Appendix 12b - Defensive Medicine

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

From the sociological study of the house staff subculture Getting Rid of Patients: Contradictions in the Socialization of Physicians:

They [the medical trainees] portrayed themselves figuratively and literally, as doing battle.... Their collective descriptions of patient-related encounters included such violent and aggressive terms as 'hits,' 'crashing and burning,' 'under fire,' 'getting killed,' 'time bombs,' 'trainwrecks,' 'killers,' 'under the gun,' 'going down the tubes' all of which connoted siege-like, assaultive circumstances. One resident: 'You can't examine [obese patients].... They get you before you get them.... They just destroy you and you don't even want to deal with them.'[176]

House Officers

From an article in Academic Medicine:

It has been remarked that the team-player ethos of medical education has many similarities to the military and its unwritten rules. Indeed the medical wards... are rife with battle epithets. Residents get 'shelled' on call, taking 'hits' and being 'bombarded.' Patients 'torture' their residents with midnight complaints. Residents 'divide and conquer' their admissions. Wars are notorious for changing people forever.

As a new third-year clerk, I had the displeasure of being pulled aside by my senior resident. In the relative privacy of a conference room, he attempted to give me introductory lessons to the wards. 'You got to understand.' he said. 'This is a war....'

My job apparently was to be a recruit in his fledgling army. The casualties of this ongoing war are many, and include not just the patients caught in the crossfire, but also the values and ideals many bring with them to a conflict they probably never envisioned themselves engaged in. I began my work on medical student ethical development trying to help students cope with the war. Now I believe we must work to end the war.[177]

They know Galen well, but the patient not at all - Michel de Montaingne

Some physicians defend the militaristic model. For example, this from Academic Questions:

Competence and availability are the quiddity of the good physician. A competent and available physician can do a great deal of good even if he is otherwise a despicable human being. An incompetent though saintly doctor is a great danger to the public. From these considerations it is easy to see why medical training has always had a semi-military character, hardly likely to be amenable to sensitivity-training. There is an iron bond involved. One is expected to extend oneself. One is also expected to exercise a certain authority over patients, since one must do, or have done, to them things that are painful.[178]

Alan Gregg, described as one of the greatest medical educational spokesmen of his generation, disagrees. "The thing that really matters," he wrote, "is not whether you do this or do that well. The thing that really matters is how much you care...."[179] Patients tend to agree. One study, for example, found that most people consider bedside manner more important than even the technical skill of a physician.[180]

Of course compassion and competence are not mutually exclusive, but medical training often places them at odds. From a prize winning essay entitled "The Self-Contradiction of a 'Humane' Profession":

How does this supposedly humane and person oriented profession handle the all-important process of educating its professional offspring?.... The answer is basically a cruel paradox: the powers that control medicine have evolved a process of education with the idea that only a tough, unrelenting, uncompassionate system can produce physicians truly capable of fulfilling its noble principles.[181]

An article entitled "Humane Medicine Begins with Humane Medical Schools" notes that medical students, "have consistently denied or suppressed the emotional impact of disease in order to function within a system that rewards technical competence at the expense of personal development.... If medical students are not cared for, they may learn not to care."[182]


[176] Mizrahi, T. Getting Rid of Patients: Contradictions in the Socialization of Physicians Piscataway: Rutgers University Press, 1986.

[177] Hundert, EM. "Characteristics of the Informal Curriculum and Trainees' Ethical Choices." Academic Medicine 71(1996):624-640.

[178] Braverman, AS and B Anziska. "Challenges to Science and Authority in Contemporary Medical Education." Academic Questions 7(1994):11.

[179] Wallace, AG. "Educating Tomorrow's Doctors." Academic Medicine 72(1997):253-258.

[180] UPI Science News 3 October 1998.

[181] Burra, P and AM Bryans. "The Helping Professions Group." Journal of Medical Education 54(1979):36-41.

[182] Penney, JC. "Humane Medicine Begins with Humane Medical Schools." Humane Medicine 5(1989):13-17.

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