Tag Archives: doctor patient relationship
Why Doctors Don’t Come Clean To Their Patients
Brian Goldman, Leana Wen, Archie Cochran, are all doctors who dared to challenge the status quo.
When Leana Wen decided to become a doctor she was inspired by her childhood pediatrician, a woman who allowed her patients to know her, not only as a doctor, but as a person, showed a sense of humor, and treated them not as merely a body, but as a human being with dignity, relating to each patient person-to-person.
Dr. Wen went through medical school and residency with this role model in mind and when she graduated and became a doctor she never fully realized how insular and secretive a microcosm the field of medicine had become until she shared with a group of colleagues and merely proposed “why not be transparent to our patients?” This innocent question suddenly made her a target for a full frontal attack on her by those very people who were supposed to be her peers and supporters.
Archie Cochran, a doctor and a prisoner in a German prison camp during WWII challenged the status quo and the mystique that doctors often embrace when he realized that prisoners were lacking in Vitamin B12 and Vitamin C. Not only were other prisoners suffering from a mysterious illness but so was he. He has Marmite (an English bread rich in Vitamin C) smuggled into the prison. Informally he gives half of the prisoners B12 and the other half Vitamin C and their illness improves. He publishes his findings but feels that nobody will listen or care about what he’s discoverd.
Later a young German doctor discovers the material, is shocked this is happening, and says to his colleagues that something must be done; that this data is irrefutable and that it is actually a war crime not to provide vitamins to those prisoners. Next morning lo and behold vitamins show up at the prison.
After he himself had recovered in the prisoner of war camp, Archie Cochran later spoke before colleagues at a lecture in which he presented findings of a clinical trial he’d conducted on whether heart attack patients recovered better at home or in the hospital. The prevailing thought at that time said that patients recovered better in the hospital and that having them recover at home was absolutely “unethical!” In his presentation he initially told them his hypothesis that patients recover better in their own homes was wrong and that he stood corrected. There was an uprorious response to this announcement delivered with lots of hate hurled at him, denouncing him and in effect they called him an idiot, telling him he was killing people and to shut the experiment down….Only that’s not where it ends.
Once the din subsided he resumed his speech and proceeded to reveal that in fact he had not been wrong and that the statistics he’d read them were actually reversed! He explained that the study showed that people in fact recovered better in their homes than in the hospital. In response to this earthshattering revelation you could hear a pin drop; no uproar, no cheers, no congratulations, but instead a chill that permeated the lecture hall as his colleagues seethed in silent anger in their seats.
In this video by Tim Harford, a writer on economics uses the analogy of design of a product to illustrate why using trial and error in todays complex medical system is important, why doctors should not be put off by what they may view or be told are “unproven” theories or treatments, and why approaching the job with humility actually works better than to adopt a stance toward patients of omniscience and omnipotence.
Medical books and the long drawn-out and rigid standard of placebo-controlled clinical trials don’t always work when you’re working with real people in the real world, and a one-size-fits-all approach to patient care ultimately sells patients short. As Tim Harford says, “People are not machines. It’s not like fixing a car.”
When the doctor cuts patients out of the process and expects total “obedience”, “compliance” rather than a meeting of the minds with an aim to solve a problem he/she loses a valuable opportunity because even out of mistakes can come happy accidents, and ultimately important medical discoveries.
If what is written in the books is in fact wrong that causes improper treatment of patients for years. As one former paramedic friend said to me, “Bodies don’t read books.” This is why the doctor patient relationship and listening to the patient should come before any textbook. Just because a book says “If a patient has these symptoms you must do X” one shouldn’t apply this across the board as if it were a pat formula for all patients who have such symptoms.
Throughout history theories have been accepted by mainstream medicine and then decades or centuries later, dismissed as outdated. It is tragic that many pioneers in the field of medicine who challenged prevailing thought were persecuted for doing so, sometimes until death, and that many were never recognized for their important contributions when they were alive.
Doctors are expected to know everything and never make mistakes (not by patients but by their own peers). They are “kept in line” by their own profession, and outed for being non-conformists and trying empirical or off-label treatment approaches (as is often the case with doctors treating chronic Lyme Disease and Chronic Fatigue/ME patients).
When they expose real corruption in their peers, report them for patient abuse or neglect, and/or their place of employment or refuse to be a part of it their careers are often threatened and sometimes destroyed. What is done to patients by doctors in the form of gaslighting and character assassination is the direct mirror image of what their peers and employers do to them if/when they attempt to go out on a limb for their patient(s). It doesn’t even have to have happened yet to a particular doctor. Just the fear and unspoken “threat” that it could by virtue of urban legends and talk around the water cooler is enough for most doctors to “stay in their place” and too often fail to act in a patient’s best interest.
Drawing outside the lines can have dire consequences. This is made clear in subtle and sometimes not so subtle ways along the path of a doctor’s career. A patient may be left dangling and minimally or untreated for months and even years because a doctor is more afraid of the corporation that employs him or what other doctors might say or do to him than afraid that a patient may get worse, die, or that a family may sue.
Why? Because when conventional treatments don’t work sufficiently a doctor is often given the message (and sometimes directed by policy) by the employer he works for to do nothing. If he sides with the employer and does nothing and a patient dies, gets worse, or a family sues, he is shielded by the corporation he works for and they take the heat as his supervisor which legally is ultimately the responsible party, however, if he sides with his patient against the recommendation of his employer and or most widely accepted treatment practices of his profession it is highly likely his employer will either fire him or claim they had no knowledge of his actions and claim he is singly responsible should anything go wrong.
Most doctors in today’s “managed care” environment work for corporations, therefore they stay “on the safe side” often to the detriment of their patients. They become comfortable as puppets of the corporation in exchange for certain comforts and immunity provided them because of the power and wealth of the entity which employs them such as a Legal Department, Dept, of Patient Relations, Risk Management Dept. etc. The corporation may offer them some sort of 401K or retirement benefits, they don’t have to worry about overhead, nor do they have to hire office staff or billing staff and pay them out of their profits as they would if they were in private practice. They give up a considerable amount of decision-making power and autonomy in return for those perks…and oftentimes they sell their soul.
There is one unwritten rule that all doctors working for a corporation are expected to live by; to uphold the reputation of the corporation they work for. The employer may or may not officially put this in their contract, but the implication is clear and unmistakable.
The moment a doctor signs on to such an arrangement he/she takes on the face of the corporation. For the same reason that large gifts of money from special interest groups to state and federal legislators and people running for office are problematic, so is this kind of working relationship in which a doctor is “housed” within a healthcare company. From that moment onward a doctor has divided loyalties. It is likely that doctors in such environments are confronted with daily ethical dilemmas of one type or another, but as patients we rarely hear about them.
For the patients reading; how many of your doctors have openly admitted that their employer instructed them to do something they didn’t ethically agree was in your best interest? I doubt very many have. And as Dr. Leana Wen suggests wouldn’t it be better if they openly disclosed this to you, and said, for instance, “I agree with you that it makes sense to try this treatment but I’m afraid I would lose my job if I move forward to order it.” Only then could doctor and patient stay alligned, engage in effective disalogue, and figure out how to handle that obstacle. Instead what too often happens is that the doctor presents the circumstances very differently, refusing to accept valid reasons or proof offered by the patient as to why this would be a good course of action, denying the existance of a condition, falling back on a dictatorial or hostile stance, even questioning a patients’ sanity or motives (none of which are effective coping mechanisms in their work, and only serve to place doctor and patient at odds).
That said, doctors do have their part of the responsability to put their patients first. While as patients we can acknowledge that doctors have pressures placed upon them these facts do not excuse doctors from the responsibility for placing highest priority on the health, safety, and wellbeing of their patients. Whatever conflict-of-interest that may exist in their relationship with their employer they, not we have chosen that trade-off and it is up to them to find a way out of this divided loyalty conundrum.
I get it that they’re often scared to make a move on behalf of their patients for fear of retribution or retaliation from either peers or employer, but it is encumbent upon them that they refuse to trade our comfort for their own.
The symbol of Caduceus, a staff with wings and two snakes wrapping around it in Greek Mythology was carried by Hermes. In Roman Mythology it was carried in the left hand of Murcury who was said to be the messenger of the Gods (emphasis on the word, Messenger). Not God himself, LOL. Here’s an excerpt from that article;
“It is said that the wand would wake the sleeping and send the awake to sleep. If applied to the dying their death was gentle; if applied to the dead they returned to life.”
Another symbol, The Rod of Asclepius is often used to denote the field of medicine and it seems was the original symbol.
Nevertheless, the original message was supposed to be that doctors were given this responsibility by God, a mission to attend to the health of their patients. It was never meant for them to abuse the power that comes with the responsibility against their patients just because there are currently no legal consequences. It is a moral imperative. This message also comes through loud and clear in the Hippocratic Oath.
It is said that in order to change a person must first admit there’s a problem. When I was abused, bullied and defamed at Emory Healthcare I was only given empty apologies. “I’m sorry you’re not satisfied” is not a sincere apology. I tried to suggest a number of solutions including my being on their board of directors, getting involved in sensitivity training for their residents, and a number of other ideas but every one of my suggestions for conflict resolution was turned down. They weren’t interested in fixing the problem THEY created because they weren’t willing to take the first step in admitting there was a problem.
A genuine apology involves 3 important parts;
“It’s my fault. I was wrong”, and
“What can I do to make it right?” Then really doing it.
There are some doctors who got this right and then began a dialogue with patients to improve relations. Here is one of them. He says studies have shown that in addition to being the right thing to do, apologizing actually makes the risk of lawsuits less likely. Patients really are not wanting to sue and generally only do that as a last resort when a doctor absolutely refuses to accept responsability for his actions. In fact most patients just want the mistake or wrong decision corrected so they can go on with their treatment and go on with their lives.
It seems that the root of the problem lies in that there are too many middle-men between doctor and patient who have no business being there in the first place and that further confuses a doctor as to what his job description is and who it is he is there to serve. The power structure in too many medical facilities as it exists today encourages (if not dictates) that doctors sacrifice their patients’ best interest in order to save themselves in a hostile work environment where doing the right thing is frowned upon heavily.
In fact, doctors are actually reinforced for putting a patients’ best interest last, corporation first, and him/serself second.
In a word? Unbundling. Quite simply corporate-controlled healthcare doesn’t work in the long-term for most of those in it (except for those in top-heavy positions in administration who are making six figures or more). It doesn’t work for doctors, it doesn’t work for nurses, and it doesn’t work for patients.
Doctors must find creative ways to practice outside these corporations which now have bought and paid for so many’s silence and collusion. The cycle of abuse has to stop and doctors need to go back to working for and with patients as the profession was originally intended.
Sign the petition for a legislated system of accountability for all chains of command. This is just the beginning of a new system of healthcare.