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.

Yup.

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.

Yup.

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.

and

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.