"The customer is always right": Does it apply in medicine?

Attention patients and families of patients, regulators, government officials, commentators, angry bloggers and reporters: I am the physician. That makes me the expert. I realize that we live in the age of polls, surveys, empowerment and self-help. I realize that the opinion of the masses generally matters more than the opinion of the educated. But as one of the educated, as one of those who considers his opinion more valid than many others, let me say what most physicians are too nice to say. Medicine is not a democracy. I appreciate your opinion, and you may accept or refuse anything I offer. You may even tell me what you think, and what has worked before. But I get the final vote. I have earned that vote through years of caring for the sick, and I am accountable for my mistakes, as is evident by my very expensive malpractice insurance. You may refer me to any one of your resources or family members, but in the end, like it or not, one unassailable fact remains: I’m the doctor, not you. Deal with it.

(via GruntDoc)

Comments

Meanest patient in the world
Dear Dr. Leap,
Practice medicine as you wish; however, I have the final vote.
I will take my paltry sum and visit another physician if you are not performing to standard. My standard.
Anonymous
I agree with Dr. Leap. Any doctor who thinks differently is doubting the validity of his training, and probably should not be practicing.
Medical practice is not retail sales, no matter how much our twisted shopping-mall culture wants to force everything into that mold.
Anonymous
The original post has to be one of the most arrogant pieces of commentary that I have seen in quite some bit of time. Here is a hint: You are a service provider. Nothing more and nothing less. You are no different than an auto mechanic, a gardener or any other service provider. It is the client to whom the service is being provided that has the final say as either they are paying for your service or payment is being made for your service in their name.
Anonymous
I read Leap’s blog regularly and should I need emergency care would fervently hope to be treated by him or someone very like him.
I also consider myself the final decider about medical care I receive (if I’m conscious). What that means is I listen to my doctor carefully, but also ask a lot of questions, and he answers them. If I did not trust this doctor, as I do, I wouldn’t be going to him, I’d find someone else.
Anonymous
Dr. Leap is right on target. God bless you for saying what needed to be said.
Anonymous
To consult an expert, i.e. a physician, and then disregard or disagree with his/her advice is a waste of everyone’s time.
*However* doctors do not always get it right. Reasonable people can disagree, otherwise why bother with second opinions? As so many of you are so fond of reminding us here, many medical situations are not clear cut.
And some physicians, frankly, are awful listeners or indulge in stereotypes that seriously get in the way of communication.
It’s a two-way street. The doctor might be driving a ginormous 18-wheeler and I might be driving a VW Beetle, but we both still share the road and have to be paying attention to each other.
Anonymous
Anon 11:03
A gardner has no ethical responsibility towards my plants, a mechanic towards my car. If I instruct my gardner to do something that he knows will kill my plants, but I insist anyway, he has no responsibility.
If I prescribe opiates at the patient’s request in contradiction to my judgement of appropriate need, I can go to jail.
My own conscience, my professions ethics, society in general, and the law–all demand that any treatment that I provide be in accord with my judgement regardless of any demands made by anyone else–includig the patient. I leaned this long ago, but it took a while longer to learn that essential to surviving being a physician is to get and keep persons with your attitude of the practice. They only create irreconcilable conflict.
Anonymous
Anon. 11:03 confuses his doctor with his drug dealer. The latter is probably not on his PPO panel, though.
Hint: doctors are services providers and professionals. The responsibility is greater than that of a mere retailer. And it doesn’t matter whether you agree with that understanding or not. That is the way it is.
Sorry, you don’t get to define the scope of responsibilities of other people’s professions. Getting that under your belt is all part of the growing up thing.
Happyman
anon 11:03 –
what an idiotic statement. can your gardener prescribe treatments & perform procedures that can kill you? can your gardener INVOLUNTARILY hospitalize you against your will?
the “client” cannot force me give them opiates for arthritis or antibiotics for a cold, no matter what the source of payment is – the government gives ME that right to decide and not you, because of my years of training.
I weep for your doctor, and am glad my office has the sense to quickly dispose of patients who feel “empowered” to dictate their own treatment.
One good thing that the current crappy situation with primary care reimbursement has yielded: a low threshold to say “find another doctor” to patients like you. Good luck when your lack of primary care lands you in an ER somewhere. Then you’ll REALLY feel empowered.
Hurray for Dr.Leap, telling it like it is.
Anonymous
Keep at it Happyman. It is arrogant attitudes such as yours that will finally turn the mass of idolatry around to saying enough and turn healthcare into a system that places the patient before the provider. It is attitudes such as yours that fostered the unethical testing on humans without their consent or knowledge (as you know better) that are shameful smears on the reputation of your field. You are just another service provider and at least in regards to those with the funds, you are easily replaced by the next provider.
Anonymous
Oh Anon 3:10 (erstwhile Criminallopath, most likely), out with your “idolatry” business again. Why it makes me want to dig out my big wooden mask and bone rattle and start to work.
Need a health care system that places the “patient before the provider?” Sorry, just because you back-handedly imply that the present system isn’t placing the patient before the provider doesn’t make you correct.
Placing the “patient before the provider” does not imply the patient and the provider have equal knowledge. They don’t (except perhaps in your imaginary world.) Nor does it imply that the patient has unlimited rights to demand whatever he wants from a provider; he doesn’t. Nor does it make a physician the health-care equivalent of a hardware store clerk.
It appears your wish is for some reality other than the one that exists. That is fine, as long as you understand that your wish is a fantasy.
Happyman
To each his own.
I don’t know why it’s so hard to understand that the decision-making is necessarily MOSTLY one-sided, since the education & experience are ALL one-sided. Perhaps you think there should be no such thing as prescription medications, that everything should be over-the-counter. That’s the way it is in places like third-world caribbean countries – you can walk into a pharmacy & buy the equivalent of ativan for pennies! great system indeed.
Once again, I’m glad I’m not forced (yet) to be YOUR doctor, and likewise you have the power to seek care from whomever you please (perhaps the “nice” chiropractor or GNC down the street).
If you ever need a real doctor, you might have to suck up your pride & see someone with the confidence that he knows better than you.
Anonymous
Read my posts carefully. The patient has the right to demand whatever the patient wishes. The provider has the right not to acquiesce to said demand. If the patient is unhappy with the service then they are free to find another provider. This is no different than any other consumer provider relationship (just as with an auto mechanic who has more training, background and experience in repairing cars than a typical healthcare provider does).
As far as chirofrauders go… Give me a break. I have still to see one that can prove that the “subluxation hypothesis” is anything more than junk science much less the cause of any determinable pathology. Those clowns are even more up to their eyeballs in the world of insurance fraud and junk science PI litigation (sleeping with the trial lawyers) than the allopaths are.
Megan
I went to a doctor and told her I had diabetes. She told me that was ridiculous, I would be sick if I did. She didn’t do any tests be it a u/a or blood work. I was diagnosed 2 months later with a blood sugar of 600.
Anonymous
Any doctor who doesn’t ask the patient what he thinks is wrong with him, and give it serious consideration is a fool. Any doctor who doesn’t listen to a patient’s requests for treatment and try to accomodate, where medically appropriate, is a poor businessman and a clod.
On the other hand, after all the listening and attempts to accomodate, any doctor who in the end doesn’t take personal responsibility for the correctness of the diagnosis and treatment irrespective of what the patient requests, is a quack.
As long as there are people around like anon 11:03, there will always be quacks around to serve them. They just don’t like the fact that we don’t all play that game because it makes the quacks and their narcissistic patients alike look bad.
Richard
It is interesting how medical ethics has shifted over the past 50 years to the point where patient autonomy dominates all discussions. Physician beneficence, which is the basis of the Hippocratic Oath and medical ethics, is now passed by.
Yes, there are bad doctors. Yes, doctors get it wrong sometimes.
But the expert is still the physician. Thus the physician is much more than a service provider. As a professional the physician has a DUTY to refuse to provide treatments for which he/her judges inappropriate, regardless of a patient’s opinions. The patient’s opinion should certainly be taken into account (that’s why we take a medical history and FIFE a patient). But to consider a physician a simple dispensary of treatments or drugs because a patient self-diagnosed themself is foolhardy. Even if the patient himself is a physician!
Anonymous
The answer is, as always, to eliminate credentialization requirements. Let anyone become a “doctor” Rather than have weirdos like Dr. Leap go on, Rodney Dangerfieldesque, about all the respect he needs, let those doctors with proven trackrecords get the respect, and the lessers work at redicares.
let prescription become a personal matter (as it is in most countries of the world). Tax antibiotics to limit their negative externalities. Give judges and judges alone the power to commit.
And let the market sort it all out.
It certainly couldn’t be worse than our current system.
Anonymous
>>”The answer is, as always, to eliminate credentialization requirements. Let anyone become a “doctor” “
Letting anyone become the doctor was possible once. The present system of university-based education and hospital training is the developed response to the screaming failure that preceded
it. But you pine for that anyway. Pine alone, please.
>>”Rather than have weirdos like Dr. Leap go on, Rodney Dangerfieldesque, about all the respect he needs, let those doctors with proven trackrecords get the respect, and the lessers work at redicares.”
That is what the system today is supposed to provide. Having a good reputation is what builds your practice. The doctorate is the prerequesite, but is far from sufficient. You actually do have to depend on what people have to say about you, and (surprise), that depends on how good a job you do. You don’t seem to understand the world of medical practice from the inside, but that is how it works.
>>”let prescription become a personal matter (as it is in most countries of the world). “
Since when has it been anything else but a “personal matter,” here or anywhere?
>>”Tax antibiotics to limit their negative externalities.”
What? And how exactly would that work? And why antibiotics but not analgesics or allergy medicines or antidepressants?
>>” Give judges and judges alone the power to commit.
Seems like a personal gripe. Judges already have the right to commit. They also have a right to overturn or truncate temporary mental health detention procedures that many states confer on licensed medical doctors, psychologists, counselors, police officers and social workers. I don’t see a groundswell of support to change this anywhere. Legislatures have felt the commitment procedures belong to authorities in the communities as well as to judges. Why do you presume to second-guess that?
>>”And let the market sort it all out.”
Wishful thinking. That presumes a degree of information transparency, education and rational thought processes that has never existed in recorded human history.
>>”It certainly couldn’t be worse than our current system.”
Sure it could. There are lots of things worse than our present system.
Anonymous
“Letting anyone become the doctor was possible once. The present system of university-based education and hospital training is the developed response to the screaming failure that preceded
it. But you pine for that anyway. Pine alone, please.”
IDIOT. The credentialization of medicine got going strong with the Flexner report–its author Abraham flexner, it is now widely acknowledged,was a pawn of the AMA. Curiously, it was authored in 1910–at a time at which (pre-antibiotics) “university trained” physicians certainly did as much harm as they did good.
“Having a good reputation is what builds your practice. . . . You don’t seem to understand the world of medical practice from the inside, but that is how it works.”
AGain, you’re an idiot. It is very difficult to gain useful information about physician performance. Why? could it be because it’s a protective guild? Consider the National Practitioner Data Bank–the AMA does everything possible to keep it secret. Dirty monopolists . . . may they all burn in Ricardian hell.
“Legislatures have felt the commitment procedures belong to authorities in the communities as well as to judges. Why do you presume to second-guess that?”
Uhh . . . I guess you never heard of special interest lobbying.
And, finally, just in case you want to know what doctors really think of laymen:
“That presumes a degree of information transparency, education and rational thought processes that has never existed in recorded human history.”
I believe that human beings can make the right choices for themselves. I’m on the side of Jefferson, Smith, and Locke–why are doctors on the side of Stalin, Mao, and Sweden circa 1970?
Anonymous
God… Does anyone else tire of hearing criminallopath discuss what he considers his “ace in the hole” of the Flexner report! I tire of reading your comments that you state over and over.
This is the only poster on KevinMD that I can identify even when he is anonymous becuase he brings up the same tired points that have been disproven over and over again.
Are you listening criminallopath. People have already schooled you about your “Flexner Report Theory” that you so adamantly love! They can’t go around to every thread and write the same reply. Just because you say it over and over does not make it so!
Isn’t it funny that I can identify you when you are anonymous, but you cannot identify me when I am anonymous?
Anonymous
^^^^^
The idiot has identified him/herself. I have said nothing about the Flexner Report on this thread you monosynaptic oligopolist. Get a clue before you start attributing my name to other people’s posting. One would think that after all of the time that has passed that even the borderline mentally deficient such as yourself would be able to discern my writing style. Remember: The world doesn’t know that you are an idiot until you tell them, and you, sir, have now told us. Here is a hint for you. My last post was at 5:19 pm.
~Criminallopath~
Anonymous
As far as “schooling” goes… Your “god complex” and inability to discern reality is again showing. No one has “schooled” me on the Flexner Report (now that you have brought it up) and its implications on the anaconda like restrictions on the supply side of the equation when coupled with legal machinations to assign vast swaths of healthcare to the sole purview of the provider class (see the difference in writing style). You will have to do better than the equivalent of a liberal rewrite of the history books if you wish to accurately portray the results of the discussions on this blog that I have engaged in with members of the subject oligopoly.
~Criminallopath~
Anonymous
The inevitability with which internet blog discussions deteriorate into foaming rants by the 20th post underlines the instability and unsustainability of democracy based on universal sufferage and public debate.
Anonymous
Anon. 10:56 P.M. is making his argument on the basis of name calling. Not very persuasive, you have made yourself and your argument look foolish and unconvincing.
Mike
Patients are just ungrateful.
The AMA “lobby” is so bogus. If they were so great, I’d be making more money, not insurance companies and drug companies.
All of the people who want no crenetailling… you should have to take care of the sick ones who end up in the hospital because they ignored their doctor and decided to take Gingko or see their Chinese herbalist. Remember Suzanne Sommers??? She snuck in the back of her Oncologist, claiming to be doing “herbal cures”.
I spent 3 yrs in a residency, working 110 hour weeks, saving people who were sick as dogs. Yet I’m just a mechanic.
Patients are ungrateful.
Anonymous
Yes. Just like a mechanic you have just a job. Get over it and get over yourself. Unlike auto mechanics, however, your profession has a pay out based on restricting the supply. Any other “job” could have the same basic economic impediments to supply added to it to result in excessively high pay for its practitioners.
Anonymous
Dr. Leap,
I’m the patient – I get the final vote. Unless of course you are advocating coercive medicine?

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