MD Program

  • Aesculapian Authority, 24/7, and You

    Presentation at the
    White Coat Ceremony
    University of Iowa

    Roy J. and Lucille A. Carver College of Medicine

    Friday August 22, 2003

    by
    Susan R. Johnson, M.D., M.S.
    Professor of Obstetrics & Gyynecology, and Epidemiology
    Associate Dean for Faculty Affairs


    President Skorton, Deans Robillard & Ephgrave, Mrs. Katen-Bahensky, Dr. Helms; OSAC staff; faculty; students; families; , and friends --

    It is an enormous privilege to be invited to give these remarks, which I dedicate to my grandmother, Ida Porter, who today is celebrating her 98th birthday -- she lives independently in Lake City, Iowa, where I will be joining her and the rest of my family tomorrow. Her long healthy life is in part a testament to the advances of medical care in the 20th century (and to a set of genes that I hope I have inherited!).

    This is a wonderful day – and one that you and your family and friends have awaited for a long time.

    My own wait began in the 4th grade when I decided to be a doctor, and in fifth grade when I chose the UI COM to attend. I changed my mind briefly in the first semester of 8th grade, but after that did not look back. After 3 years as an undergraduate here, I entered medical school on a beautiful fall day that I still remember clearly. The orientation then was brief; we were the first class in the then brand new BSB, and there was no ceremony like this.

    I can’t help but remark on one other difference: this year, I am told, the class is for the first time equally divided between men and women; my class, the class of 1976, was 9% women, and that was doubled from the previous year.

    Why is the white coat such a big deal? I am sure you are aware that the members of other health care professions often wear white coats as well, so the coat itself is not the thing that we celebrate today. And, it is not the person inside the coat, at least, not merely the person. Rather, it is when the person in the coat has the role of physician that the white coat becomes an important symbol.

    Unlike the symbols of some professional groups, this symbolism is not something made up by and promulgated within the profession -- rather, it is conferred by society upon the medical profession, and so has more meaning.

    I thought it would be useful today to consider the underlying reasons that society has chosen, throughout history, to confer special status on doctors, and then to draw out some of the implications these ideas have for you, even now as you are beginning your medical career.


    Part I. Aesculapian Authority

    Here is the general question: why do patients listen to their doctors, usually believe and do what they say, and, why, despite increasing complaints about the medical care system, does the public continue to list physicians as among the most admired of professionals?

    The theory of Aesculapian Authority is an attempt to answer these questions.

    Aesculapius you know something about.

    The definition of “Authority” that applies here is “power derived from opinion, respect, or esteem; a claim to be believed or obeyed.

    The theory was developed in 1957, not by a physician, but by an organizational development expert, TT Paterson. He had already developed a general theory of 5 different types of authority that support different groups such as government officials, military leaders, etc. He was then asked by a physician named Humphrey Osmond, a psychiatrist at the University of Alabama, about what was the source of authority for physicians.

    Paterson realized that he could not explain the authority of physicians by any one of his categories, but rather by a combination of 3 of the types: sapiential, moral, and charismatic.

    Sapiential Authority

    Sapiential means “having wisdom,” and so sapiential authority refers to the power physicians have as a result of what they know. This source of authority is obvious.

    The scientific content of medicine is what attracted many of you to medicine in the first place.

    (For me, in my 4th grade classroom was a book titled Huber the Tuber. No, this was not about potatoes, but rather, about tuberculosis. During WWII, the American Lung Association published this cartoon story about the evil TB germs called tubers (cast in the story as Nazis) and the immune system white blood cells (cast as the Allied forces) in a battle for the lung. The purpose was to educate the public about TB -- but for me, it served as my introduction to pathophysiology and the fascination of human disease.)

    On Monday, you will begin the first of many years -- at least 7 -- formally learning an increasingly complex body of knowledge, and you will need to learn continuously throughout your career in order to keep your knowledge base up to date.

    At my graduation from residency, our speaker, the late John Moyers, former Head of Anesthesiology said something which I think about every time I am tired, irritated, or distracted when seeing a patient: “When your patient is in trouble, what he cares about most is that you are competent.”

    The ubiquitous availability of medical research and opinion on the internet has made our patients more informed, which is all to the good, but has also has led some people to say that the physician’s authority based on knowledge is eroding because medical knowledge can now be accessed by anyone.

    However, every practicing physician knows that “just the facts” is not enough. It is rather the ability to integrate all these facts, and, equally as important, to understand what you do NOT know, and to be able to apply all this to the particular circumstances of the individual patient sitting in front of you.

    Moral Authority

    Moral authority derives from the principle that physicians are expected to act not based on their own needs, but rather on behalf of the needs and best interests of their patients. We are to act as leaders to our patients, giving guidance not just mere advice - in fact, based on our moral authority, we should act paternalistically, or parenterally if you prefer. At first, this may appear to be at odds with the modern emphasis on patient choice and autonomy, but it is not, as long as this paternalism is tempered with respect for the patient’s choices and values.

    A famous illustration of the need for moral authority is the story of Franz Ingelfinger, most famous as long time editor of the NEJM, but also an international expert on cancer of the esophagus, an aggressive disease that is difficult to treat effectively. Berger, a Russian psychiatrist, describes Ingelfinger’s dilemma when he himself developed esophageal cancer: “One can hardly imagine a more informed patient than him. After surgery, ... he received from physician friends throughout the country a barrage of well-intended but totally contradictory advice. As a result he and his physician family members became increasingly confused and emotionally distraught. Until somebody wise said to him “what you need, is a doctor.”

    What did that mean? That what was needed was someone who could take all the relevant medical facts, assess Dr. Ingelfinger’s individual situation, and then advise and take responsibility for that advice.

    Moral authority requires that the physicians work from a place of personal integrity, not just in their work life but in their personal life as well.

    Charismatic Authority

    In the original meaning, charismatic authority derives from the historical confluence between medicine and religion; between physicians and priests.

    That combination may at first seem irrelevant, or even inappropriate, in these modern times.

    In fact, it is both relevant and appropriate.

    The modern basis of Charismatic Authority has nothing to do with religion per se, but rather with the reality that life and death may be on the line at any moment, and there is no way that any physician, or even medical science, can know all that is relevant; thus, in a real sense, the sick person must relate to the physician with faith, and the belief that the physician can help. Beyond this, charismatic authority leads many patients to bring issues to their doctors from all parts of their life, not just their health -- think, for example, of how often Ann Landers recommends to readers: “talk to your doctor” about problems of all sorts.

    This is an awesome responsibility -- and one that should lead the physician to feel, not arrogant, but humbled.

    Every practitioner has had priest-like experiences -- it can be a bit eerie the first time it happens, when you realize that people really do see you as more than just a person providing medical care.

    Here is a very small example from my own practice:

    Just three weeks ago a woman, in her late 50’s and postmenopausal, came to my clinic to review her laboratory tests. We had found a small ovarian cyst several months ago, and I had ordered an ultrasound for follow up to be sure it was stable, and thus unlikely to be cancerous. The ultrasound actually showed that the cyst had gone away. When I saw her name on the schedule that day, I thought, with irritation, “Why is she coming in -- we could have done this by phone or with a letter. This is a waste of my time.” I went to the room, and quickly told her the good news that the test had been normal, and that no more tests were needed.

    She did not look particularly happy with this news, and then she said, “ I need to tell you some things.” Over the next 15 minutes or so, she went on to tell me that her husband had died of cancer 5 months ago, her granddaughter was shortly thereafter diagnosed with a severe psychiatric illness, and her brother had just developed advanced, disabling chronic obstructive lung disease. She had no friends or family to talk to, and she did not feel she could still be sad. She cried. I listened. That was all she needed that day.

    A characteristic you must develop to fulfill the mandate of charismatic authority is empathy - not just for the patient’s illness, but also for their whole being.


    PART II. 24/7

    (subtitle): a brief poetic interlude

    Twenty-four hours a day, seven days a week, and, I should have added, 365 days a year.

    This is when you will be a doctor.

    This is when the world will expect you to behave like a doctor.

    This is when you may feel you need to be available as a doctor.

    This is when you may want to stay in the role of a doctor.

    Monday /12 am - diabetic ketoacidosis;

    Tuesday / 3 am - motor vehicle accident;

    Wednesday/ 10 pm emergency caesarean delivery;

    Thursday / 2 pm in the middle of clinic, a cardiac arrest

    Friday / 5:30 pm - a 3 year old child with acute otitis

    Saturday / 1 pm - fourteen journals to read

    Sunday - no day of rest

    24/7: cures, needs, adrenaline, fatigue, “saves,” uncertainty, exhilaration, trouble, ... the truth.


    Part III. …and You

    First, you, the class of 2007.

    Actually, not you as a class, but you as individuals. You - Melissa Cervantes; You - Michael Friedman; You - LaKeesha Randolf; You - Nicky Stoik; You -Ginny Harris; You - Todd Stevens; You – Hong-Phuc Tran -- and so on! We will listen to all your names in a few minutes.

    At first glance it seems that it must require superhuman effort to be a physician. But it does not -- it only requires your best human effort.

    In fact, it is those physicians who attempt to be superhuman who often fail -- themselves, their families, and ultimately their patients. In my roles as a collegiate administrator working with faculty, and as a member of the Iowa Board of Medical Examiners I have seen first hand the toll that this approach can take:

    • Workaholism - which can lead to fatigue related mistakes, among other things
    • Loss of relationships with children, your partner, and friends
    • Obviously, in a few cases, troubles such as substance abuse or disruptive behavior that ruins relationships with colleagues and patients
    • Subtly, and more common, failure to meet others as a fellow human being -- and leading to loss of yourself

    Some of you are saying to yourselves at this moment “STOP”- “What does this have to do with the excitement of today!

    Everything, I think. Because now is the time to develop a life that is immune to these troubles.

    For starters, here are three steps you can take to integrate your work life and personal life

    1. Accept that you can’t be perfect:

    It would take days to relate to you all the times I have not been perfect, but here are a few:

    • The first semester of medical school, I failed my first mid term exams Anatomy and Biochemistry
    • The first week of my internship, I gave penicillin to an allergic patient.
    • In my first year in practice, I perforated the uterus of a young woman during a D&C, leading to the need for abdominal surgery to repair a damaged small intestine. Perforation is a recognized complication of this procedure, and she healed just fine, and so in the end I felt relieved.

    However, there is a second part to this last story. Three years ago, almost 20 years after that event, I was listening to a second year medical student present the case of a patient he had worked up as part of the 3rd semester Patient Centered Learning course. All of a sudden, while listening to the past medical history, I realized that it must be this same woman. Imagine, then, if you were I, and heard the student say next: “and ever since the perforation, she has not trusted any doctor.”

    Mistakes are inevitable, not discussed during training or in practice often enough, and sometimes they do have long-term consequences for the patient. However, mistakes learned from ultimately make you better, in fact, as much as you should try to prevent them, in some sense, you must also welcome them.... and find a healthy way to deal with the emotional aftermath.

    2. Improve your resilience

    “Resilience is the ability to bounce back after being psychologically stressed,” say Mary and Wayne Sotile, psychologists at Wake Forest University School of Medicine, and authors of the book The Resilient Physician.

    Resilience is a key factor in job and life satisfaction -- and so is well worth developing.

    The Sotiles describe numerous strategies to help physicians do just that -- such as using your stress related symptoms as a signal to change the next step in your usual coping process to something more healthy; re-frame the way you think about change, from a negative to an opportunity; learn to be optimistic; etc . I encourage you all to read the book someday.

    But for now, I want to mention a particular problem the Sotiles have identified among medical students and residents:

    Addressing practicing physicians about this time in training, they say:

    “Along the way of your medical training, you probably became proficient at self-denial -- ignoring your feelings, your appetites, and your own needs -- in order to get your job done and provide whatever is asked of you. Perhaps you entered medical school already prone to please others, even at your own expense. If not, you soon learned that doing so was a survival skill that allowed you to meet the extraordinary demands of medical training ... [But] when ...you repress awareness of your own needs and feelings and rely too much on your ability to delay gratification as you work to gain approval from others, the result can be a life of struggling... The paradox: The very coping skills learned in your efforts to become a good caretaker serve to stress not only yourself but those around you.”

    To counter this problem:

    • Pay attention to your relationships
    • Develop or continue good self-care habits (rest, exercise, eating) -- think of this as an educational effort, since you will be asking your patients to do the same!
    • Be aware that if you are a perfectionist, you will need to work on being realistic in your expectations
    • Seek help -- there are lots of resources here for you -- if you have concerns.

    3. Pay attention to the research on physician career satisfaction

    The number one factor enhancing satisfaction in most surveys, which will come as no surprise, is having developed “A personal sense of competence.”

    In a recent study by Horowitz, the other factors identified had to do not with the achievement of spectacular cures, or technological wizardry, but rather, with the development of relationship to patients

    Specifically:

    • Making a personal connection with patients
    • A difference made in someone’s life
    • And, having a fundamental change in perspective.

    There are other “you’s” here today: administrators, faculty, family and friends:

    You each have a role to play in helping these students achieve these goals of dealing with mistakes and uncertainly, improving resiliency, and developing relationships with patients.

    I hope you will take this responsibility seriously.


    FINALLY, your first homework assignment: a walking meditation

    The factor identified in the Horowitz study “a fundamental change in the doctor’s perspective” referred to the physician’s having sudden insight about herself or her attitudes during a particular, often problematic, patient encounter - and usually these led to increased awareness of patients as fellow human beings.

    I can’t assign you to see patients just yet; but in the meantime, here is an exercise that can lead you in the direction of that same result.

    The objective of this assignment is, in the words of Horwitz, to expand the boundaries of your role as scientifically detached observers and prescribers of tests and treatments ... (to) recognize (your) patients as fellow human beings, rather than objects of care.”

    Here are the instructions:

    Go to the hospital lobby --( But don't all go at once!) or, you can do this at the Coral Ridge mall, the O’Hare airport, or a even a Hawkeye football game.... anywhere there is large crowd of “real” people.

    Look at each person you see - carefully (but without staring!) and say to yourself:

    • This child is the reason I am doing this (whether you intend to be a family physician or a physician-scientist doing bench research) -- it is for him, not myself or my teachers or my family, or anyone else.
    • This woman is the one who will trust me - not because of ME -- but because she trusts me by my white coat.
    • Just like this man, I am human, with both frailties and potential.

    Do this for 20 minutes, every once and a while.

    There are few professions as fascinating, challenging, and as rewarding, as medicine. Today, on behalf of all your future teachers, I welcome you as you start on the road to a life of medicine, and I wish you to be well on that journey.


    References cited

    Berger M: Chronically diseased patients and their doctors (in Russian).
    Tschelowek [Moscow] 9 (4):119-125, 1998 (available on the web at http://www.uni-duesseldorf.de/WWW/MedFak/MDN/Forum_Kritische_Diabetologie/patdoc.htm)

    Horowitz CR. Suchman AL. Branch WT Jr. Frankel RM. What do doctors find meaningful about their work? Annals of Internal Medicine. 138(9):772-5, 2003

    Osmond H. God and the doctor. New England Journal of Medicine. 302(10):555-8, 1980

    Paterson, Thomas T. Management Theory. London: Business Publications, 1961

    Sotile, W and Sotile, M. The Resilient Physician: Effective Emotional Management for Doctors and Their Medical Organizations. American Medical Association; (January 2002)

    Wilmer, Harry A. Huber the Tuber: Lives and Loves of a Tubercle Bacillus, New York, N.Y.: National Tuberculosis Association, 1942