Do I Want A Philosopher As My Surgeon?

February 20, 2012

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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