An old friend, who is a practicing physician, wrote to me last night. I haven’t had a chance to ask her permission to post her letter, but here’s my response. It might make some sense.
Tomorrow I’ll post part II of “Union of Patients,” which contains some unorthodox suggestions.
I think doctors have lots of good reasons to fire patients; I just think they should step up and state the reason. At least in New York State, a doctor can fire a patient with a certified letter giving thirty days notice. What the doctor does not do, and does not have to do, is give a reason. Wouldn’t we all be better off if the patient knew why s/he was getting kicked out? How can a patient learn or change if they don’t know the reason?
Without any question, anyone who violates a professional’s personal boundaries should have that professional’s services terminated. The doctor’s responsibility to interact with the patient ends at the office door.
Your next comments seem to involve two issues: patient responsibility, and the benefits of being sick.
My parents had a chronically unhappy marriage that lasted sixty-three years. If my father told my mother that he had chest pains, she would snap, “You might not if you hadn’t stuffed yourself at supper!” However, if my father told a nurse that he had chest pains, he’d get an ambulance, an EKG, an Emergency Room visit, a cardiologist consult, possibly a hospital admission, and follow-up appointments. A great deal of (very expensive) attention was focused on him, which made him feel like he was a valuable person.
I could go on at great length to give multiple variations on this theme, but it’s summed up by the woman who says—repeatedly—“My doctor is so worried about me!” What she means is, “I want my mother/husband/daughter to worry about me. I need somebody to notice that I’m not living a life that makes me happy.”
There are a lot of complicated reasons why people—particularly as they grow older—become emotionally focused on their doctors. One of the reasons is that Medicaid will pay for doctors, and transportation to go to doctors. Consequently, the doctor’s waiting room becomes the community center for many people. Imagine if Medicaid would pay for healthy choices: you can go to the doctor or you can go out to dinner. Which would make you feel better? Which would be cheaper for the taxpayer?
What options does the doctor have if the patient is gaining emotional benefits from staying sick? How about if the doctor agreed to continue seeing the patient only if the patient enters into a working relationship with a therapist, and brings the therapist to the physician’s appointments? Having the therapist in the room would (a) educate the therapist on the real medical issues, and (b) inform the therapist about the issues the patient needs to work on apart from the physician’s treatment.
Physicians are awful about not treating medical problems when the patient is also presenting with complicated emotional problems. Having a therapist in the room would also provide an advocate for the patient when her doctor is failing to treat her physical ills. [And remind me to write a whole piece on this.]
The other issue is responsibility: patients are neither encouraged nor permitted to take responsibility for their own health. The problem has many parts, the first of which is that we all want somebody to take care of us. We began as children who mommy and daddy took care of and as we grow, when we’re sick and afraid and feeling vulnerable, we still want somebody to take care of us. We want somebody to know what to do.
The bottom line is double: on one line is the fact that the doctor doesn’t have all the answers. On the other line is the fact that only Brahman/Yahweh/God/Allah does. We are asking doctors to save our lives when they cannot be saved; we are not asking the Divine One to save our souls when they can be.
And this is one of the places where we get into the doctor/god thing: we all like to have people look up to us. We all like people to think we have knowledge and power. It feeds our egos. Doctors aren’t exempt from this, so they may feed on their patients looking up to them as saviors.
Then there is the issue of compliance. If the patient wants you to fix them, then the patient is more apt to do what the doctor says, which is convenient for the doctor.
The problem is that, ultimately, only the patient can heal the patient—and if the patient doesn’t take responsibility for that then, ultimately, there’s nothing the doctor can do.
I have known many, many—way too many—people who will not take responsibility for their health. The doctor says very clearly and unequivocally, “You need to exercise,” but the patient won’t do it. It is faster and easier for both doctor and patient if the doctor writes another prescription and the patient takes it.
America is a country of fat people, and that fat leads to all kinds of respiratory, orthopedic, and self-respect problems, to name a few. The doctor can do a referral to a dietician, but what’s the use? The patient doesn’t want to start eating healthy; it’s easier to take diet pills.
Somewhere in my foggy memory there is a doctor telling me about a bad patient. When I said, “Why don’t you refuse to treat him?” the doctor replied “I can’t”—something about the canon of ethics.
I think that’s a bunch of crap. If the doctor is committed to the patient’s wellness but the patient isn’t, then the doctor should have the right to refuse any further contact. It is unconscionable to ask a doctor to heal you and then work against her. That’s like hiring a plumber to fix the problem in your kitchen and then going in every night and tearing out the work he’s done each day.
There are a whole lot of exceptions and tangential issues involved here, but the fact is that I took pills every day for twenty-six years and it nearly killed me. The healthiest I’ve ever been in my life was after I stopped taking pills and started (a) getting a good night’s sleep; (b) eating right; (c) engaging in challenging exercise, and (d) developing a mature spirituality.
Most people don’t want to take responsibility for their own health, and that is one half of a vicious circle. We did not get “health care reform” under the recent legislation from Congress. What we got was better ways to put more people in doctors’ offices and enable them to take more drugs.
That’s what the people wanted and that’s what the people got, and there’s no blame on the doctors for that