Physicians recommend different treatments for patients than they would choose for themselves. The preceding statment is true according to a similarly titled article recently published in the Archives of Internal Medicine by Ubel et al and has, I will argue, important implications for how we view the doctor-patient relationship. In the study, one group of physicians was asked to choose between two hypothetical treatment alternatives for either avian flu or colon cancer as if they themselves were the one with the disease. The other group was asked to choose between the same hypothetical alternatives as if they were making a recommendation to a patient with the disease (either avian flu or colon cancer). In the colon cancer scenario, both hypothetical treatment alternatives presented were surgical. One surgical procedure was 4% less likely to cure the cancer, but did not carry the same 4% complication rate as did the more curative procedure. The avian flu example involved a hypothetical treatment which decreases the chance of death due to flu from 10% to 5% and hospitalization rate from 30% to 15% but which also carried a 1% risk of a fatal reaction and a 4% risk of lower extremity paralysis. In this example, physicians were asked to choose between the options of treating versus not treating.
What did they find? Physicians were significantly more likely to choose the option which carries a higher mortality rate but a lower risk of complications for themselves than they were when making a recommendation to thier patient. Why was this the case? The authors point to cognitive bias. They suggest that the biases of “betrayl aversion” (an exagerated feeling of harm caused by an action designed to prevent harm) and “omission” (the added regret of harm caused by a treatment when compared with the same degree of harm caused by a withholding of treatment) are more at work when doctors are choosing for themselves than they are when choosing for patients.
The idea that we make better decisions for others than we do for ourselves and our loved one is entirely plausible. Indeed there is other research to suggest that this is the case. It is a big part of the reason why doctors shouldn’t operate on friends and loved ones, deliver their babies or, in my view, even prescribe them medications. This is why I am disturbed by what I believe to be the prevailing view in medicine today – namely that we, as Dr. Wes (http://drwes NULL.blogspot NULL.com/) recommends, “Treat every patient like our mother (http://drwes NULL.blogspot NULL.com/2011/06/for-interns-ten-rules-to-go-by NULL.html).” I will elaborate.
In the ideal situation, medical decision are based on good evidence, reflect the patient’s beliefs and values and are ethically permissible to the physician. For this to happen a good doctor needs to a) dispassionately weigh the evidence including all attending risks and benefits of any possible intervention and b) establish a relationship with his or her patient which promotes the expression of autonomy. Treating patients as we would ourselves or someone who is close to us (i.e. with kindness, respect and empathy) is clearly necessary for the latter of these goals. But, as the above study demonstrates, it is likely detrimental to the former.
Many commentators worry that the rigorous nature of medical training beats the empathy out of young doctors – that medical students loose their idealism during the third year of medical school, become jaded and cynical. This may be true, but is the wrong question to ask. I would argue that being caring and empathic are qualities which are necessary in order to effectively perform one’s function as a physician, but are not goals to be achieved for their own sake. Just as it helps us develop a rapport with patients and establish an effective therapeutic relationship, empathy impairs our ability to rationally weigh evidence and make decisions free of cognitive bias. Treating every patient like your mother should not be seen as an ideal to strive for. Rather, it should be seen as a first step which providers must then overcome in order to provide the best possible care.
Since it strikes at the very core of what this blog is all about, I couldn’t pass up the opportunity to comment on Dr. Karen Siberts recent op-ed piece (http://www NULL.nytimes NULL.com/2011/06/12/opinion/12sibert NULL.html?pagewanted=1&_r=2&sq=sibert&st=cse&scp=3) in the New York Times. She argues that, especially given the current shortage of primary care doctors in this country, being part of the medical profession confers one with the moral obligation to serve and, as such, conflicting interests, such as raising a family, should take lower priority. I worked with a radiology attending once who expressed a similar view of his relationship to his profession this way, “It would be irresponsible of me to have kids because I spend so much time working. I wouldn’t be able to spend enough time with them.”
The notion that doctors have a moral obligation to serve – to make their profession their top priority, their “life’s work,” as Dr. puts it, or their otherwise full-time endeavor – comes out of the still prevailing view that doctors have an obligation to the public as well as their patients. There are, of course, ways in which this is absolutely true. As licensed professionals, doctors do have certain obligations to the public, among them to maintain patient confidentiality, to practice in accordance with current standards of care and to address any dangerous or unethical behavior in their colleagues. As Dr. Sibert correctly points out, the practice of medicine is a privilege. Where I very strongly disagree with Dr. Sibert, is that being afforded the privilege of providing a particular service confers an obligation to do so. What is the nature of this obligation? How much medical care are doctors obliged to provide? How many hours per week is enough? What kinds of conflicting interests justify taking us away from the practice of medicine? These are personal considerations which every professional must answer for him or herself, not questions for public to answer.
There are a subset of physicians who do have a unique service obligation. The National Health Services Corps (NHSC) as well as many state funded organizations will pay back all or a portion of new physicans’ medical education debt in return for a commitment to practice in an underserved community for a specified time period. Doctors in these programs enter into a very special contract with the state and therefore have a unique obligation to serve the public which other doctors do not share. Yes, it’s true that residents’ salaries are paid largely by medicare. But, far from conferring true financial or symbolic debt upon residents, this payment is in return for valuable services that doctors provide during residency. If anything, it is the government who is indebted to new doctors for the years of nearly free service they are compelled to provide throughout the course of their training.
It is absolutely true that we have a current shortage of primary care providers in this country. However, we cannot and should not depend on doctors’ intrinsic motivation to work more simply because it is needed, or to move to rural areas simply because that is where they are needed, anymore than we should any other professional to do so. As much as we enjoy it when people voluntarily do things which are not in their own self-interest in order to benefit society, change needs to come through rational healthcare policy. The Affordable Care Act represents a first step in this direction by increasing funding for NHSC scholarships and with new grants to increase the number of primary care residencies. This is how the problem must be addressed. A doctor’s relationship to his or her profession and the number of hours per week that he or she decides to practice is a matter of personal, philosophical reflection, not a matter of moral obligation or public debate.
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Thomas Nasca, CEO of the accreditation council for GME published, on October 28, 2009, an open letter (http://www NULL.acgme NULL.org/acWebsite/home/NascaLetterCommunity10_27_09 NULL.pdf) to the medical community. It details the findings of a 16 member ACGME (http://www NULL.acgme NULL.org) task force regarding the effect that limiting resident work hours has had on medical professionalism. Thanks to DB (http://www NULL.medrants NULL.com/archives/4973) for bringing it to my attention.
My problems with this letter are severalfold, but can mainly be distilled down to the following. Dr. Nasca would seem to suggest that it is ACGME’s belief that medical professionals, bound as we are by the oath of Hippocrates and motivated as we are by altruism, should not be held to the same standard as other industries when it comes to safety and work hour regulations.
Thus, while residents must not be forced to remain on duty for excessive periods, they must not be precluded from demonstrating the caring and commitment required of them as altruistic professionals. ACGME’s standards, and the expectations of the public of the nature of enforcement of those standards, must match this important principle. It is here, as in other places, that the analogy with the airline industry fails. A pilot, running out of hours, can refuse to fly the plane, and the passengers are no worse off for the decision, other than the delay. The Neurosurgeon, faced with a patient requiring an emergency craniotomy, does not see an option to, nor does he or she want to say no. The patient struck by a car, with multiple trauma, acute rhabdomyolysis with hyperkalemia and acute renal failure, needs dialysis now, not after the Nephrologist has slept for five hours. The patient needs and demands no less, as does our vow of Hippocrates.
I vehemently, though respectfully, disagree, Dr. Nasca. It is here that the analogy to the airline industry is more appropriate than ever. No more is it ok for a pilot – who is responsible for over a hundered lives – to violate his work hour restrictions than it is for a neurosurgeon who has been awake for 14 hours to perform an emergency craniotomy despite the fact that it is only one life that is at stake. Taking care of patient needs in violation of duty hour restrictions is not the hallmark of professionalism. Quite the contrary. Lack of adherence to standards that are put into place for the explicit purpose of protecting patient safety is irresponsible and clearly unprofessional
Within the boundaries of reasonableness, and with a goal of patient safety, residents must demonstrate willingness to sacrifice for their patients’ needs, being taught and given the opportunity to demonstrate the practical manifestations of altruism, the core virtue undergirding professionalism.
In this case, Dr. Nasca, I will vehemently and disrespectfully disagree by referring the above quoted text as ‘BULLSHIT!’ As professionals, it is not our job to “sacrifice” for our patients – unless you’re referring to the whole enterprise of being a doctor as “sacrifice.” On the contrary, it our mandate as professionals to remove ourselves from situations in which our own well being has the potential to come into conflict with that of our patients – just as any professional in any other industry should recognize when his or her interests come into conflict with the interests of those whom he or she is purported to serve. I don’t know about you, but I don’t want my doctor to be in any situation in which he may have to choose between my well being and his own.
I think the medical profession is going to continue to struggle with this issue until there is some kind of cultural shift toward a more rational conception of the doctor-patient relationship.
The L.A.P.D. searched the office of Michael Jackson’s doctor yesterday. According to DEA spokesperson Rusty Payne, whose agency is assisting with the investigation, the search warrant was issued relating to the drug propofol. Propofol is a powerful anesthetic and is almost never used outside of an operating room or ICU setting – certainly not the kind of thing any doctor would ever admit to prescribing on an outpatient basis. So far, there seems to be only speculation as to why authorities suspect Michael Jackson had propofol in his system. According to E! online (I’ll have more reliabe sources for you when this blog generates enough revenue to hire a full-time researcher) the preliminary results of a second autopsy turned up lethal amounts of propofol.
Obviously, we need a lot more information before deciding on the gullt of innocence of Michael Jackson’s doctor. But, what if he did OD on propofol? Maybe that’s what his doctor was using to treat insomnia. I’m only playing devil’s advocate here, and I challenge the reader to not so quickly dismiss the above described scenario as malpractice at best, manslaughter at worst. After all, in primary care we give patients drugs to help them sleep all the time. These drugs have risks; people can and do overdose on them. Your response is probably along the lines of, “But propofol for insomnia! This is madness. The risks of giving someone propofol in an unmonitored setting vastly outweigh the benefit of helping them sleep!” Sure, I don’t disagree with you. But how does one decide where to invoke one’s own values preferentially over patient values? I mean, if the patient truly understands the risks, maybe the risk does outweigh the benefit from his or her perspective.
One solution is, simply always let the patient decide. If he understands the risks and benefits of treatment, prescribe whatever he wants. You’re just the expert consultant, the patient is the one directing care.
At other extreme are those who wouldn’t subject their patients to any risk whatsoever unless they have clear evidence that treatment will result in decreased for morbidity or mortality. Such a doctor will never treat something like insomnia until someone can prove that people with untreated insomnia die sooner or have some other, quantifiable, adverse outcome and that said outcome is worse than the risks of treatment.
Most of us fall somewhere in the middle. But where? How do you decide? This question is particularly relevant to treating patients with chronic pain. How much pain medication do they need? Who decides? The solution I favor is to legalize all narcotics. Make them widely available so that people can treat themselves taking doctors out of the equation completely. There is no science, after all, to inform us as to how much pain medication is “enough.” There is no “optimal” dose aside from 0mg PO q4hrs prn. The less you take the better. You don’t need a doctor to tell you that. Of course, that doesn’t mean you shouldn’t see a doctor. Your doctor may be able to diagnose and fix whatever it is that’s causing the pain, obviating the need for pain medication. That would be ideal. Unfortunately, doctors aren’t always able to do this. Which puts us in the unenviable position of either prescribing or withholding medications that only increase morbidity and mortality and have only subjective benefit?
I had an epiphany today regarding the most concise way to articulate my longstanding position on disparities – be they in health care or in any other sector of society. I may have only written one post on this topic previously…you can find it here (http://www NULL.jamesloganmd NULL.com/2008/07/index NULL.php#000057). Turns out I wrote it exactly 1 year and 1 day ago.
In his research lecture, one of our faculty members defined disparity in the following way: “A disparity is a mismatch between need and care associated with membership in one socially identifiable and disadvantaged group compared with their non-disadvantaged counterpart. This may include, but is not limited to race/ethnicity, socioeconomic status, culture, rurality and disability.”
My qualm has always been with race. I have no problem looking at disparity based on socioeconomic status, or gender or a whole host of other things. These represent real differences and it’s fine that they continue to be real differences. We don’t need everyone to have the same amount of money, have the same age and to be the same gender. As regards to race, I seem to remember a time when the ideal society was conceptualized as “color-blind” – one where race was not a significant difference and thus peoples of different races would not even be recognizable as socially identifiable groups. What happened to that? I mean, maybe we’re not there yet, but isn’t this still the end goal? I believe that we reach this goal not by looking at every place where there exists a disparity and correcting it, but rather by ignoring such places as there exist disparity. Paying attention to racial differences only reinforces that they are real and important – which, I think most of us agree, they are not.
We have to work hard enough to overcome our differences as it is. Why place greater emphasis on them than they merit? Whatever happened to the goal of having a color-blind society?
Have I written about this before? It seems like I must have. I certainly have been bombarded with the idea that doctors should screen their patients for relationship/domestic violence during these last several weeks. And the idea continues to appear no less ill-conceived.
As any good epidemiologist knows, if you are going to screen for some condition, that condition should meet two basic criteria:
1. the condition you are screening for should be asymptomatic
2. intervening earlier should have some effect on the disease process in terms decreasing morbidity and mortality.
There is also the issue of cost-effectiveness which it only makes sense to talk about once criteria 1 and 2 are met. Domestic violence fails to meet the first criteria – it is not asymptomatic. Getting hit, kicked or raped by your partner are all symptoms of domestic violence. By screening for it, we are not using our medical expertise to identify a condition for which we can intervene, thereby helping our patients live longer and healthier. What we are doing is identifying a condition that our patients already know that they have (because the only way we know they have it is by asking them) and then telling them that it’s a problem. Telling patients what is or is not a problem rather than letting them decide for themselves is pretty much the definition of paternalism.
I don’t deny that the prevalence of domestic and relationship violence is huge. Nor that there are thousands of women out there in very bad situations. And I’m glad that there are some resources that these women have available to tap into. But, I don’t believe that there is anything about medical school or residency training that confers the expectation upon doctors that they identify ALL of their patient’s problems and try to solve them. Patient’s may have a whole host of problems which doctors are equally unqualified to deal with. Should we screen our patients for excessive credit card debt? Excessive debt can cause huge emotional distress, bankrupcy and can ruin lives. But, I’ve never heard of any doctors advocating that we should screen for excessive credit card debt. Why is domestic violence different?
Now, if a person comes in complaining that they’re being abused by their domestic partner, I’m more than happy to put her in touch with appropriate resources. But this is not the same as screening. This is a case of the patient having identified a problem and asking for help. And, as a doctor, I will provide whatever help I can. But seeking out patients via screening in whom you try to identify an additional problem? This is fine for conditions like diabetes, hypertension and cervical cancer – conditions for which our medical training has supplied us with privileged information about how much of a problem the condition may or may not be for the patient. But we have no privileged information about how much of a problem the behavior of our patient’s boyfriend is for her. She is much more qualified to make that determination than we are. Therefore, in the final analysis, it simply is not a doctor’s place to screen for domestic violence.
Just ran across Dr. Phil and a panel of “experts” all giving their opinions about the woman who gave birth to octuplets, the fertility doctor who helped her get pregnant and the hospital where she gave birth – among other things. Note: I do not routinely watch Dr. Phil. We don’t get very good reception where I live. I have two channels worth watching and then a bunch of crappy channels. It was on one of these crappy channels that I found Dr. Phil. He won out over celebrity news and black history documentary.
In any case, I think it’s time for the medical community and the press to leave the octuplets alone. We don’t know all the details. We’ve said our peace about the limits of what kind of medical procedures consenting adults should be permitted to agree to. Good night, good luck and we wish them all the best.
In his op-ed piece in the Philadelphia Inquirer, Art Caplan argues that the fertility doctors involved engaged in “grossly unethical” conduct by failing to set limits on who may take advantage of reproductive technology (article here (http://www NULL.philly NULL.com/inquirer/opinion/39190377 NULL.html)). The idea that patients are not entitled to whatever elective procedure they ask for and that doctors may ethically refrain from providing certain procedures based on their own perception of the potential risks involved is widely accepted and I have no disagreement with Prof. Caplan on this point. But, to claim that it is simply obvious that inserting 8 embryos puts the woman and her potential offspring at grave risk and should not be done is entirely unhelpful and unsatisfactory. There is a rather long list of elective procedures which doctors routinely perform – procedures which are not “medically necessary” in the strictest sense, procedures which subject the patient to unnecessary risk and procedures which at the same time are NOT considered to be unethical – or at least not obviously so. Among these: any type of fertility treatment, gender reassignment, any type of cosmetic procedure, gastric bypass surgery, vision correction procedures, etc. Shall we have the government weigh in on ALL such procedures in order to make sure that rogue doctors aren’t practicing unethically, or shall we keep such decisions between the doctor and the patient as has been our tradition? I believe the government does have a role to play in keeping us safe which is why I believe the limit of 3 embryos per in vitro cycle imposed by most European countries is not unreasonable. But we must tread with great caution when allowing the government to have a say in decisions once made exclusively by a patient in consultation with his or her doctor. Other medical procedures our government has legislated upon include female circumcision, electroconvulsive therapy (banned in Berkeley, CA) and, of course, abortion. We should be careful about adding in vitro fertilization to what should and must remain a very short list.
My Suzuki GS 500 had been acting up. It would start up great, but whine, sputter and stall whenever I open the throttle. It was becoming unsafe to ride, so I took it to my local mechanic last week.
GARY (my mechanic): Hi James! Come, sit down. Let’s have a chat about your motorcycle.
GARY: Is there anyone else you’d like to have here for this discussion? Anyone else who needs to be informed about what’s going on?
JAMES: No, I don’t think so.
GARY: And you’re the primary decision maker for the GS 500?
JAMES: Yeah, that’s right.
GARY: James, what’s your understanding of what’s wrong with your motorcycle?
JAMES: Um, it’s not working.
GARY: Sure. And what’s your understanding of why it’s not working?
JAMES: Um, I don’t know. Seems to me like a problem with the gas tank or carburetor.
GARY: That’s right. When I took off your gas tank, I found some rust and mud inside. That rust and mud can get into your carburetor and keeps the engine from getting fuel which causes the erratic behavior you were experiencing. This kind of thing often happens when the bike is left sitting for a long time without putting stabilizer in the gas tank. Have you ridden this bike at all during the past year before bringing it in?
JAMES: Not really.
GARY: And did you put stabilizer in the tank?
GARY: James, what do you see as the main barriers to your accomplishing these things?
JAMES: (sobbing) I – I don’t know! I’m sorry…I just, it’s hard. You know? You get busy and there’s no time and sometimes it’s just easy to let things slide.
GARY: Sure, it’s hard for all of us. But it sounds like you’re interested in changing your behavior. I would say you are in the contemplative phase of motorcycle maintenance behavior change. The next thing we need is a plan in order to get you into the action phase.
JAMES: (sniffles) Ok. What should I do?
GARY: I’m going to give you the tank from your motorcycle. I want you to take it home tonight.
(opens the tank and shines a light inside revealing extensive rust spots) See that rust inside? I want to you fill your tank with dilute acetone. Then put some bolts inside. Swish it around for a good 30 minutes. That should break up the rust. Then, empty out the acetone. You can fish the bolts out with a magnet. Once the rust is out, you’ll need to prep the inside. You can get a prep kit at any motorcycle shop; the instructions are right on the bottle. When that’s all done, bring the tank back to me and we’ll have GS 500 up and running again in no time.
JAMES: Ok, I’ll do it. I just miss riding so much! Are you sure my motorcycle is going to be ok?
GARY: Yes, it’ll be fine. But, I should tell you that whenever there is a possibility of motorcycle neglect or abuse, I’m legally obligated to make a report to the Department of Automotive Protective Services or DAPS. Your GS 500 will have to stay here until the DAPS representative has determined that you can provide a safe home environment.
I nodded and took the diseased gas tank from him, promising myself that I would show my motorcycle the love and attention it needs from now on.