when the science is lacking, but they are certainly not science or art.

    • Anonymouus says:

      I would like to clarify my response stated above. I believe one should be expected to be the best and keep striving in their given profession to constantly achieve excellence. Certainly a tall order and leaves no room for anything other than all out perseverance. This has nothing to do with being blind to everything else that life informs us of and contributes to. I do not expect my MD to sit in as second violin in a 4tet or dance Balanchine masterworks. Although, come to think of it, if you do not remain at the top of your game in most art forms, there is someone younger and better right at your heels! You may have some leeway in your reputation, but it is and will be quickly extinguished. What you can, as doctors, bring to the table is your thirst for knowledge and quest for excellence and a life long desire, curiosity and intelligence in how you practice medicine. I think, especially for Psychiatrists that know real mental illness, will know this to be true. Also, I like the word practice as applied to medicine – practice makes perfect!

  12. Carol Levy says:

    I wonder if, at the end of the day, if med school can be analogized to law school where young idealistic folk go in and lawyers come out: people who have been molded to thnk like lawyers and have had a lot, some (many?) of them having had the idealism, curiousity, wonderment at the world taught out of them.

  13. […] in a greater societal context.  Soon the Medical College Admissions Test (MCAT) will include more questions about cultural studies and ethics.  Medical education should go one step further and offer more exposure to economics, politics, […]

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