Tuesday, October 20, 2009

Every Patient Tells a Story



You just don’t feel right. Maybe you’re a little more tired than usual. Your muscles themselves seem weak. That’s odd, since you lift weights nearly every day. Maybe you’re just pushing yourself too hard. Over a few months, you notice that your handwriting is hard to read, and it takes both hands to lift a cup of coffee. In the Emergency Room, they said that you weren’t having a heart attack and sent you home. Then, gradually, your fingers seem less sensitive….

In this remarkable book, Dr. Lisa Sanders opens a new and original window into the diagnostic process. As patients, we’ve all had a sore throat or sprained ankle, and the doctor’s work seemed obvious: do a test, get an x-ray, write a prescription. But sometimes we don’t have a straightforward collection of complaints that we could have figured out by ourselves. Is the headache I had a few days ago somehow connected to my cough today? How do doctors make sense of the information we give them?

She’s got great material. As the long-time author of the Diagnosis column in the New York Times Magazine, she has been collecting the stories of diagnostic hits and misses for years. She uses her network of medical contacts to find the valuable pearls of seeing patterns in what looks like chaos. Her column’s focus on diagnoses that aren’t obvious always makes for compelling reading that can’t be put down.

But there’s a lot more in this book than a compilation of some of her columns. In her Diagnosis writing, she seems like an invisible narrator, allowing us to observe a medical detective story unfold before our eyes.

Every Patient Tells a Story has plenty of those medical mysteries. But Dr. Sanders has shared not just the events, but her own insight into the process. She’s completely candid about missed diagnoses, tests that should have been done, questions that should have been asked—including instances when she was the physician who might have done better. She does not hesitate to point out the dangers of skimping on the physical examination of every patient, and has convincingly written about changes that need to be done to change medical education in a way that brings physicians back to basic exam skills and diagnostic thinking.

The book’s focus is not the detective stories, though they are fabulously written and fascinating to read. It is the process of discovery that clearly interests her. Why do some doctors miss something again and again, even though it’s right in front of them? Why do others see what’s hidden? How can we teach doctors to see the forest for the trees? Computer technology would seem to lend itself well to the understanding and improvement of this kind of analytical task, in which diverse bits of information are processed into a coherent result. She examines the development of artificial intelligence models for making a medical diagnosis, with data to illustrate their weaknesses and strengths. (They’re not quite here yet.)

Dr. Sanders makes her strongest arguments when pointing out a major weakness in physician behavior. The title, Every Patient Tells a Story, says exactly what she means. Doctors need to listen to what the patient has to say. Again and again, the trail of clues—even to the most obscure and unlikely diagnosis—starts there.

This is the most interesting book I have read in years. I couldn’t put it down. The narrative stories are fascinating, and her insight is right on target. Everyone who’s ever been a patient, and certainly every doctor, should read it.

The book moved me in many ways, so this won’t be the only blog post about it. If there’s a unifying theme to the book, it’s the importance of doctors listening to what patients say. Yes, she points out at length how many doctors don’t do or don’t respect the physical exam. She describes interesting cases in which basic observation would have provided a crucial diagnostic clue, yet the doctor didn’t observe—or maybe didn’t see—what was right in front of her. I don’t know if this was the work of her editor, but she does a very good job of staying ‘on topic.’ That’s a reasonable thing, and makes the book focused and coherent reading.

Dr. Sanders gives convincing proof that doctors are skimping on the physical exam of their patients, and doing a particularly poor job listening to patients. Many of the stories she recounts hinge on a key physical observation, or an event the patient described but didn’t seem important at first. She describes some new educational methods to improve these weaknesses. For example, doctors in training are now required to pass a practical exam on interacting with and examining a patient.

That’s a great idea, but I’m very pessimistic about its long-term impact. Here’s a statistic I’d love to see that she did not mention in the book: for a perfect score in this practical patient exam test, how much time would be necessary? Even if it wasn’t done by a medical student—I want to see the head of a patient-care department do it. Even if that department chairman had the notes in her hand (the teacher’s edition of what tasks had to be done in that exam to have a perfect score), how long would it take? I know nothing about this effort, and I applaud it. But when I read about it in the book, I started to think: introduce yourself, wash your hands thoroughly, find a seat and sit; describe what you’re going to do, ask some basic demographic questions. Most important in the interview: ask open-ended questions, listen to the patient’s complete answer. I figured that before even the most organized and experienced interviewer got to the physical exam, quite a while would have gone by. 15 minutes? 30? More?

Many medical practices schedule patient visits every 20 minutes. Some places I know are every 10 minutes.

I discussed this in my series of posts called Slow Medicine. I’ll add, after reading this book, that if the factory model of medical care is, as Dr. Sanders shows, likely to result in missed diagnoses and frustrated patients, it’s much, much more of a problem with children.

In pediatrics, the patients often don’t get to tell their story. I believe that every child does tell a story about themselves. The only way to hear it is to take the time to establish some level of rapport with the child. With many children, and with children the doctor is meeting for the first time, that’s just not possible in 5 or 10 minutes.

Until doctors stop getting paid per visit, the irresistible pressure to see more patients and spend less time with each one will force those laudable lessons of medical school into the dusty trash bin filled with good ideas.



Book Review, Part 2

The key success factors that make diagnoses appear for some and stay hidden from others are pointed out in compelling clarity by Dr. Sanders.

She's just the right person to do this, too. Writing her column in the New York Times Magazine, Diagnosis, she must see hundreds more cases that she can possibly write about. Each of the cases are intricate, and even for relatively common conditions the diagnosis often hinges on one key piece of information—sometimes a few pieces. And very often, the clues are there in the patient's own words. Sure, a specific test might confirm it, or rule out some alternatives, but in many of these mystery cases, the patient's story is indeed the single most important factor.

This has led her to important insights into the method of diagnosis, and the impediments to teaching it. She cites evidence that key physical exam skills continue to weaken among recent trainees. I recall hearing that when I was in medical school 15 years ago, and an older colleague confided that he had heard it 35 years ago also. (I speculate that the optimal exam skills are probably found in places where there is not enough technology to do the work for the physician, but there is just enough to validate the doctors findings. Maybe this should be called the second world, somewhere between First and Third.)

And most importantly, she documents the failures of listening skills among doctors. Frequent interruptions, closed-ended questions, and premature closure of the differential diagnosis are cited by example and in research studies. Her thorough approach assesses the impact of artificial intelligence decision models and innovations in hands-on medical education. As I pointed out in my previous essay[link to epts1] on this great book, however, the current economic model of physician-patient interaction is likely to put irresistible pressure on the examining physician to keep visits short, questions closed, and interruptions as frequent as ever.

Every Patient Tells a Story is about doctors. How they think, how they approach patients, problems, and data. It's particularly brave of her not to sugar-coat the stories of several doctors missing an important diagnosis because they didn't do the full job of examination and history-taking. She never says, but it's clear by example, that some doctors are just more motivated and tenacious than others about getting to the bottom of a patient's problem. Dr. Sanders does a superb job of pointing out what some did right.

But there's another book here, too. It's the unwritten shadow book, this same book, these same stories, through the looking glass. Sanders gives the reader insight into what is usually invisible to them—the intensely caring physician who's calling all her colleagues and spending time in the library for the benefit of a patient. The mirror book would give the physicians insight into what Sanders shows to be completely invisible to them: what the impact of a rushed or absent physical exam means to the patient, how the frequent interruptions feel, the frustration of not being able to tell the story that every patient tells.

Illness often affects us in unanticipated ways. For a child, the new feeling of feeling bad is usually unfamiliar and frightening. Fortunately, the relationship I have with most of my patients is helpful under these circumstances. Kids are usually not afraid of me. Many awaken and tell their parents that they need to see Dr. Wolffe, just because they think I'll make them feel better. I'm not interjecting this to brag—I think it gets to an important part of the patient-side of Every Patient Tells a Story. Usually, when I see a sick child, I don't start even by talking to the parent in the exam room. I am totally focused on the child. I always start by asking them if anything hurts. They generally will tell me, often to the surprise of the parent. I ask them to tell me how it happened, what it feels like, and when it started (this last is often the least dependable of the questions, and sometimes results in a 3-year-old telling me that her ear has been hurting for 5 years, while holding up 2 fingers). Only rarely does a parent not interrupt. This is done, I know, with the best of intentions, to help give me the most accurate information on which to base my professional assessment. They stop when I hold up my hand and indicate that I want to listen to the child, but they will get their turn soon.

Here's why I do it. It makes the child feel better. To them, their symptoms are not just uncomfortable. The symptoms are out of their control, and appear to trigger actions by their parents that are obviously concerning and also out of their control. This all can be very anxiety-provoking. I purposefully give them this opportunity to voice these anxieties in a safe place, where they can say it their way and I will listen to them and respect them.

One of my patients just started preschool for the first time. Every morning before he was to leave, he complained of a stomach ache.

Just like adults and headaches, there are stomach aches of all different kinds and intensities. It didn't take a particularly intense interrogation to figure out that the child wasn't having any other gastrointestinal symptoms. The pain started on the first day of preschool, when mommy was leaving for work. A couple of times she called in sick to stay with him. On those days, his abdominal pain vanished as soon as she said she'd stay. I gave the mother some ideas of behavioral things to try to make the transition easier, and told her to call and let me know how it was going. Realistically, no exam was going to help me make a diagnosis in this happy active boy who was running and jumping around in my office. But I knew that the exam could have a powerful effect on the patient. I had listened to him tell his story. But he had to know that I would understand his pain when I examined him. Carefully, without joking, I listened to his chest and stomach. I looked in his ears and mouth, felt his neck. And last, I slowly examined his abdomen. I had a serious expression on my face, as if searching for something. Finally, I spoke to his mother directly, with him in the room. She's a school principal—but I used mostly 1-syllable words in my most grown-up voice and cadence. 'I can see what the problem was,' I said thoughtfully. 'I'm sorry he was so sick and his tummy hurt so much. I think it's all better now and it won't hurt any more.'

OK, maybe the analogy to this use of the placebo effect isn't perfect. But I hear it from adults all the time. 'The doctor saw me but he didn't even examine me.' I hear it from my mother.

I believe there is something important in gentle physical touch. During a physical examination, the touch isn't as a friend, and sometimes elicits pain. But the touch of the doctor's hands is more than a one-way data cable from patient to doctor, providing resources to the diagnostic algorithm. The patient is getting information, too. The patient's information is not examined in Every Patient Tells a Story. I suspect some of the information is about the caring of the physician. But the deliberation of the touch, how unhurried it is, how focused it is on finding out just where it hurts are all things that I suspect every patient perceives. And patients value this as well.

This is more than a placebo effect. Obviously, when we don't feel well, it's good to have somebody available who's a sympathetic and patient listener, a good observer, with a gentle and caring touch. That would make anybody feel better. But I think there's an important feedback loop here that has a real impact on the Story that Every Patient Tells. It's the rapport, the unrushed atmosphere in the exam room, the openness of the examining physician that elicits that story. And hearing that story--listening to that story--can sometimes determine if the patient lives or dies.


Book Review, Part 3
What, exactly, is a physician’s ethical obligation to a patient? Though not discussed in the book, Every Patient Tells a Story, the question lingers in my mind after a careful reading.

A man with chest pain is seen in the Emergency Room. They do all the appropriate tests to rule out a heart attack. They send him home. He told them about the tingling in his fingers, but they didn’t really consider it. Is the definition of the ER physician’s job to diagnose the patient? Or is it to rule out diagnoses? Many ER docs, I think, would like to diagnose a patient if possible. But if not, their basic responsibility is to rule out diagnoses that must be treated immediately or conditions for which the patient must be admitted. If you’re not acute, and don’t need to be admitted, you can go home. The ultimate decision node in the the ER decision tree is whether or not to send home. It’s not about what the patient has, it’s about what the patient doesn’t have.
Every Patient Tells a Story is the most important book I’ve read in years. Dr. Lisa Sanders discusses, through riveting case stories and her own accumulated insight, how diagnoses are made. Her own considerable experience in documenting case reports of unusual and difficult diagnoses, from years of writing the Diagnosis column in the New York Times Magazine, has left her in a unique position to see the diagnostic process in both minute detail and in overarching trends.

Again and again in the book, difficult and sometimes obscure diagnoses are presented as exciting detective stories. The stories wouldn’t have made it into the book, I suspect, if they were obvious or straightforward. Often, the right diagnosis is missed again and again, by generalists and by specialists. I’ll ask again, what is the obligation of the physician? Are there limits?

I like to think that I’m like the doctors described in some of these stories. When faced with a seriously ill patient without a working diagnosis, they are tenacious, nearly obsessed. They call their doctor friends, they contact experts they don’t know personally, and they go to the library.

A little girl I take care of was brought in by her mother. She had a fever for a couple of days, but wasn’t complaining of any pain or other symptoms. Her mother was particularly concerned about a tick she removed from the girl’s abdomen about a week before. They were at a lake house, and the 3-year-old was swimming naked. The tick was tiny, not engorged, and could not have been attached for more than a couple of hours. Mom removed the tiny thing with her fingernail. A day or two later, there was about 1 cm (less than 1/2 inch) of redness around a tiny black spot where the tick was. The redness went away in another couple of days, and until the fever, mother wasn’t concerned. Having gone to medical school in Connecticut, I feel pretty secure in my basic knowledge about Lyme disease (named for the town of Lyme, Connecticut).

Here’s why I reassured the mother that this was unlikely to be Lyme disease. Generally, transmission of the disease requires the tick to be attached for at least 24 hours. The classic rash of Lyme disease, erythema migrans, is one I’ve seen several times. It has the distinctive look of an archery target, and 70-80% of people who have Lyme get the rash. Here in California, the incidence of Lyme disease is about 2 cases per million people (some other examples: Wisconsin 324 per million, Connecticut 873 per million). So it’s also just pretty unlikely. So I reassured her that unless the child had other symptoms, I wouldn’t recommend that we take her to the lab for a test for Lyme disease. But I said I’d look up some of the other possibilities to see if she needs to be worried about other diseases. It wasn’t a lot of research, not nearly as much as I have had to do for some diagnoses, nor as much as was done by some of the doctors working on the mystery diagnoses in Every Patient Tells a Story.

But I know this much for sure: nobody pays me for that time. Nobody pays me to pay another professional I might call for advice, just as nobody pays me for the time I spend on the phone coaching other doctors who call me for advice about their own mystery cases. I was impressed with the tales of caring and motivated doctors who clearly spent time in medical libraries and online and on the phone in order to make the difficult diagnoses in this great book. I know that they weren’t paid for that time. Is it their ethical obligation to the patient to do this work? Is the obligation of the physician ‘best efforts’ or, as in most malpractice cases, ‘at the standard of care?’ Or is the obligation to ‘do what it takes to get it right?’

I often point out that the current model under which we provide medical care, in which doctors are paid per visit is not always compatible with optimal care. But now I have a new concern. If doctors are paid for a visit—and indeed, patient-related work that isn’t done face-to-face with the patient is usually not paid—and if working for free is not ethical, are doctors obligated to work for free, on their own time, until they get a diagnosis for the patient? Presumably, the patient benefits. But economically speaking, the physician is effectively donating her services not to the patient but to the payer, the insurance company. It’s the insurer which gets the economic benefit of hours of additional physician work with no incremental cost to them. It is the insurer who has the most incentive to keep paying the doctors the way they do, to keep them churning through patient visits as fast as possible.

What is the ‘standard of care’ in the stories that are described in this book? (Or in the case reports described in her fascinating column, Diagnosis? It’s not getting the diagnosis right. If it were, then there would be a long trail of physicians who didn’t meet the standard in these cases.

Does the doctor have an ethical imperative to listen to the patient? It’s certainly appropriate professional behavior to be polite, but to listen?

If you’re the patient with the mystery diagnosis, however, what do you do? Who do you see? Some primary care doctors shunt difficult diagnoses automatically to specialists, just to save time. Sometimes, they send these patients to me.


As a primary care physician, I see an additional problem. When I have a real mystery, I do sometimes send my patients to specialists with the assumption that their specialized training and experience will give them insight I don’t have. And it frustrates me and my patients when, as so often happens, I am told that while they don’t know what’s wrong with my patient, they are sure the problem isn’t in their department. [I guess that’s why they make so much more money than I do.] What is their ethical (not contractual) obligation?

Is the job of the specialist to rule things out? Who gets to rule things in? And let's be blunt about it--it's easier and quicker to cross things off a list of possible diagnoses than it is to think of new things to add to a list. Whose job is that?

Monday, October 12, 2009

Problems with Medical Ethics: Perimortal Obsession

scythe1

Some of the most wrenching and difficult issues for us humans to resolve occur in circumstances near the end of life. The animal world has, I think, a pragmatic approach to leaving the crippled zebra behind for the lions as the rest of the herd runs away. It’s not so easy for us. It’s important to bring these difficult issues out into the open air. The current world of medical ethics continues to do an excellent job of figuring out what the issues are and helping the rest of us find rational ways of looking at these problems.

I did a search on PubMed, the National Library of Medicine online medical research reference source. I searched:

ethics AND death

and got 12,416 publications.

In pediatrics, there are grave and important decisions to make when babies are born with such severe developmental problems that their survival is in doubt. How much should we do? What interventions truly help this baby, and what interventions just prolong the suffering? Should we treat every such afflicted baby the same, or will it matter what State the baby is in, or what doctor it has? There’s a lot of healthy discussion in the bioethics world about babies on the edge of viability.

Likewise, it is partially to the credit of bioethicists that we now have ‘living wills’ and ‘advance directives’ which can guide our loved ones and caregivers if we cannot. This is a genuine advance in medical care, and has prevented a lot of suffering. (More on this in a later post.)

Despite this help with some of our most difficult choices in life, the bioethics field, in some ways, has chosen the easiest path. It’s true that one thing we all have in common is our mortality. Perhaps we also share a reluctance to deal with it, talk about it, and plan for it. About 65%of Americans die without a will.

This is the easy path because there are no right answers. The case will eventually end in a concrete way. Was the right thing done? Academically speaking, it doesn’t matter, since the focus will have shifted to the next edge-of-survival case.

I’ll say again that I’m glad that smart, literate people are concentrating on this. If I were ever pregnant with a severe brain injury and a fetus hovering at the age of survival, separated from my husband and father of this fetus but with a new live-in partner who doesn’t get along with my parents who are divorced because one of them is a fundamentalist believing in predestination and eternal afterlife so thinking that my demise will result in relief from suffering and ascent in grace and the other a devout believer in the sanctity of all life who insists that every possible intervention should be exhausted, then I’m sure I’d be happy there was an Ethics Committee at the hospital. That way, the burden would not fall on just one doctor to populate the daytime talk shows.

In fact, these cases do occur, and they highlight important topics we might never have thought of.

But they aren’t common. It’s also an easy path for professional bioethicists precisely because the situations are so vanishingly rare. The very fact that a medical case has ivory billed woodpeckermade it onto the news, that bioethics bloggers are blogging about it, means a priori that it’s a rare bird. For every case like this, there must be thousands and thousands of problems that occur every day for which doctors receive no guidance but their own gut feel. There are ethical questions that arise every day, but publications and debates on these issues are few. Nobody gets interviewed on TV for this.

Hank, a very bright 15-year-old patient, came to my office a few months ago to talk to me. He was sent by his mother because his unstable moods and erratic actions were a serious problem for him both at home and at school. His parents were divorced, and both had new partners. He came to the office by public transportation, after school. After we talked about what had been going on, I told him I thought he needed a mood-stabilizing medication. He thought that would be OK, and we talked about possible side effects. I asked him explicitly if he would be willing to try the medication, and take it just as prescribed. He said he would, but only if I didn’t tell his mother.

Though he moved between his father’s and mother’s homes, he was aware of differences in his life at each place. Mom had better food, a well-stocked refrigerator, and was easy-going about bedtimes and curfews. Dad had better video and video games, and was more lenient about computer access but stricter about curfew. His mother, he told me, had sometimes used his previous medications as a threat or as a crutch to explain his behavior. She’d say ‘you need a higher dose’ or ‘I liked you better when you were on….’ This hurt his feelings. If he was arguing with her, he figured, maybe there was a good reason for it. Maybe she was actually wrong about something. His dad never did this. As he told me this, he was completely calm and rational. I believed every bit of his description—and I thought he was right.

  1. Should I have seen him without a parent there in the office?
  2. Are there topics of discussion that are off-limits?
  3. Should I insist on telling his mother?
  4. What if his mother calls and asks me what we talked about? Am I required to tell her the substance of our conversation?
  5. What if she asks about my diagnosis and plan for him? Doesn’t she have a right to know that?
  6. What will happen to my relationship of trust with this teenager if I say I won’t tell his mother but then I do?
  7. What will happen to the teenager’s care if he stops trusting his doctor? He is my patient. I am responsible for his care. What’s best for him?
  8. If I tell the father, and he pays for and picks up the medication, is he obligated to tell the mother (with whom he hardly ever speaks)?
  9. If I want to monitor the patient once on medication, I will want him to return weekly for at least the first few weeks on medication. Who makes these appointments? Do I have to cover up the fact that the kid was even seen?
  10. Even if I agree not to tell his mother, do I lie to her? If she asks if her child is on medication, do I say no? (OK, this is an easy one, since I am not willing to lie.)
  11. In fact, California law does permit a minor to consent for certain mental health services without a parent. Other states vary, but many have similar provisions.

These are just some of the questions that arise from this one actual encounter.

From this single visit, the questions, I think, can be grouped as follows:

  • What are the doctor’s legal obligations?
  • Of the legal obligations, which are subject to interpretation and judgment? (Would my license be in danger if I did tell the parent, but not for a day or two?)
  • What are my obligations to the patient?
    • Do these obligation vary by chronological age?
    • What about developmental maturity? (Surely a mature 12-year-old should have more autonomy than an immature teenager?)
    • Are the obligations to the patient more important than the obligations to the parent?
  • What should I write in his chart? Should I document things he tells me that he doesn’t want a parent to know when they can request the chart at any time?
  • Is this mix of obligations changed when medication is involved? Is it changed when psychotropic medication is involved, as opposed to antibiotics, for example?

I did a search on PubMed, the National Library of Medicine online medical research reference source. I searched:

ethics AND “primary care”

and got 837 publications. That’s about 1/15th as many as when I searched for 'ethics AND death.' I know the situations I’m in are common and happen every day, to me and thousands of doctors.

Of course this is the tip of a very big and very cold iceberg. There will be more dispatches from this ice field soon. Climate change notwithstanding, it won’t be melting soon.

iceberg1

Epilogue: Here's what I did. I took the time to convince him to inform his mother. I told him that if he didn't and she found out he was on medication--and the chances were good that she'd find out somehow--she could use against him the fact that he wasn't honest with her. She could also stop trusting me, as part of this deception. That could change his access to me. I offered to call her directly, and explain in medical terms why I thought medication was a good idea at this time. Hank liked this and jumped on it. I told him that the next time she said something about his medication that he didn't like, he should say "Talk to Dr. Wolffe," and not argue with her about it. I would contact him directly and keep him informed about any conversations I have with either of his parents about his medication. I got a portable phone and took it into the exam room. I called his mother right then, with him there, and told him that I'd like him to start some medication. She was OK with that. Hank was visibly relieved.

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Thursday, October 1, 2009

Problems with Medical Ethics: Holistic Ethics


It’s been established that doctors who own their own x-ray machines do a lot more x-rays on their patients than doctors who don’t own their own machines. Some of this, no doubt, is because it’s so convenient, and the doctor could get results right away. But part of it is also the fact that the doctor will earn money not just from the visit but also from the x-ray. Knowing this, I recently changed dentists. dental x-ray machine

I had a good dentist. But it really bugged me that every time I was there, he was selling me on…whitening products, tooth grinding products, and x-rays. That was the final straw. He told me that I needed a full set of x-rays every year. I had no dental insurance, and would be paying in cash. I asked if it were really necessary, and he told me it was essential. I asked him if this had teeth2 ever been studied, and if he could send over to my office any papers about the difference in outcomes between those people who went to the dentist and had x-rays and those who went to the dentist and didn’t have annual x-rays. He said he didn’t have a paper like that. So I got a new dentist, who is very nice. She examined me and told me that a crown was worn on one side. She said, “We should replace that.” It would cost $1200. I chose to wait until something went wrong with it.

Why does the dental profession think it’s OK for every dentist to have their own x-ray machines? Is their conflict-of-interest somehow less powerful than a medical doctor’s? Are dentists immune from the influences of conflict-of-interest?

Every now and then, I am sent a flyer from a company looking to produce for me bottles of vitamins and ‘supplements’ with my name on them. The idea would be that I’d sell the products in my office, telling patients that they need these products, and that the products are not available elsewhere. Obviously, they would be a lot more expensive than similar (maybe identical or superior) products you could get at the supermarket. I would give everyone the same advice: be cautious about the so-called professional—wait, anybody—who says you need to buy something you can only get from them.

Of course this applies to physicians as well. Do you really need that follow up visit if you are fully recovered? Do you really need that follow up x-ray? Do you really need to return for all 16 visits? (I don’t want to seem too cavalier about this. It’s tempting to think we don’t need follow up care when we’re feeling OK. But that’s a serious mistake for many problems, especially the ones we might not feel, like diabetes or high blood pressure. Sometimes, even when the baby looks great, I really need to weigh and examine the baby every day.)

The never-mentioned elephant in the room—one of several—will get me in troubleelephant1 here. [Maybe by burying it in the middle of this 4th post on ethics will I prevent the storm of backlash I expect.] Alternative Medicine.

I want to keep this to a reasonable length, and not focus on safety or efficacy of alternative treatments. I reserve the right to rant at another time. The topic is ethics.

A PubMed search of ethics has 139,072 references. A search of ethics AND chiropractic has 63. How come when my patients go to the acupuncturist, for example, they are told they need another visit, and another visit and another? How many visits does it take? Has this been studied? How come they are so often sold on various supplements and herbal remedies only available there in the practitioner’s office? Is it ethical to do business that way? Is it ethical to prescribe products which are untested? Do they need to disclose that the products have not been tested? Do they have to disclose that what’s on the label may not include stuff that’s in the product? Do the practitioners need to obtain some sort of informed consent for their procedures or for these untested products? Is it ethical for these other practitioners to raise doubts about the treatment plan I proposed? Is it ethical for me to raise doubts about the alternative treatments and medications my patient is taking? In Squirmy, I think it was the pharmacist at the ‘natural’ pharmacy who advised the parents to put calendula cream on their baby. Exactly which health care provider is ethically restricted in what they can say and which provider isn’t?

In many places, there are laws and liability precedents that restrict what licensed physicians do. But surely the ethics of what is done with patients doesn’t vary with the initials after your name. I don’t think that my patients should get cheated or carelessly harmed by a doctor. Or a chiropractor, ayurvedic practitioner, naturopath or guru with a fleet of Rolls-Royces.

In this series of posts, I complain that there’s too much attention placed on really unusual medical situations and not enough on common situations. But the field has developed a cadre of smart, perceptive thinkers who are very quick to understand some of the problem issues in patient care. It would be great if they looked at patient care from a holistic point of view, not just the patient-physician interface. Real-world medical decisions, faced by patients every day, touch on all aspects of their care. Their personal relationships, their supplemental caregivers, their medications and supplements, financial situation and alternative practitioners all influence the patient’s wellness. It would be great if our field of medical ethics could take its eye away from the telescope and see the whole Milky Way.

milky way candy

There is still an ongoing debate about whether physicians can refuse to provide certain services depending on their own consciences. One side believes that doctors shouldn’t reasonably be forced to give a patient advice they don’t believe in—like using birth control, for example. The other side thinks that the patient won’t know what the doctor believes, and as their medical expert who is supposed to have their best interest at heart, so the doctor should present all available options, including choices they wouldn’t make personally, such as abortion. In 2005, there was an editorial in the New England Journal of Medicine discussing the case of pharmacists who refused to fill prescriptions for pills that could terminate a pregnancy. My letter in response was published, but here’s what I said, and I believe it more today, 4 years later:

To the Editor: It is curious that pharmacists might refuse to fill a prescription. Must all the prescriptions they fill result from morally acceptable diagnoses? The Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not allow breaches in confidentiality about diagnoses and therapies so that strangers can make individual judgments about whether to cooperate in treating a patient. A prescription may be written for a diagnosis of which the pharmacist is unaware (e.g., oral contraceptives to treat ovarian dysfunction). There are many other people involved in every patient's care. What if receptionists refused to make an appointment or refused to give the physician a telephone message because they did not approve of something? The pharmacist might refuse to fill a prescription, the cashier might refuse to sell the prescribed item, or the driver of the distributor's delivery truck might refuse to transport it. Why is the pharmacist's moral judgment dominant? Ethically, there should be open disclosure that some prescribed drugs, products, or services will not be provided. Disclosure is also ethically required for diagnoses, symptoms, or clinical issues about which the pharmacist, health care worker, or others in the chain of health care delivery have such feelings that their cooperation in the care of patients is compromised. Will this trend inevitably lead to a balkanization of medicine, whereby patients will go only to doctors of their own sect, who prescribe only for pharmacists of that sect, and refer only to specialists of that sect? Shouldn't patients be warned?


Wolffe Nadoolman, M.D., M.B.A.