Zubin Damania -AKA ZDogg MD– shares his ideas on how medical education is not adequately capturing the shift in medicine -to focus on helping people rather than carrying out medical procedures- and how medical errors can be avoided through honest communication and understanding between physicians.
[vimeo width=”500″ height=”281″]https://vimeo.com/66573770[/vimeo]
MedCrunch: One of the problems in health is medical training. As you mentioned in your talk, medical students are being trained to do things to people instead of for people. How can medical institutions change this concept in their programs?
Zubin Damania: The idea of doing things to people instead of for people is a fundamental problem in our system. If you’re looking at medical education, you really have to start from the very beginning -before people get into medical school. Currently, the premedical admission process is so wacky. It’s based on MCATs and grades. The, “Are you interesting? Have you done cool things? What are your personal skills? How do you relate to people? What’s your passion?” is less important. I think it should be inverted. We should really be screening people for culture and interpersonal skills at the beginning. If we do so, the idea of a system that is about sick-care and doing things to people will start to evaporate. Instead, we’ll end up bringing people into medicine who are passionate about doing things for people. The other thing is the training process, that’s is a whole can of worms. If we continue to focus on culture throughout and keep in our mind important questions like, “What are our core values? What are our noble causes? Why are we doing this?” throughout education, then we’ll keep our eyes on the right prize.
MedCrunch: You are clearly an enlightened physician, but there are physicians that are more traditional and struggle to embrace this change. It might be overwhelming to them. How can they stop fearing change and embrace it, and what are specific things they can do to improve themselves?
Zubin Damania: We often talk about older physicians as being part of the problem. I actually think that what they sense in their careers is still what’s fundamentally wrong with medicine: the approach on the autonomy of the physician. The idea that there still is a lot of external pressure to do certain things in medicine -like quality measures, outcomes and insurance companies- is pressing. All of which is valid. What older physicians maybe haven’t been trained as much in are things like collaborative care, teamwork of systems. If you give them a checklist and say, “This will save lives”, they’ll say, “I don’t need a stinking checklist, I’m an autonomous agent.” It’s a tension between autonomy and system improvements. I don’t think that this tension necessarily needs to be there if we can demonstrate that these measures are actually going to make their jobs easier. All physicians fundamentally want to help people and make people better with as little red tape as possible. If we can make that the default system, they’re going to fall right in the line; that’s what they want. I really don’t think they want to obstruct improvements in the system. They just don’t see things that are happening now as improvements. We have to get everyone in the tent.
MedCrunch: You’ve been through quite a journey. Would you say that you’ve changed as a physician from being one type of physician to another? And if yes, what was the key thing that made that shift happen and when did it happen?
Zubin Damania: I went into medicine like a lot of people do. I was super idealistic saying, “I’m going to change the world; helping people is going to be the most fulfilling thing ever.” Then you get into the system and for the first couple years you still have a lot of that residual -even though your training has just damaged you. It’s not a one-time event; it’s death by a thousand paper cuts, where every little humiliation, trauma and loss-of-self add up. By the time you start your career, the first thing you’ll say is, “Ok, this can work, I’m still helping people”. Then things start to pile on. The system keeps getting worse, it’s not like it’s getting better. Suddenly, this collective trauma adds up. One day you look at yourself and you go, “What? I don’t even recognize the person that’s here. Where is the empathy? It’s gone. I’m treating patients as problems. I’m treating my colleagues as problems. I’m ignoring my family. I’m going home angry, upset and ruminate all night. What’s going on?” Suddenly, that realization happens. The process is slow and insidious. The question now is, “What do you do with that realization?” I kind of see it as submit versus surrender. You submit to the system and say, “You know what? This is just how it is. This is what I need to do. I’ll get to retirement -which is wish for tomorrow but I know it can’t be. I’m just going to plot through, keep my head down and do my thing. I’m not going to worry about all the idealism that got me into medicine.” That’s route A. Route B is “No, this is not who I am. I give up; I’m not going to try and play this game anymore. I’m either going to get out of medicine and do something completely different -which sadly a lot of people are forced to do- or I’m going to step out of medicine and do something disruptive using my strengths -whatever those might be- and contribute the way that I can.” There are a many people engaging in startups, companies and disruptive innovations. I think that’s one space to do it. What I want to do is build something where doctors don’t have to make that decision, where the system starts to become something that they can get passionate about, be a part of and help people so that they can fulfill that idealism within the system. Why does this broken system exist in the first place? It’s hard; there is no easy answer. Anyone who professes to have an easy answer to this question is clearly trying to sell something.
MedCrunch: Doctors are human and make mistakes, but this obviously remains a taboo topic. How can we make this topic less frightening and help doctors to talk about their mistakes?
Zubin Damania: It’s such a taboo topic that I have to take a deep breath before I talk about it. I think that part of the idea of surrendering to who we are is to surrender to the idea that we are human and we are vulnerable. Being able to display that vulnerability, as a physician, has been a no-no for decades. Physicians are all powerful, godlike creatures. They need to maintain this aura or patients won’t respect them. When patients see the cracks in the Wizard of Oz’s façade, the game is over. This is as far from reality as it can be. I discovered this myself a few years ago when I missed a case of endocarditis in a 90-something year-old woman who had shoulder pain. I didn’t think it could be endocarditis. Things were triggering my spider sense but I thought, “Let me just get her to a nursing home. She’ll declare one way or the other and she’ll probably be ok.” She came back to the hospital and found out she had endocarditis. She ultimately died. The family was furious with me for sending her to the nursing home. Of course, I felt awful for missing the diagnosis. They came to me extremely confrontational, with the finger pointed saying, “We’re going to sue you, bad things are going to happen to you, you have done a horrible thing”. What I did after that was something that was incredibly hard, especially since, when confronted, our first mechanism is to go, “No-no-no-no, here are all the reasons that all I did was right”. On many levels that was true, but I said, “I’m so sorry, if I could do it again I would do it this way. I’m sorry for your loss. Your mother was an amazing lady. I made a mistake that I will never make again and that I have learned from. You can do what you need to do but I’m telling you that I’m profoundly sorry.” That apology did two things. Number one: for the first night in two weeks I was able to sleep. Number two: you could see acceptance in the faces of the family members. After what had happened, the person who did it accepted his responsibility and came clean with it. After that the relationship changed 180 degrees. Accepting that we are human, owning up to mistakes and trying to improve is what we have to do. It’s not easy, especially in the medical climate, where there is so much litigation. But the truth is that, when we do so, the risk of litigation actually goes down. Regardless of all this, as human beings, what should do we do when we hurt another human being inadvertently is own up to it.
MedCrunch: It also helps when doctors to speak amongst each other. This is also often not happening. The risk of litigation might be less, but they should have a form to discuss things. I feel though they have judgmental litigation internally.
Zubin Damania: You know what’s interesting? Brian Goldman, a Canadian physician, gave an amazing TED talk about this: it’s not even so much that they’re judging you; if you tell other physicians, “This is a mistake I made” they get so uncomfortable because they’re judging themselves. They know they’ve made similar mistakes and feel so vulnerable that they don’t want to talk about them. It’s so uncomfortable to discuss. The first thing that a doctor will do when you tell him/her “I did this” is, “Oh, anyone would have done something like that. Shoulder pain could have been a million things, I wouldn’t worry about it.” That’s not what we want to hear. What we want to hear is, “Yeah, that’s a tough one, I’ve made mistakes like that. In the future this is maybe what we can do about it. I know how it feels.” That’s what we want. We’re not getting this type of answer because everyone has got his or her shields up. It’s very hard. This gets back to the medical education issue. What are we screening for when we get people into medicine? We’re not screening for the ability to address these issues. We’re screening for, “Can you do a physics equation properly and how good are you at math?” It doesn’t make sense.
MedCrunch: What would be your advice to young medical students or people that are thinking about studying medicine?
Zubin Damania: I’ve been talking to some doctors recently and they said, “If medical students asked me for tips, my tip would be: don’t do it.” I think that’s horrifying. What I would tell them is, “You’re going into one of the greatest, most noble professions on the planet. Never forget that. Never forget why you went into medicine. Keep your eyes and ears open. You’re smart, energetic, idealistic, brilliant and creative. When you lose sight of who you are, that’s when things go wrong. When you come out of your training, you’ll find your niche. If you don’t see it in medicine or if you see that the system is so broken that you can’t fit into it: create your own. Rip your own hole in that piece of the universe and fill it with something better. You can do that because you’re awesome. You were able to get to this point; you cared enough to get to this point. You suffered and gave up your twenties; you can do anything. That’s what I would tell them.