Saturday, August 30, 2008

What I Really Think

A couple of weeks ago during office hours, I saw a particular name on a chart, and my heart sank. This is a patient who sucks up an inordinate amount of my time every time she comes in, and to no discernible benefit to anyone. She has severe hypertension, for which she is on medication, and she obsesses about it. She takes her pressure three times a day, documents it each time, and brings the list in to convince me that she doesn’t really need blood pressure medication. Thing is, her numbers don’t even look very good. She doesn’t want to stop her medicine – I’ve told her that she is of course the boss of herself and doesn’t have to take my advice – no, she wants me to tell her to stop.

I sighed heavily to myself, then went into the room. And as I was sitting down to talk to her, she handed this article to me. Uh-oh, I thought, here we go.

My patient had circled one of the statements from the article:
I know that Reader’s Digest recommends bringing in a complete list of all your symptoms, but every time you do, it only reinforces my desire to quit this profession.
And I’m thinking, How am I going to get out of this one? Because I absolutely do feel that way. Then my patient says, “I read that, and I thought, That’s me! I bet that’s what DoctorMama thinks! So you know what? I didn’t bring any notes with me! And I stopped taking my blood pressure all the time – and you know what? I feel so much less stressed!”

And we had a really pleasant visit; she even hugged me on the way out.

Naturally I was curious to read the rest of the article, but I found that while I did agree with some of it, most of it didn’t resonate with me at all.

Here’s some of the things I have to admit I do agree with:
The most unsettling thing for a physician is when the patient doesn’t trust you or believe you.
“Unsettling” is the right word for this (though not necessarily “the most”). It doesn’t make me mad, it doesn’t make me insecure – I just don’t know where to go once I realize that a patient thinks that I’m full of it. Usually I just back off and say, “I can only tell you what I recommend; what you decide is up to you.”
It saddens me that my lifelong enjoyment and enthusiasm for medicine has all but died. I have watched reimbursement shrink, while overhead has more than doubled. I’ve been forced to take on more patients. I work 12- to 14-hour days and come in on weekends. It’s still the most amazing job in the world, but I am exhausted all the time.
At least a third of what doctors decide is fairly arbitrary.
Absolutely. But I usually let patients know this right up front.
Most of us haven’t been to see our own physicians in five years.
Quite true, but not just because we don’t practice what we preach. People mostly shouldn’t go to doctors as often as they do. I never lecture a patient who is essentially healthy about not coming in more often. Every visit is an opportunity for iatrogenesis, really. And most screening is overrated. Doctors screen folks a lot more often than the data say they should, partly to avoid having to argue about it and partly to avoid being sued for it.
In many ways, doctors are held to an unrealistic standard. We are never, ever allowed to make a mistake. I don’t know anybody who can live that way.
Sometimes it’s easier for a doctor to write a prescription for a medicine than to explain why the patient doesn’t need it.
Kind of true, but not stated correctly. What it should say is, Sometimes it’s easier for a doctor to write a prescription for a medicine that won’t work than to explain why it won’t.

Some of the statements seemed neither here nor there to me – such as:
Those so-called free medication samples of the newest and most expensive drugs may not be the best or safest.
Well, duh – I hope that most doctors are telling their patients this!
In many hospitals, the length of the white coat is related to the length of training. Medical students wear the shortest coats.
This is not a secret, is it? Medical students identify themselves as such, in my experience.

But most of the stuff in the article I could not relate to at all. For instance:
Not a day goes by when I don’t think about the potential for being sued. It makes me give patients a lot of unnecessary tests that are potentially harmful, just so I don’t miss an injury or problem that comes back to haunt me in the form of a lawsuit.
I would say the potential for being sued crosses my mind maybe twice a month, max. I long ago realized that the thing you get sued for is never the thing that you would have avoided had you been thinking about being sued.
It’s pretty common for doctors to talk about their patients and make judgments, particularly about their appearance.
No, not particularly about their appearance – about their personalities, yes.
In most branches of medicine, we deal more commonly with old people. So we become much more enthusiastic when a young person comes along. We have more in common with and are more attracted to him or her. Doctors have a limited amount of time, so the younger and more attractive you are, the more likely you are to get more of our time.
I feel almost the exact opposite. I am much more impatient with and bored by people who seem a lot like me. I love the crazy old coots – I could talk to them all day. (And “attracted to”? Um, eww.)
Doctors are only interested in whether they are inconvenienced—most don’t care if you have to wait for them.
What an awful view of the rest of the world this person must have. This is far, far from the truth in my experience.
When a doctor tells you to lose 15 to 20 pounds, what he really means is you need to lose 50.
Huh? Why would you do this? I don’t tend to talk in absolute numbers anyway, because a healthy weight for one person is different from that for another of the same height, but if a patient asks me how much they should lose to improve their health, I’ll give them an honest estimation.
Ninety-four percent of doctors take gifts from drug companies, even though research has shown that these gifts bias our clinical decision making.
Doctors often make patients wait while they listen to sales pitches from drug reps.
Long ago I took the No Free Lunch Pledge, and I’ve stuck to it. I don’t take stuff, and I don’t talk to drug reps. I made this decision when I realized that everyone thinks they’re the one who isn’t influenced by such things, and yet studies show everyone is. Why should I think I’m special?

Overall I think the article probably caused more harm than good. But maybe it will inspire a few more doctors to take the pledge. And I’m sure glad my patient read it.

P.S. Now that you know what I really think, you can go here for a (flattering) idea of what I’m really like.


Just me said...

Outside of my private practice, I work in public psychiatry, where about half of the patients I see makes me want to quit... Not necessarily that the patients drive me batty, but that how am I suppose to treat depression when a patient is homeless, with a first-grader, no money, no support, and even if the mother got a job, she woul be making about $10/hour, and rent would eat up her entire check...
Many frustrations...
Glad to see that we all feel so helpless and hopeless from time to time. (Probably because our patients feel so helpless and hopeless...)

Blue said...
This comment has been removed by the author.
Blue said...

I'm doubting your claim that her idea of what you're really like is flattery. What a fun thing meet IRL someone whom you've only known virtually. (at least it sounds fun if it's not a romantic liaison. that would be a bit freaky.)

Used to read RD. So many thing of it as the Holy Bible though. Kind of weird. ♥

PS: if i ever come to new york, want to meet up?!

Blue said...

think. Think! i don't know what my deal is with typing today!

JK said...

Great post.

Could you go check in on my 87 year old Dad? He's a crazy old coot and could really use a good doctor.

It's really hard right now.

Thanks again for a great post.

Btw, I probably won't become a runner, but I do work out HARD 3-5 times a week. I love that you inspire people to run.

Anonymous said...

Do you think maybe the issue with what kind of patient makes us happiest is the kind who's a little different from everyone else we see? When I was in residency, mostly everyone was like me (read boring and strait-laced), and I used to love the occasional cocaine user or woman who slept with someone different every Friday night. Now, most of my patients are poor, uneducated heroin addicts, and I am so excited to get a professional with a graduate degree. Mostly, though, the patients who make me happiest are the ones who really like me, regardless of how non-compliant or crazy they are (or how boring and middle-class.)

The one thing I thought of adding to the article was, "There really isn't anything that works all that much better than diet or exercise for weight loss."

Orange said...

What's all this mumbo-jumbo about doctoring? Everyone knows that laughter is the best medicine.

Eliza said...

You know what I'd really love to see you come out with? The Young, Chronically-Ill Patient's Guide to Getting Taken Seriously By Doctors. I've been a chronic pain patient since I was twelve (broke my back, have syndrome that causes hyperflexible, hypotonic joints that dislocate and subluxate easily, have had Stephen-Johnson's Syndrome twice yes TWICE, crappy immune system, four current strains of EBV, MRSA twice, have a few other syndromes, hypothyroidism, adrenal insufficiency, fibromyalgia, etc.) and fairly ill the majority of my adult life (the past three years especially). I am not an idiot. I have a terminal degree (not in medicine, but I'm a good researcher). I also have three kids with special needs and various medical concerns (didn't know about the autosomal-dominant syndrome until the last one was born). Between me and the kids, I've had to learn how to insert an NG-tube, care for a G-tube, do home IV therapy (S.A.S.H.!), and be an armchair pharmacist. I've saved my own life a couple of times (like hahaha that time they gave me Zyvox , an MAOI, for MRSA, and I'd been on Cymbalta and stopped taking it and got withdrawal from it and the psychiatrist on call kept telling me to just take a Cymbalta, I'd feel better, which um, no, I already had Seratonin, probably I'd just die, or that time my PCP dressed a MRSA lesion in her office with Silvadene, forgetting that it is a SULFA DRUG, and I figured that out in time to get to the nearest ER with the help of Dr. Google). I do not feel qualified to practice medicine, which is why I see all of my various specialists regularly. But the ones who don't know me very well, and the ones who fill in for the ones who know me well, and the ER hospitalists who get me through luck of the draw all see a twenty-nine-year-old woman who hasn't let her looks go yet and listen to me for about two seconds then smile patronizingly and say "and why are YOU here today?" And it's like dude, the giant suppurating thing on my cheek? But first let me tell you what antibiotics NOT to give me, and that my platelets are ALWAYS that low, and that is why I am not taking an NSAID, not because I just enjoy narcotics (frankly I do not, I have a hard enough time staying awake) or because I WANT to tell you my entire life story. I'm just trying not to get killed. I've tried condensing the vital information down to a note on my PDA and offering them that, but that seems to set off the "WOOT-WOOT CRAZY PERSON!" alarm. Is there such a thing as a balance between knowing your history as far as life-threatening stuff goes and sounding like a total weirdo if that's a lot of history? I've found that my doctors who have seen me in-house when I've been REALLY sick tend to be a lot cooler than the ones who haven't; when I'm sick I'm VERY, VERY sick but when I'm having an okay stretch and not using a walker my orthotics don't show through clothes and I can "pass" for "normal" (if by normal you mean "relatively functional person on sixteen prescription drugs"). I would love to hear a physician's take on this, because I really just want to make sure I don't turn into iatrogenic roadkill or get a Hep-lock put in (BLEEDING DISORDER! NO HEPARIN! JUST LEAVE THE LACTATED RINGER'S RUNNING SLOWLY OR TAKE IT OUT!) or something else that would be FINE for most people...just not me. Ideas?

OMDG said...

Just finished my medicine rotation and OH MAN is the personality thing true. The part about judging. Some patients WERE really tough to take. Of course, I've long since realized that I am one of those difficult patients myself, so I try to be understanding. But Geeze!

Anonymous said...

So how often should a generally healthy 39 year old woman see a doctor? :)

Anonymous said...

Nice about the no free lunch pledge. Good for you!

I have friends who are doctors and so I know doctors are just regular people with specialized knowledge who can make mistakes. But the problem is that, being overeducated like I am, I have that annoying tendency to feel like 'hey, let's collaborate on my treatment.' The funny thing is that a lot of doctors are actually cool with this.

(Eliza's comment is really interesting in this vein--because what if you have a variety of conditions and learn a massive amount about them? Are you the most annoying patient ever? How do you work with the doctors? Can doctors accept that situation with equanimity, given the fact that an ill person can become a sort of specialist themselves?)

You didn't mention that type--the college professor type. I'll bet we're annoying! But to be honest, I'm also intimidated by doctors...not so much because they know more (and they do know waaaay more...I recognize this fully) but because you have to ask them for things and this is hard for me--to ask people for things. So I don't like going to the doctor. I feel like I'm bothering the doctor.

I sort of extrapolate from my own job and think about how hard it would be to be a doctor...being a teacher is more like being a doctor than you might think--in the sense you have to constantly consult with people and meet with them and help them all day long--and this is so tiring. Except NOTHING is at stake...well, OK, students' futures. But not in the same way.

And therein lies the awe for doctors--so much more is at stake. There's just nothing like being a doctor. The level of dependence that people have--I'm burdened just by giving grades in the way I can affect someone's hats off to you Dr. Mama.

Anonymous said...

Making a difference is patient's lives is kind of a random thing - the one's that I jump through 1000's of hoops sometimes are the most ungrateful. Sometimes I say something that really resonates with a patient or parent and that's all it takes. I'll never know fully what kind of impact I have on people.
I disagree with a lot of the RD article - I like a good complicated patient. It exercises my mental muscle by trying to help them through all of the interconnected issues. One of my favorite patients is a 17 year old, 300 pound female who graduated high school with an associates degree, too. She's smart as a whip,fun to talk to, and has a lot of medical issues.
Then there are some of the beautiful people that will suck the life out of you with their hypochondriasm. I make a concerted effort to go into each exam room with an open mind everytime - because you never know. One of those same hypochondriacs now has alopecia totalis.

Anonymous said...

A lot of those statements resonate with me, but then again I got really tired. I loved what I was doing but after a certain point it became more giving than I had resources to give. I never renewed, reinvigorated or restored myself. I was too much of a darn martyr to find balance, so I couldn't keep up the passion.

Anonymous said...

As for being sued, eh...I think people sue for a stubbed toe nowadays. Back last year I was particularly suicidal. My family physician had no idea I had OD'd and I went to her 2 weeks after I came home from ODing and walked out with an Ambien prescription. Three days later, I OD'd on it. My husband called her and chewed her out for not "knowing" but how could she know. She asked for me to come in as soon as I was back out of the hospital. She then chewed ME out, which I deserved I suppose. I don't think she's sueable, but my husband wanted to. I stopped him from pursuing it because it just wasn't her fault.

BTW, I'm no longer suicidal.

Shirky said...

any advice on finding a doctor who is nice and normal and non-mean? it is hard for me to find a doctor even though I don't think I am particularly picky.
I want a doctor who:

1) does not treat me bad once she finds out I'm gay

that's pretty much it. It's harder than you think although I know they're out there.

Anonymous said...

Another maggot asks:

OK DM, I've got two stumpers for you:

1) Should you run sick? What is your personal decision tree when you are truly ill?

2)What about toenail fungus that running seems to induce? This isn't the same as athlete's foot that your toe/butt/vagina cream works wonders on. I'm talking the digusting, yellowing, fungal-infested nails. What about that, huh? And all those antifungal oral drugs seem scary because of their impact on major organs like, oh, say, the liver. Any advice/opinion/experience here? When I've inspected other runners feet up close, including my own, we all have a thick, flaky, yellow, nasty nails.


Nicole (SummersComing) said...

Rainy Saturday here yesterday so I read your whole blog. Figured I better comment in case you have a site meter and thought someone was a)stalking you or b)knew you in real life.

Negative on both counts. Although, I do find you very motivating. I am battling a very nasty increase in my PCOS symptoms and I am going to start running. The walking just isnt cutting it anymore. Thank you for "permission" to do what I have been craving to do, despite extra weight.

-Nicole in NY

Aimee said...

As someone not in the medical profession, this insider peek into what you're thinking is really interesting and helpful and humanizing. Thanks.