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Humility
Matchett and associates from the Mayo Clinic have published an article on physician humility. 1 Starting with Osler’s call in 1892 to rank humility as first among physician virtues, they review the literature using the definition of humility as “including unflinching self-awareness, empathetic openness to others, and profound appreciation of the privilege of patient care.” They found literature supporting a pivotal role for humility in five domains: learning and professional growth, preventing and managing error, tolerating uncertainty, trust, and teamwork and communication. While I had not previously thought of humility in this way, it does support many of the issues we have confronted in other articles on this website devoted to aspects of physician leadership. Interestingly, there are three other articles in the same issue that shine some light on the issue of humility. In the first, Joseph Zarconi, a nephrologist, tells the story of trying to establish a doctor-patient relationship with a man he knew casually from watching their sons play on a ball team. 2 Things were not going well until he took the step of meeting the man away from the office, where he learned the cost of talking about “the numbers” to the patient. It reminded me of many conversations with hospitalists and ICU nurses, where I often reiterated “the numbers are for us—the family only wants to know if their patient is doing as expected, or not, and what we were going to do today.” Montez-Rath and associates did an emulation study trying to parse out survival and home time in older patients with advanced CKD who did or did not start dialysis. 3 In line with other studies, they found dialysis added 9.3 days of life over three years, at a cost of 13.6 fewer days at home. Compared to those who decided to forego dialysis, treatment added a mean of 77.6 days at a cost of 14.7 fewer days at home. Much to the dismay of young nephrologists and family members, dialysis in elderly patients does not result in significant extension of life, but does exact costs. The current notion that every patient with advanced CKD deserves a trial of dialysis does not really comport with physician humility. I routinely counseled patients that the real issue is for them to decide what it is worth and what the goals should be. Some could not deal with this, but I had more people thank me for helping them than those who sought care elsewhere. In an editorial by Welch 4 commenting on a study by Halpern and associates assessing the annual cost of cancer screening in the United States, 5 he noted their estimate of $43 billion did not include the costs of working up false positive studies. But the primary issue is that nearly 2/3 of this cost estimate is accounted for by colonoscopy screening. A study is underway to compare the survival benefit of colonoscopy to fecal immunochemical 1 Matchett CL, Usher EL, Ratelle JT, Suarez DA, et al. Physician Humility: A Review and Call to Revive Virtue in Medicine. Ann Intern Med 2024;177:1251-1258. doi:10:7326/M24-0842. 2 Zarconi J. Boundary Crossing. Ann Intern Med 2024;177:1285-1286. doi:10:7326/ANNALS-24-00830. 3 Montez-Rath ME, Thomas I-C, Charu V., et al. Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults with Kidney Failure: A Target Trial Emulation Study. Ann Intern Med 2024;177:1233-1243. doi:10:7326/M23-3028. 4 Welch HG. Dollars and Sense: The Cost of Cancer Screening in the United States. Ann Intern Med 2024;177:1275- 1276. doi:10.7326/M24-0375. 5 Halpern MT, Liu B, Lowy DR, Gupta S, Cromwell JM, Doria-Rose VP. The Annual Cost of Cancer Screening in the United States. Ann Intern Med 2024;177:1170-1178. doi:10.7326/M24-0375. testing, but Welch doubts the results will “bend the curve.” He also notes the limitations of screening for other malignancies, and the problems of overdiagnosis and overtreatment. “What is the value of all this? Promoters assert that cancer screening “saves lives.” Yet its effect is so small that randomized trials must enroll tens of thousands of participants to reliably detect a change in cancer-specific mortality—not all-cause mortality…As few as 1 person per 1,000 who are screened over 10 years will benefit.” Clearly there are data challenging many aspects of current practice, which impose large costs of uncertain benefit. Humility when counseling patients is certainly appropriate. Maybe the appropriate position to take is what I used to say to the medical young. “We do what we do, and sometimes it works and sometimes it doesn’t. If we don’t take too much credit for the good outcomes, we won’t take too much blame for the bad outcomes.” 20 September 2024 |
Further Reading
Cathedral Thinking What lessons does building cathedrals have for healthcare reform? Empathy Is empathy the value we have tossed out as part of "improving" health care? New Leadership Skills for Physicians David Brooks has identified highly valued skills in the modern world. The good news is that physicians already use three of them. Physician Work It might seem obvious what a physician's work is, but there are conflicting definitions which are causing problems. Regret Regret is a universal emotion. Although we try, avoiding regret is not possible, and our desire to do so creates costs to everyone. |