Palak V. Patel1,2
1 Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
2 Stanford Medical School, Dept. of Ophthalmology, Stanford, CA 94305, USA
Correspondence concerning this article and requests for reprints should be addressed to Palak V. Patel (palakvpa@stanford.edu)
Abstract
In the modern clinical era, physicians, even those with Dr. Anthony Fauci’s expertise, are no longer seen as the unerring gatekeepers of medicine. The “Faucisian” model of care embraces this shift in the patient-provider relationship: the model’s central tenants, as exemplified by Dr. Fauci himself, are collaboration and emotional regulation. Dr. Fauci has practiced these principles during the coronavirus pandemic, allowing him to spur targeted, nonpartisan response. This article explores how Faucisian principles could help physicians better treat noncompliant patients, and how these principles might improve coronavirus response. It also explores how current clinical curricula fall short of teaching medical students how to handle challenging clinical encounters. Students trained in collaboration and emotional regulation could take a more Faucisian approach to medicine, developing treatment plans with, rather than for, their patients.
On April 12, President Donald Trump retweeted the hashtag “#FireFauci” amid conflict on coronavirus legislation [1]. The post sparked a media blitzkrieg, with reporters speculating that Dr. Anthony Fauci, the nation’s leading infectious disease specialist, had been ousted by the President. In his interviews, Dr. Fauci was unflapped. “My job always is…to give advice on the basis of evidence and science,” he said, a neutral smile playing over his lips, “[firing me is] not even on the table” [2].
Since lockdown, Dr. Fauci has become a political lightning rod – critics have called him reckless, a conspiracist, and a fascist [3]. But despite a dozen opportunities to defend himself, the NIH director has refused to pit himself against the President or the American people. Instead, Dr. Fauci has treated America like a reluctant patient: he’s offered a clinical diagnosis (COVID-19), suggested treatment alternatives (strict quarantine measures), and heard the patient’s concerns (an economic collapse). But what is most striking, and perhaps most educational for medical students, is Dr. Fauci’s commitment to the physician-patient partnership: he’s offered America his best advice but does not balk at the patient’s pushback, as the final treatment plan should be rooted in mutual understanding.
In the modern clinical era, physicians, even those with Dr. Fauci’s expertise, are no longer seen as the unerring gatekeepers of medicine. Today’s model prioritizes shared decision making -- the physician and patient develop a treatment plan together, after non-judgmental discussion and debate [4]. Many doctors have resisted this shift, mourning the time when their patients answered to them, rather than the other way around.
The “Faucisian” model scoffs, albeit politely, at such sentiment. According to Dr. Fauci, collaboration should undergird all medical interactions, and the patient should have final say on any proposed treatments. This philosophy was evidenced in a recent conversation with Senator Rand Paul: Dr. Fauci advised against reopening Kentucky schools, but Senator Paul disagreed, arguing that students without access to homeschooling would fall behind, widening the education gap between the privileged and the poor. “I respect [Dr. Fauci]…but I don’t think [he’s] the person who gets to make [the final] decision [for Kentuckians],” Senator Paul said. Rather than reprimanding the Senator for noncompliance, Dr. Fauci respected Mr. Paul’s priorities and judgment-call. He’d offered his guidance; any decisions made beyond that were at the discretion of the Senator and his constituents [5].
Teaching medical students that noncompliance is a common phenomenon, and should be expected in clinical encounters, is an important step in teaching patient care. Learners that want to be effective under the new model of physician-patient interaction should expect their choices to be questioned, rather than take offense to such dialogue. However, research shows that recent medical graduates have a negative perception of argumentative and noncompliant patients [6]. For example, a resident in Oliver’s study described a patient who wanted oxycodone over the drug she recommended as “a drug seeker who was just here for the pills” [6].
This troubling “my way or the highway” attitude can stanch response to national emergencies such as the COVID-19 pandemic. While social distancing dramatically slashes the spread of COVID-19, not all patients can afford the luxury of staying at home – 30 million Americans have filed for unemployment since mid-March, sparking nationwide protests to reopen the economy [7]. Instead of seeking a middle ground, some healthcare workers are describing patient noncompliance as a “slap in the face” [8]. This indignance precludes investigation into alternative mitigation strategies. If some Americans can’t stay home, can they commit to wearing face masks? Avoid nonessential travel? Maintain a six-foot distance from their neighbors? Such compromise is surely better than the alternative reality, which is playing out across the United States – Americans who have opted for the metaphorical highway are protesting in large groups, many of them sans-mask, creating a ripe breeding ground for the coronavirus [9].
If the foundation of the Faucisian model is physician-patient collaboration, the keystone tenant is emotional regulation. To watch Dr. Fauci in interviews is to observe an elegant example of this philosophy. At a news conference on March 20, President Trump touted the anti-malarial drug hydroxychloroquine as a “game-changer” for coronavirus treatment. Dr. Fauci politely disagreed with him, stating that the drug’s promise had been “anecdotal…so [it’s hard to] make a definitive statement about it” [10].
Like the resident and the oxycodone-seeker, Dr. Fauci and the President had a difference in opinion regarding treatment options. However, unlike the resident, Dr. Fauci has six decades of experience with “difficult” patients – and it shows. Rather than expressing ill will towards the President, Dr. Fauci stepped out of his scrubs and into Mr. Trump’s shoes: “I was taking a purely medical, scientific standpoint, [while] the President was trying to bring hope to the people” [11]. By recognizing context, Dr. Fauci effectively kept a discussion from spiraling into a publicized argument.
Doug Oliver has developed a framework that teaches medical students how to appreciate difficult patients, individuals he describes as argumentative, noncompliant, or skeptical [6]. The framework hinges on emotional regulation. Medical students need to do more than evaluate the behavior of a patient; they must also understand how their own emotional responses affect the outcomes of difficult encounters.
This framework helps students gauge the behaviors that throw off their emotional balance and practice response techniques in a controlled environment. Students who have seen a difficult patient might feel angry, frustrated, or disrespected, but reflecting on these feelings can yield discussion on counter-transference and teach students how to change the tone of a challenging clinical encounter. Further, if students hope to understand patient behavior, they must take the time to understand each visit in the context of a patient’s life. This exercise can help medical students understand that while a clinical encounter was “difficult,” broadly applying that label to an individual is unfair.
The coronavirus has left many patients with their backs against a wall: diagnostic kits are in short supply, remdesivir remains elusive, and antibody tests are failing quality standards [12]. Patients navigating such systematic healthcare inefficiencies might redirect their frustrations onto individual providers, causing clinical encounters to go less than smoothly [13]. Emotional regulation training helps physicians deescalate such encounters--instead of automatically assigning “argumentative” patients a negative label, caregivers learn to think of them as patients facing tough circumstances. By recognizing the power of context, physicians can shunt patient frustrations towards a productive end and ask meaningful, empathetic questions. This re-contextualizes the encounter; it’s no longer physician versus patient, but both versus a clinical challenge.
When the resident in Oliver’s study encountered a difficult patient, she decided she didn’t “want to see that guy again, because [she] didn’t think [she] could help him” [6]. This negative attitude reflects the outdated clinical curricula of medical schools: students learn to doctor under the old, authoritarian model of medicine, but are expected to practice in the new one – where shared decision making is highly valued. It should come as no surprise that they’re struggling. Rather than waiting for years of clinical experience to lend them Dr. Fauci’s calm manner, students should advocate for more realistic clinical encounters in medical school. Students trained in collaboration and emotional regulation could take a more Faucisian approach to medicine – developing treatment plans with, rather than for, their patients. If America’s dependence on Dr. Fauci has demonstrated one thing, it’s that these skills are essential during crisis.
REFERENCE
Sherman M, Superville D. President Trump Promotes 'Fire Fauci' Tweet After Disease Doctor Critiques White House Coronavirus Response. Time Magazine 2020.
Park A. Dr. Anthony Fauci 'Not Overly Confident' With U.S. COVID-19 Testing Capabilities. Time Magazine 2020.
Wilson J. Why Trump’s media allies are turning against Fauci amid the pandemic. The Guardian 2020.
Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221–2226. doi:10.1001/jama.1992.03480160079038
Top health experts paint a bleak picture of pandemic. The New York Times 2020.
Oliver D. Teaching medical learners to appreciate “difficult” patients. Can Fam Physician. 2011;57(4):506‐508.
Tappe A. 30 million Americans have filed initial unemployment claims since mid-March. CNN Business 2020.
Eastman K. This is a Denver nurse's message to protesters. 9News 2020. (Accessed on April 30, 2020 at https://www.9news.com/article/news/local/denver-nurse-has-a-message-for-protesters/73-10e04b93-eb2a-4d4a-8c01-f47481dd8168).
Abrams F, Langford J. The right of the people to protest lockdown. The New York Times 2020.
Chiu, A. Fauci gets frank about Trump: ‘I can’t jump in front of the microphone and push him down.’ The Washington Post 2020.
Brennan M. Transcript: Dr. Anthony Fauci discusses coronavirus on "Face the Nation," March 22, 2020. (Accessed April 29,, 2020 at https://www.cbsnews.com/news/transcript-dr-anthony-fauci-discusses-coronavirus-on-face-the-nation-march-22-2020/).
Abdelmalek M, Christi M. Mayo Clinic doctors find many COVID-19 antibody tests fail their quality standards: ABC News exclusive. ABC News 2020. (Accessed on May 23, 2020 at https://abcnews.go.com/US/mayo-clinic-doctors-find-covid-19-antibody-tests/story?id=70803740).
Chipidza F, Wallwork RS, Adams TN, Stern TA. Evaluation and Treatment of the Angry Patient. Prim Care Companion CNS Disord. 2016;18(3):10.4088/PCC.16f01951. Published 2016 Jun 23. doi:10.4088/PCC.16f01951