In search of Marcus Welby
By Gayle Stockland Fixler
In constant transition–much of it encouraging –modern medicine has distanced itself from the Hippocratic Oath – a physician’s commitment to practice medicine while remembering that “there is art to medicine as well as science and that warmth, sympathy and understanding may outweigh the surgeon's knife or the chemist's drug.”
The human touch–shown to be a powerful and effective age-old tool much like grandma’s chicken soup–is an essential and profound part of the healing process, and for those of us who have experienced a departure from the centuries-old vow, it is disheartening particularly if we remember otherwise.
From 1969 to 1976, the late actor Robert Young portrayed a universally-revered family practitioner on ABC’s award-winning series Marcus Welby, M.D. Dedicated and compassionate to a fault, he practiced medicine in a way that we now perceive as idealistic and impractical if not prohibitive with regards to financial and time constraints.
Dr. Welby’s fictional medical practice existed at a time when by today’s standards, medical technology was archaic and treatment options severely limited. Consequently, physicians had to rely on their diagnostic skills, intuition, experience and the ability to accurately decipher, understand and trust what their patients were telling them during highly personalized appointments.
In the current and real world of medicine however, competition for medical school admission has increased, causing tuition and student debt to continue its meteoric rise; insurance costs, including that for medical malpractice are high and sometimes prohibitive; political and policy changes are complex and ever-changing; medical appointments are abbreviated and overbooked; and physician specialties, sub-specialties and medication options have become numerous and confusing.
As a result, the medical profession has become big business: bureaucratic, competitive and often times extremely lucrative, thereby making Dr. Welby’s altruistic philosophy obsolete. And although the medical profession has advanced, it has not necessarily always been for the best interest of the patient.
So it is both telling and encouraging that there is increasing recognition of the need to return to Marcus Welby’s brand of doctoring.
In his book, How Doctors Think, Dr. Jerome Groopman, a Harvard Medical School professor and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, calls the essence of medicine “a mix of science and soul."
Once a patient himself, Dr. Groopman became frustrated while navigating the system in which he had worked for decades. Dismayed when he realized that it takes the average physician only about 18 seconds before interrupting after a patient begins talking, he stresses that “shortcutting” does not allow for sufficient time to fully appreciate what a patient has to say. Off-putting at best, it is also disturbing because medical school students learn that a physician can obtain a patient's diagnosis 80 percent of the time solely from the information that patient provides.
Moreover, Dr. Groopman admits that during those 18 seconds, physicians generate a hasty diagnosis, and too frequently, make what is called an “anchoring mistake” — a fixation on a snap judgment that ofentimes is not only faulty, but harmful and even fatal.
A fierce proponent of bedside medicine, author and Stanford University professor and physician Dr. Abraham Varghese likens today’s patients to “data points” and has called for a return to the traditional one-on-one physical exam. “Once upon a time doctors examined patients not with CT scans or MRIs but with their senses. We are losing a ritual that is the heart of the patient-physician relationship”–a ritual he believes is not only soul-fulfilling for both doctors and patients, but more effective.
Reflective of both doctors’ concerns, Virginia Tech Carilion, the country’s newest of our 134 medical schools, integrated the use of multiple mini interview (MMI) into its admissions process last year. Considered the equivalent of speed dating, the format involves short, independent assessments, typically in a timed circuit and requires less resource expenditure than traditional interview formats.
Dr. Harold Reiter of the Michael DeGroote School of Medicine at McMaster University in Ontario, Canada developed the system to address an increasing recognition of two persistent problems: That traditional interview formats do not accurately predict performance in medical school; and when physician performance is reviewed following patient complaints, the most recurrent areas of concern are interpersonal skills, ethical/moral judgment and professionalism.
In a 2011 New York Times article, Dr. Stephen Workman, Carilion’s associate dean for admissions and administration explained that use of the MMI assists in “weeding out the students who look great on paper but haven’t developed the people or communication skills we think are important.”
Following Carilion’s lead, the majority of medical schools in Canada, Australia, Israel and Asia now use this method. Fifteen in the United States including Stanford, the University of California, Los Angeles and the University of Cincinnati have also adopted the format. With more than 40,000 applicants vying for approximately 19,000 slots each year, MMI can be a highly-impactful tool.
Stanford’s School of Medicine senior associate dean Dr. Charles Prober says that the university has always valued social skills in students–particularly the ability to establish trust with patients and collaborate with colleagues–but did not have a reliable way of assessing them until implementing the mini-interviews.
Validating the success of his program, Dr. Reiter says that candidate scores on multiple mini interviews have proved to be highly “predictive of scores on medical licensing exams that test doctors’ decision-making, patient interactions and cultural competency.”
According to the American Academy on Communication on Health Care, a company established to promote research, education, and professional standards in patient-clinician communication, “The research is very clear that communication and relationships issues are critical to patient care and have multiple influences on outcomes. Communication and relationship have been demonstrated to have an impact on patients’ experience of care, patients’ experience of care, improved patient adherence to treatment regimens, clinical outcomes and quality, patient safety, teamwork, cultural sensitivity, and reduce medical malpractice risk.”
While many will agree that our complex and faulty healthcare system cannot be easily and quickly overhauled, incremental changes need to occur and a good place to start is in training the medical professionals of the future and retraining some of the current ones.
Until then, we can benefit from the cautionary tale that at a 1980s American Academy of Family Physicians conference. An attendee told Robert Young that "You're getting us all into hot water. Our patients tell us we're not as nice to them as Dr. Welby is to his patients," to which Young replied, "Maybe you're not.”
-Gayle Stockland Fixler has a Bachelor of Science degree in journalism from Arizona State University, is a Washington, DC freelance writer and a regular contributor to Reflections. She is the daughter and sister of physicians.