he year is 1938 and a physician has been called to the home of a young child whose parents are worried she might have diphtheria, then a leading cause of death among children. To confirm that the girl has the disease, the doctor must examine her throat and look at her tonsils. She has no intention of letting the doctor do that.
What ensues is a push and pull between the doctor, the child, and the parents, a scenario all too familiar to modern pediatricians. As the doctor begins to lose patience, he becomes fixated on making the child open her mouth.
He proceeds to the point at which he later admits he “had gone beyond reason” and in that moment could have “torn the child apart in my own fury and enjoyed it.”
This story is recounted in “The Use of Force,” a famous piece of medical writing by William Carlos Williams, a renowned physician-writer. It is often used to demonstrate the challenging psychological processes and dynamics that accompany caring for another human being.
To me, it is a story about motivation. It offers a lesson that doctors may at times be driven by motivation that is more about themselves and less about what is best for the patient.
Williams, feeling ashamed by his behavior, admitted in the essay that his motivation changed during the course of the exam, and that his “care” for the child was eventually driven by his own uncontrollable conviction to overpower her.
Williams was able to determine that the child did have diphtheria and began treating her for it, probably saving her life. But was the interaction the best for his patient? Williams could have come back a few hours later, as he admitted, and examined the girl when she was calmer, with probably the same outcome, but with less terror and resentment on her part.
Reading “The Use of Force” prompted me to look at physician-patient interactions through a new lens. In my work as a medical student, I came to realize that the care that doctors give their patients can often be influenced by non-clinical factors.
For instance, in the clinic and in the hospital, time and sleep often dictate how quickly or with what depth we see our patients.
On my hospital rotations, team rounds were at 9 a.m. sharp. Medical students and residents had to complete all of their pre-rounding work by then — if you were late you would hold up the rest of the team. That work could easily be delayed by a lengthy examination or an unplanned discussion with a patient. On overnight call shifts, many of us work 24 hours or more without sleep. In both of those scenarios, seeing patients as quickly as possible often trumped seeing them as thoroughly as possible.
Here’s another example. It’s common for resident physicians, who complete their medical training by working in hospitals, to be paged in the middle of the night to place a central line. This is a tube (catheter) placed into a large vein in the neck, chest, or groin to deliver certain medications, provide easy access for blood draws, and do certain tests, like measure blood pressure in specific blood vessels.
Placing a central line isn’t without complications: If done incorrectly or unsuccessfully, it can damage blood vessels, cause bleeding or an irregular heart rhythm, and even trigger a heart attack. The most significant factor related to a complication is the number of previous attempts to place the line.
If the resident’s primary motivation is patient care and safety, and the first or second attempt to place the line fails, he or she may be more willing to return and try the line placement later, or seek help from a more experienced physician. But if the main motivation is to place the line quickly in order to attend to other patients or to get some sleep before the next patient needs something, the resident may be more careless or hasty in his or her attempt. No physician would do this deliberately, but subconsciously this motivation might lead to an unsafe outcome.
Thanks in part to reading “The Use of Force,” I began to wonder if the intrinsic motivation of a physician matters, and whether it affects the clinical outcome.
There is surprisingly little research into the effect of physician motivation on patient outcomes. Most studies have focused on financial incentives (an example of an extrinsic motivator) as they relate to physician behavior. There haven’t been major studies on personal or emotional incentives (intrinsic motivators). Such studies would be hard to conduct because how we feel at any given moment is constantly changing. But it is an area that demands research, particularly because financial motivation is only a small part of what influences why doctors do what they do.
As a medical professional, I have certainly cared for patients when my motivation wasn’t completely in sync with providing the best care possible. Sadly, this is unavoidable. I have seen patients at the end of a 30-hour shift, when I was thinking about my bed almost as much as about my patient. I have cared for patients booked at the last minute for the end of the day, meaning I would be late to dinner with a friend, my stomach’s grumbling an unhelpful distraction.
At times like these, I find it helpful to recall “The Use of Force,” check myself and how I am feeling right then, and re-center my focus on the patient and his or her needs.
Even when physicians are tired or under stress, most of them don’t intend to provide unsafe or hasty care. But reminding ourselves about our primary motivation, especially in challenging patient circumstances, can help keep us accountable and our patients safer.
Abraar Karan, MD, is a physician at the Harvard T.H. Chan School of Public Health in the Department of Health Policy and Management.