^¦SM
Talking to people is a doctor game that doctors don't play W. Gifford-Jones, MD is the pseudonym of Niagara Falls? gynecologist Dr. Kenneth Walker, the author of a recently published book, "The Doctor Game". While Gifford-Jones has not joined the shrill cries of the headhunters in full pur¬ suit of the medical profession, he is a constructive and outspoken critic. In this interview, he discusses the doctor game with CMAJ contributor David Woods.
Q: Why did you write the book? A: The primary motive was patients. I had more and more patients over the last few years say to me, "Why can't I get what I want from my doc¬ tor?" "Why won't he do an abortion?" "Why won't he sterilize me?" "Is this operation necessary?" I (also) thought there was too much iatrogenic disease; much of it was doctor-oriented, much was due not to the fault of the doctor or the fault of the patient but rather the quickening pace of the society we live in, trying to do too much in too little time; I thought the book would explain this to patients: explain some of the areas I saw patients worrying about, such as cancer, chronic disease,
degeneration.
..
The idea for the book came to me about 5 years ago. It seemed to me that a book called "The Doctor Game" would be an interesting new approach to writing a medical book; there are many "how-to" books in medicine, but no one had really told people about the most important player of all the doctor. Q: On the subject of doctors, you say in the book that some of the art has gone out of medicine, that it's become big business... there are 67 specialties in the United States; there are too many technicians rather than healers. Why do you feel that there has been this apparent depersonalization of medicine and are, in fact, books like "The Doctor Game" an attempt to put some of the art back into med¬ icine? .
A: I don't think they put the art back into medicine because the art is in the doctor's office, but I believe that they can be an adjunct to medical care. The woman who leaves her doctor's office where she has been told she needs a hysterectomy may forget 99% of what the physician said; if she can go home and read a book which hope¬ fully gives common sense informationit on this or any other medical topic, can be helpful. Q: How has the public reacted to "The Doctor Game"? A: It's been reviewed by a good cross-section of reviewers across the country. Some have given it an average review and some have given it rather glowing reports; the only really "anti" one was the one in the Toronto Star. Q: Perhaps we can talk about the kinds of responses you've had from your own professional colleagues? A: Generally bad. As one might ex¬ pect when one is, in part, criticizing colleagues on some primarily social is¬ sues, the response from the profession has not been overly good. I think the interesting thing about doctors and their relationships or feelings toward Gifford-Jones is that they are a little bit paranoid about me; often, they are extremely critical without even having read what I've written. I don't think that more than 5% of the doctors in my own community have read "The Doctor Game". Q: Have you had any flak about the advice you gave in the book to patients to phone the local hospital and ask to speak to the scrub nurse and get from her a kind of consumer rating on the surgeons there? A: Yes, that has come from both medical and nonmedical sources. It's maybe the only one thing in the book that I wouldn't put in if I had to do it over again. But I can't see any reason why peo¬ ple can't call switchboard operators or CMA
get in touch with paramedical person¬
nel whether they be nurses or lab tech¬ nicians or x-ray technicians. Q: You say in the book that physi¬ cians need to communicate better. Why do you think they don't communicate as well as they should and how do you think they might be persuaded to im¬ prove in this area? A: Some doctors are medically ex¬ tremely competent, but very incompe¬ tent at communication. Their personal¬ ity is not in tune with a particular they're on different wave¬ patient lengths. There's another kind of doctor who is incompetent with most of his patients because he is not on the same wavelength with any of them. He's a nontalkative doctor; regardless of how hard doctors will try, or patients will try, to get him to talk to them in a common sense way, it's impossible for him to do because he is not that kind of personality. There's another group of doctors who are able to communicate but re¬ fuse to because they belong to that Victorian school that believes "me God, you moron". They put themselves up on a pedestal and do not commu¬ nicate because they don't want to. I think the doctor of the future will be one who will communicate better. So¬ ciety will force him to communicate better, and I do believe that, in the future, we will in part judge applicants to the medical school on whether or on their not they can communicate personal characteristics. It's a very dif¬ ficult topic to get into because no one has really come up with a good way to pick premedical students. But I think that going on the basis of high scholastic standings in mathematics, physics and chemistry is maybe picking the very people who can't communi¬ .
cate.
Q: Surely something depends
what For
on
they're going to do in medicine? example, it is said that a lot of
JOURNAL/DECEMBER 13, 1975/VOL. 113 1105
the attrition rate among general practi¬ tioners has to do with the fact that the individuals who get into general practice become frustrated with their inability or their lack of training in dealing with certain personal relation¬ ship aspects of their craft; but obvious¬ ly, if you have a guy who has no com¬ munication skills whatever, and he goes into some backroom research position, that's entirely suitable, so basically we're looking at personality skills for front-line physicians. A: You don't have to have a great personality to be a pathologist, or to be involved in research medicine. It may very well be that in the future we might even have two kinds of med¬ one to train people ical schools who are going out into the practice of medicine and communicating with pa¬ tients and another to train the more research-oriented students. I think that in the future there will be courses in medical school which will be run by nonmedical people may¬ be advertising people, maybe people in public relations and areas of promotion and marketing, who could come in and, within a few hours, impart more in the way of how to communicate with pa¬ tients than some of the professors who have spent a lifetime in medicine can. Q: Do you mean that medical stu¬ dents of the future might get as much Dale Carnegie as Gray's Anatomy? A: I don't think there is any doubt about that.
Q: Although your book isn't an angry one, it does contain some criti¬ cisms of the medical profession. You refer, for example, to the amount of unnecessary surgery being performed in North America, and to iatrogenic diseases. Are these two phenomena in¬
creasing?
gery. I hope my book gets through the message that 75% of the surgery is necessary. But the fact is that 25% isn't; that's a big percentage. Q: In the book, you provide a lot of reassurance about lifestyles. You think we worry too much about diet, smok¬ ing, exercise. that we're too cossetted. I wonder, though, if books of this kind may not add to a kind of public introspection about health. A: Yes, I think there is that danger that too many medical books may make people introspective, but there's a risk in anything that you do, and hopefully the asset value of this book will be greater than the liability part of it. I don't see that as a great problem for "The Doctor Game" because it is less about actual diseases than about the health care system. For instance, one in four people moves every year. We live in a very mobile society. Then people leave a doctor they are fully acquainted with, and need to know how to find a new one to know what good medical care consists of. If they follow the rules of this book, they could be fairly well assured they are in safe hands. I don't mean to imply that smoking two packs of cigarettes is good for you, or a lack of exercise is good for you, but these things have to be put in the perspective of one's total health care and also in the total game of Russian roulette we ali play in this life. You may be the healthiest guy in the world and die of cancer at 65 with a perfect body of muscles. Q: In your book, you have not focused wholly on the patient's rights; you have dealt also with the patient's responsibilities. It seems to me that you have been critical of the medical pro¬ fession where that is justified, but you have also taken pains to explain the reasons for the income level of physi¬ cians, for example, which is something that is often misinterpreted by the public. Do you feel that the traditional gulf of misunderstanding between med¬ ical profession and public is beginning to narrow? A: No, I don't think it is narrowing, I think it is more than likely widening, and will widen further in the negotia¬ tions for increases in doctors' incomes due to take place in 1976. Actually, I spend as much time defending the medical profession in my trips across Canada as I do in criticizing it. I did that primarily by emphasizing what hockey players are making $75 000 a year. The cashiers in supermarkets are now asking $12 000 to $16 000 a year; by and large, nurses are making about half (after tax) of what most doctors are making. The message that I have driven home repeatedly is that 99% of Canadian doctors deserve the ..
..
..
.
A: I think that the book tries to get the message across to patients that medicine is a two-way street. The faults are not all doctor-oriented. We're liv¬ ing in an age where patients, to get good medical care, have to learn to be patient patients. It's the impatient ones who push the doctor into giving unnec¬ essary surgery, unnecessary x-rays, un¬ necessary tranquilizers. This is, in part, related directly to the fact that we are living in a tremendously exciting scien¬ tific age, in which we are used to see¬ ing instant miracles. But patients have to realize that landing a person on the moon or transplanting a new heart or kidney in effect has very little to do with their own medical care. But North American society in par¬ ticular is overmedicated in a number of areas: radiation is one, pills are an¬ other; I think a patient who says "Doc¬ tor, can't you do an operation to fix it up quickly?" is waving a red flag in front of MDs doing unnecessary sur¬ 1106 CMA JOURNAL/DECEMBER 13, 1975/VOL. 113
Victoria Cross for their medical skills and their dedication to the practice of medicine, but that 95% of them should be shot for their sociological views. Now, it's just a way of driving home a point that I have a high regard for most doctors medically, but I have a very low regard for them from the
sociological standpoint. Q: You say in your book that doc¬ tors shy away from social issues. The fact that there are only nine physicians in the House of Commons in Ottawa, and something like 80 lawyers, may
tend to support your case. Can you suggest a reason for this apparent lack of physician interest in social issues? A: I think there are many reasons. In medical school, doctors are taught year after year to feel the pulse of a patient, and practically no one tells them how to feel the pulse of society. Repeatedly, they tell me that they are doctors taught to practise medi¬ cine and not sociologists. I don't think doctors can afford that isolated stance anymore; I don't think any sec¬ tion of our society can. But I realize it's not easy to get involved. Taking the stand on abortion that I have, for instance, has lost me some of my re¬ ferring doctors. A young MD starting out couldn't have taken that stand it would have ruined him. And then there's the fact that doctors don't like to be criticized. They are in the upper brackets of society, both economically and socially, and most of them don't like to put themselves in a position where they are going to be criticized by their colleagues or by people in general. The annoying thing is that when all these social issues finally are resolved I'm talking primarily about sterilization and abortion; abortion in the physicians who are particular sitting on the fence right now will be the first to say that it was obvious all along that, of course, we were in favour. There is no hope that the pro¬ fession will retain its dignity or its economic status in society; it's on the way down. About 10 years ago, I went to Japan to write an article and found that Japanese doctors had been relegated almost to the same status as the average worker. They were a very unhappy, disenchanted group. The same is gradually happening here the great heyday of medicine is past and things will never be the same again. We will become more and more socialistic. Doctors are too democratic and .
..
.
they're too idealistic; they're not hardnosed businessmen enough. The or¬ ganizations that represent them are using aspirin to fight pneumonia when they should be using penicillin. I'd like to see a separate bargaining organiza¬ tion created with somebody elected king and paid $100 000 a year.B
Talking to people is a doctor game that doctors don't play W. Gifford-Jones, MD is the pseudonym of Niagara Falls? gynecologist Dr. Kenneth Walker, the author of a recently published book, "The Doctor Game". While Gifford-Jones has not joined the shrill cries of the headhunters in full pur¬ suit of the medical profession, he is a constructive and outspoken critic. In this interview, he discusses the doctor game with CMAJ contributor David Woods.
Q: Why did you write the book? A: The primary motive was patients. I had more and more patients over the last few years say to me, "Why can't I get what I want from my doc¬ tor?" "Why won't he do an abortion?" "Why won't he sterilize me?" "Is this operation necessary?" I (also) thought there was too much iatrogenic disease; much of it was doctor-oriented, much was due not to the fault of the doctor or the fault of the patient but rather the quickening pace of the society we live in, trying to do too much in too little time; I thought the book would explain this to patients: explain some of the areas I saw patients worrying about, such as cancer, chronic disease,
degeneration.
..
The idea for the book came to me about 5 years ago. It seemed to me that a book called "The Doctor Game" would be an interesting new approach to writing a medical book; there are many "how-to" books in medicine, but no one had really told people about the most important player of all the doctor. Q: On the subject of doctors, you say in the book that some of the art has gone out of medicine, that it's become big business... there are 67 specialties in the United States; there are too many technicians rather than healers. Why do you feel that there has been this apparent depersonalization of medicine and are, in fact, books like "The Doctor Game" an attempt to put some of the art back into med¬ icine? .
A: I don't think they put the art back into medicine because the art is in the doctor's office, but I believe that they can be an adjunct to medical care. The woman who leaves her doctor's office where she has been told she needs a hysterectomy may forget 99% of what the physician said; if she can go home and read a book which hope¬ fully gives common sense informationit on this or any other medical topic, can be helpful. Q: How has the public reacted to "The Doctor Game"? A: It's been reviewed by a good cross-section of reviewers across the country. Some have given it an average review and some have given it rather glowing reports; the only really "anti" one was the one in the Toronto Star. Q: Perhaps we can talk about the kinds of responses you've had from your own professional colleagues? A: Generally bad. As one might ex¬ pect when one is, in part, criticizing colleagues on some primarily social is¬ sues, the response from the profession has not been overly good. I think the interesting thing about doctors and their relationships or feelings toward Gifford-Jones is that they are a little bit paranoid about me; often, they are extremely critical without even having read what I've written. I don't think that more than 5% of the doctors in my own community have read "The Doctor Game". Q: Have you had any flak about the advice you gave in the book to patients to phone the local hospital and ask to speak to the scrub nurse and get from her a kind of consumer rating on the surgeons there? A: Yes, that has come from both medical and nonmedical sources. It's maybe the only one thing in the book that I wouldn't put in if I had to do it over again. But I can't see any reason why peo¬ ple can't call switchboard operators or CMA
get in touch with paramedical person¬
nel whether they be nurses or lab tech¬ nicians or x-ray technicians. Q: You say in the book that physi¬ cians need to communicate better. Why do you think they don't communicate as well as they should and how do you think they might be persuaded to im¬ prove in this area? A: Some doctors are medically ex¬ tremely competent, but very incompe¬ tent at communication. Their personal¬ ity is not in tune with a particular they're on different wave¬ patient lengths. There's another kind of doctor who is incompetent with most of his patients because he is not on the same wavelength with any of them. He's a nontalkative doctor; regardless of how hard doctors will try, or patients will try, to get him to talk to them in a common sense way, it's impossible for him to do because he is not that kind of personality. There's another group of doctors who are able to communicate but re¬ fuse to because they belong to that Victorian school that believes "me God, you moron". They put themselves up on a pedestal and do not commu¬ nicate because they don't want to. I think the doctor of the future will be one who will communicate better. So¬ ciety will force him to communicate better, and I do believe that, in the future, we will in part judge applicants to the medical school on whether or on their not they can communicate personal characteristics. It's a very dif¬ ficult topic to get into because no one has really come up with a good way to pick premedical students. But I think that going on the basis of high scholastic standings in mathematics, physics and chemistry is maybe picking the very people who can't communi¬ .
cate.
Q: Surely something depends
what For
on
they're going to do in medicine? example, it is said that a lot of
JOURNAL/DECEMBER 13, 1975/VOL. 113 1105
the attrition rate among general practi¬ tioners has to do with the fact that the individuals who get into general practice become frustrated with their inability or their lack of training in dealing with certain personal relation¬ ship aspects of their craft; but obvious¬ ly, if you have a guy who has no com¬ munication skills whatever, and he goes into some backroom research position, that's entirely suitable, so basically we're looking at personality skills for front-line physicians. A: You don't have to have a great personality to be a pathologist, or to be involved in research medicine. It may very well be that in the future we might even have two kinds of med¬ one to train people ical schools who are going out into the practice of medicine and communicating with pa¬ tients and another to train the more research-oriented students. I think that in the future there will be courses in medical school which will be run by nonmedical people may¬ be advertising people, maybe people in public relations and areas of promotion and marketing, who could come in and, within a few hours, impart more in the way of how to communicate with pa¬ tients than some of the professors who have spent a lifetime in medicine can. Q: Do you mean that medical stu¬ dents of the future might get as much Dale Carnegie as Gray's Anatomy? A: I don't think there is any doubt about that.
Q: Although your book isn't an angry one, it does contain some criti¬ cisms of the medical profession. You refer, for example, to the amount of unnecessary surgery being performed in North America, and to iatrogenic diseases. Are these two phenomena in¬
creasing?
gery. I hope my book gets through the message that 75% of the surgery is necessary. But the fact is that 25% isn't; that's a big percentage. Q: In the book, you provide a lot of reassurance about lifestyles. You think we worry too much about diet, smok¬ ing, exercise. that we're too cossetted. I wonder, though, if books of this kind may not add to a kind of public introspection about health. A: Yes, I think there is that danger that too many medical books may make people introspective, but there's a risk in anything that you do, and hopefully the asset value of this book will be greater than the liability part of it. I don't see that as a great problem for "The Doctor Game" because it is less about actual diseases than about the health care system. For instance, one in four people moves every year. We live in a very mobile society. Then people leave a doctor they are fully acquainted with, and need to know how to find a new one to know what good medical care consists of. If they follow the rules of this book, they could be fairly well assured they are in safe hands. I don't mean to imply that smoking two packs of cigarettes is good for you, or a lack of exercise is good for you, but these things have to be put in the perspective of one's total health care and also in the total game of Russian roulette we ali play in this life. You may be the healthiest guy in the world and die of cancer at 65 with a perfect body of muscles. Q: In your book, you have not focused wholly on the patient's rights; you have dealt also with the patient's responsibilities. It seems to me that you have been critical of the medical pro¬ fession where that is justified, but you have also taken pains to explain the reasons for the income level of physi¬ cians, for example, which is something that is often misinterpreted by the public. Do you feel that the traditional gulf of misunderstanding between med¬ ical profession and public is beginning to narrow? A: No, I don't think it is narrowing, I think it is more than likely widening, and will widen further in the negotia¬ tions for increases in doctors' incomes due to take place in 1976. Actually, I spend as much time defending the medical profession in my trips across Canada as I do in criticizing it. I did that primarily by emphasizing what hockey players are making $75 000 a year. The cashiers in supermarkets are now asking $12 000 to $16 000 a year; by and large, nurses are making about half (after tax) of what most doctors are making. The message that I have driven home repeatedly is that 99% of Canadian doctors deserve the ..
..
..
.
A: I think that the book tries to get the message across to patients that medicine is a two-way street. The faults are not all doctor-oriented. We're liv¬ ing in an age where patients, to get good medical care, have to learn to be patient patients. It's the impatient ones who push the doctor into giving unnec¬ essary surgery, unnecessary x-rays, un¬ necessary tranquilizers. This is, in part, related directly to the fact that we are living in a tremendously exciting scien¬ tific age, in which we are used to see¬ ing instant miracles. But patients have to realize that landing a person on the moon or transplanting a new heart or kidney in effect has very little to do with their own medical care. But North American society in par¬ ticular is overmedicated in a number of areas: radiation is one, pills are an¬ other; I think a patient who says "Doc¬ tor, can't you do an operation to fix it up quickly?" is waving a red flag in front of MDs doing unnecessary sur¬ 1106 CMA JOURNAL/DECEMBER 13, 1975/VOL. 113
Victoria Cross for their medical skills and their dedication to the practice of medicine, but that 95% of them should be shot for their sociological views. Now, it's just a way of driving home a point that I have a high regard for most doctors medically, but I have a very low regard for them from the
sociological standpoint. Q: You say in your book that doc¬ tors shy away from social issues. The fact that there are only nine physicians in the House of Commons in Ottawa, and something like 80 lawyers, may
tend to support your case. Can you suggest a reason for this apparent lack of physician interest in social issues? A: I think there are many reasons. In medical school, doctors are taught year after year to feel the pulse of a patient, and practically no one tells them how to feel the pulse of society. Repeatedly, they tell me that they are doctors taught to practise medi¬ cine and not sociologists. I don't think doctors can afford that isolated stance anymore; I don't think any sec¬ tion of our society can. But I realize it's not easy to get involved. Taking the stand on abortion that I have, for instance, has lost me some of my re¬ ferring doctors. A young MD starting out couldn't have taken that stand it would have ruined him. And then there's the fact that doctors don't like to be criticized. They are in the upper brackets of society, both economically and socially, and most of them don't like to put themselves in a position where they are going to be criticized by their colleagues or by people in general. The annoying thing is that when all these social issues finally are resolved I'm talking primarily about sterilization and abortion; abortion in the physicians who are particular sitting on the fence right now will be the first to say that it was obvious all along that, of course, we were in favour. There is no hope that the pro¬ fession will retain its dignity or its economic status in society; it's on the way down. About 10 years ago, I went to Japan to write an article and found that Japanese doctors had been relegated almost to the same status as the average worker. They were a very unhappy, disenchanted group. The same is gradually happening here the great heyday of medicine is past and things will never be the same again. We will become more and more socialistic. Doctors are too democratic and .
..
.
they're too idealistic; they're not hardnosed businessmen enough. The or¬ ganizations that represent them are using aspirin to fight pneumonia when they should be using penicillin. I'd like to see a separate bargaining organiza¬ tion created with somebody elected king and paid $100 000 a year.B
