A contract for patient responsibility

I often refer to myself as a fireman pouring water on the flames that are burning my patients.  Often, I view my patients as arsonists, pouring gas on the fire I am working to put out.  Taking personal responsibility is a critical component of success in any of life’s ventures.  While my patients are very responsible business and family men and women, they often take no responsibility for their own health.  This blog has been successful at helping many individuals recover and maintain their health.  It has failed to help those who continue to be irresponsible.

In an effort to clearly define my patients’ role in their healthcare, I have developed the following contract:


I, (patient’s name),  am a responsible patient.  As such, I take full responsibility for my health and my healthcare.  My responsibilities include but are not limited to:

  1. Learning how to promote my own health and wellness.
  2. Learning how to deal with illness, both acute and chronic.
  3. Actively working to eliminate those unhealthy habits I have acquired over my lifetime.
  4. Eating properly, exercising, and striving to eliminate those stressors within my control.
  5. Seeking medical advice when appropriate.
  6. Understanding the medical advice I receive.
  7. Asking questions when I do not understand the advice offered.
  8. Following the medical advice when mutually agreed upon by my doctor and me.
  9. Taking my medications as prescribed.
  10. Notifying my doctor prior to stopping my medication.
  11. Notifying my doctor should I have any adverse reaction from my prescribed treatments.
  12. Keeping a list of all medications, both prescription and non-prescription (including herbals, homeopathic, and neutraceutical), that I take and who prescribed them.
  13. Bringing my medication list to the office at every visit.
  14. Knowing when I will need refills and not running out of pills.
  15. Completing diagnostic tests (lab, x-ray, EKG, etc.) in a timely fashion.
  16. Keeping my follow up appointments.
  17. Seeing consultants when necessary.
  18. Understanding my diagnosis, learning about its effects on my body and how I can help manage it.
  19. Studying.
  20. Being an active partner in my medical care.
  21. Notifying my doctor when I have added other professionals to my healthcare team.
  22. Being honest about what I am doing, taking, and who I am seeing.
  23. Paying the bill on time.
  24. Setting up a payment schedule when I cannot pay the bill and following that schedule.
  25. Know the rules of my insurance policy, what benefits are covered and what are not.
  26. Notifying the office if any contact information changes occur.
  27. Having an emergency contact listed should critical information need to be relayed to me.

My health is important to me, my family, and loved ones.  I will work hard to care for myself.  I understand that my doctor cannot help me if I will not help myself.  I expect my doctor to offer me his/her best advice based on his/her medical training.  I understand that, without my active participation, my doctor’s ability to help me is limited.  I understand that my doctor is the consulting partner, I am the working partner.  Working together, we can accomplish great things.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • http://twitter.com/colekpharm CarleneO

    Great post Kevin.  Thorough list.  Have you used it and have patients found it to be too onerous?  I know when I ask a patient to demonstrate responsibility in an area of health I usually tackle one area at a time.  But I’ve never used anything written, only verbal. 

  • http://profiles.google.com/kevintkeith Kevin T. Keith

    I appreciate the intention behind this list, but I have to say I find it offensive in a lot of ways.

    As a general remark, if you really think of your own patients as “arsonists”, and yourself as heroically working to save them while they’re actively working to destroy what you’re trying to save (their own bodies) – that is, if you think your patients are in fact violent criminals for using their own bodies according to their own needs and choices, and that you are somehow authorized by society to intervene to stop their criminal actions – maybe you’re not really cut out for this profession.

    As to the list itself, note first that it implicitly defines the doctor/patient relationship as centered on the doctor: the patient has to meet all the doctor’s rules, keep updating the doctor on everything they do, follow the doctor’s directions, and report back to the doctor – with written lists they are required to carry with them – on everything they are doing that the doctor wants to know about. Only once is there any passing reference to “mutual” decisions (#8); everything else on the list consists of the patient doing what the doctor wants them to do. The implication is that it is “irresponsible” for a patient not to promote their own healthcare interests, but the list defines “responsibility” entirely in terms of following orders, which is not the same thing.

    Also, it defines as “irresponsible” behavior that is often the result of conflicting priorities in patients’ lives, most commonly a lack of money. Not everyone can easily refill a prescription at exactly the right time (many people who are not privileged professionals have strict work schedules and family responsibilities that may make it physically impossible for them to go to a pharmacy at their convenience; most insurance policies will not refill a prescription until just before the previous one runs out, but the patient may not be able to get to a pharmacy within that short window; many patients simply can’t afford to refill prescriptions). “Responsibilities” #s 5, 8, 9, 14, 15, 16, 17, plus, likely, all that stuff about “learning” and “studying”, not to mention exercise and access to whatever programs are needed to “eliminate those unhealthy habits”, require resources of time and money that may not be available to everyone, or the highest priority to parents, caregivers for other sick family members, people working multiple jobs, etc. The list assumes an access to time and money, and the freedom to prioritize one’s personal inclinations above other demands, that is taken for granted by the professional class but is much more limited even to the middle classes, and may be wholly impossible for the working class and the poor.

    And the fact more than 10% of the patients’ “responsibilities” consist of “paying the bill” and maintaining adequate insurance makes even clearer the degree to which this list is set up to promote the doctors’ interests in the name of being a “responsible patient”. Certainly patients have an obligation to pay their bills, but it’s not a *medical* failure on their part if they don’t or can’t. Notice that #25 implicitly categorizes over 40 million Americans as “irresponsible patients” *by definition*, since they don’t have insurance to begin with. It also appears to imply that it is irresponsible to *seek treatment* – if one’s insurance does not cover it. So patients are irresponsible if they don’t seek treatment, and irresponsible if they do seek treatment – depending on whether their insurance covers that treatment. Being a “responsible patient” means not seeking more healthcare than you can pay the doctor’s charge for, and not seeking less, or, in other words, maximizing your payments to the doctor up to the limit of your financial resources and not beyond.

    The list is also insulting and condescending. Demanding that patients go through some sort of self-education process not only assumes that they can do so, and know about and have access to the resources to do so, but it both pushes the patient-education responsibility onto the patients themselves (what happened to doctors explaining things to patients as part of their caregiving?), and models “responsible” patient behavior on the kind of formal educational or scientific model that characterizes professional education. Some patients choose *not* to be fully informed about their conditions; others are not in a position to acquire knowledge on their own. It used to be part of good care for a doctor to understand their patients and their individual needs, and work with the patients from that understanding. Apparently the financially-mandated 15-minute office visit is now met by telling patients to go get their medical information off the Internet – but that is hardly good care, and it is hardly irresponsible *on the patients’ part* if they can’t or won’t.

    Most of all, the list proceeds from an overriding construction of the doctor as the privileged and knowing master, and the patient as supplicant and respondent. It appears to be an act of retaliation against the loss of prestige and authority that the medical profession has suffered in the last 50 years: once it was that “doctor knows best”, but now there are informed consent procedures, confidentiality rules, principles of patient autonomy, advance directives, complaint procedures, malpractice suits – this list puts the ball back in the doctor’s court, by making the patient dance to their tune again. And that’s what’s really wrong with it.

    It’s not about you. You can’t turn back the clock – patient autonomy is here to stay. Patients make their own decisions about what kind of care they want, who they see, what medications they take, and so on. And, importantly, they make those decisions in light of all the other interests, obligations, and constraints in their lives. Many patients can’t afford, for financial or practical reasons, to pursue an optimal course toward health. Many simply do not prioritize health above all other things. (The doctor’s top, and almost only, priority in treating a patient is to make them well. There is nothing else in the patient encounter for a doctor to focus on. Getting well may *not* be a patient’s top priority. They have everything else in their life to worry about. This may be frustrating to a narrow-minded doctor, but it’s not irresponsible on the part of the patient.) As competent and independent adults, they are free to set their priorities as they choose, and pursue them as they choose. They are not required to adhere to anyone else’s (considerably self-interested) plan for their lives or even their healthcare. They are not even, in the end, required to be healthy. Many people’s choices and behaviors are sub-optimal, even counter-productive; it is so in many ways, including healthcare. They deserve respectful and responsive care even so.

    The lax and inconsistent behavior of patients can be a great frustration. The feeling that the patient is actively undermining their own ostensible goals may lead to exasperation or even contempt. But the goal of healthcare is not to minimize frustration for the caregiver, and it is not an obligation of the patient to earn their caregiver’s respect or endorsement in order to receive treatment. It’s not about you.

  • Anonymous

    I absolutely agree, thanks for sharing. I’d like to propose physicians sign a simiilar contract– about their responsibilities in a caregiver relationship:

  • Pamela Curtis

    I agree with Mr. Keith. These are unrealistic demands. It’s not even a contract.One question I’d like to raise: Just where am I supposed to get this education? Dr. Oz? YouTube? The internet???? That one home ec class I took 20 years ago? Where’s my community college certificate course in hypothyroidism?
    Garbage in: garbage out. If your patients don’t understand, and they’ve come to you—the EDUCATED professional—do you really think that misunderstanding is THEIR fault?

    27 ways to scapegoat your patient is more like…

    • http://twitter.com/USMCShrink Kevin Nasky

      docēre — “to teach”
      I agree that it is up to the physician to teach the patient about his/her illness. My mechanic doesn’t expect me to study auto mechanics on my free time; a physician shouldn’t expect the same from his/her patients.

  • Payne Hertz

    I always love lectures on personal responsibility form the most irresponsible and unaccountable profession in this country, Your profession kills and injures hundreds of thousands of Americans every year through negligence and avoidable medical errors, but where is anybody standing up and taking responsibility for any of this? You want patients to be educated and active participants in their healthcare and yet you expect 100 percent compliance, even when their  research and personal preferences lead to different risk/benefit calculations from yours.

    I know people who died because they failed to question their doctors’ instructions. I know others who saved their lives or avoided costly, questionable and risky medical procedures because they did question their doctors.

    Conspicuously absent in your “contract” is any mention of your own responsibilities, which should begin with a recognition and respect for your patients’ autonomy and right to live their lives as they see fit whether you approve of it or not. A puritanical insistence on perfection on the part of your patients is both unrealistic and counterproductive. Your list is entirely self-serving, and doesn’t allow for your patients to have a different set of priorities and needs than yours. In trying to put out those fires, try not to come across as a “wet blanket” rather than a friend and ally. You’ll get along much better with your patients.

    Remember your patients are humans beings, not automatons.

    • Terry M

      Other than your first sentence (which is bunk), you make several good points.  Patients and physicians should each be accountable to one another.  Otherwise, it’s a waste of everyone’s time.

      • Payne Hertz

        It’s not bunk. There have been a large number of studies documenting the fact that there is a massive problem with medical error and negligence in this country resulting in death and injury to hundreds of thousands of people every year. The medical profession has done little to address the individual and systemic problems identified in these studies, other than to try to rob the victims of their right to seek redress in the courts. Articles about malpractice typically portray doctors as the victims and the patients and their families as some kind of predators or losers who are out to “win the lottery” (to use the common repulsive vernacular) through a malpractice claim.

        The refusal to acknowledge these massive problems openly and to work seriously towards a solution to them constitutes an enormous lack of moral responsibility on the part of the medical system. To the extent doctors and medical associations conspire to demonize patients or cover up facts to protect their colleagues and the system as a whole, this behavior goes beyond the mere irresponsible and well into the criminal realm.



  • http://twitter.com/livewellthy Stewart Segal

    Errors, in any job or profession, are a fact of life.  One goal of my patient responsibility contract is to reduce errors by both improving patient-physician communication and empowering my patients by making them partners in care.
    I plan on publishing the physician component of this contract in the near future.  Yes, physicians need to educate their patients; but physician driven education is not enough.  Patients need to educate themselves, question everything, and come to an accord with their caregivers. 
    As far as being a fireman and my patient being an arsonist, trying to help a smoker recover from an acute bronchitis is one of the most frustrating experiences one can imagine.  My patient complains of cough and shortness of breath.  My patient is upset, “Doc, I’ve seen you 3 times and I’m no better!  You need to help me!” 
    “I’m sorry Mr. Smoker.  That cigarette that you light 20 times a day is killing you and my medications (fire extinguishers) just can’t override you smoking (pouring gas on the fire).
    Mr. Smoker, “You docs are all the same, always blaming cigarettes for everything.”
    I have been committed, life and soul, to being a doctor for 29 years.  My job is to prevent fires whenever possible, and when not possible, to put them out as fast and as safely as I an.  Enlisting my patients as volunteer firefighters is the best way I know to accomplish my job.  Helping arsonist recognize their role in illness is the next best way.

    • Payne Hertz

      “Errors, in any job or profession, are a fact of life. ”

      There is no profession in this country where you can kill or injure people on a routine basis and still expect to keep your job. There is no profession that produces the kind of monumental casualty statistics the medical profession does, and yet is so immune to doing anything to fix the problems. This kind of hand-waving dismissal of the epidemic of medical errors in this country doesn’t strike me as being an exemplar of “personal responisbility” but it is fairly typical.

      Why don’t your patients quit smoking, drinking, overeating etc? Because it is extremely difficult to do so and depending on the unique circumstances, physiology and psyche of each patient, many simply lack the tremendous will power to effect major lifestyle changes or may simply be under too much stress from other factors to muster it.  You might just as well ask why do so many other doctors fail to maintain
      themselves in athletic condition knowing better than anyone the
      downsides of a sedentary life.

      Addictive behaviors in particular are notoriously difficult to overcome and fewer than 5 percent of people addicted to just about anything can maintain a state of “sobriety” for more than a few years at best. Relapses are common.

      Now you can recognize this reality and understand that the behavior your patients are exhibitting is perfectly normal, human behavior and adjust your expectations accordingly, or you can do what most of your colleagues do and judge and condemn them for it. I prefer approaches that start from a position of understanding, compassion and commitment to help than those that come from a need to lecture and condemn.

      • http://twitter.com/USMCShrink Kevin Nasky

        “There is no profession in this country where you can kill or injure people on a routine basis and still expect to keep your job.”

        No country’s medical profession is error-free. There will always be some degree of iatrogenic morbidity, though efforts to reduce it are ongoing. The question is this: are people better off with or without medical care?

        If you were able to take 1000 people and give them zero access to medical care, and another 1000 with our current medical care (with all its proneness for error)…which group would fare better?

        The fact is that the risk of forgoing medical care FAR outweighs the risk of iatrogenic morbidity/mortality. That is a fact. 

        • Anonymous

          “There is no profession in this country where you can kill or injure people on a routine basis and still expect to keep your job.”

          When I hired a contractor to install a countertop in my kitchen, he measurements were flawed and the countertop didn’t fit.  He apologized for the error, remeasured and replaced the countertop for no extra charge.

          When an error happens at the doctor’s office, I don’t get an apology for the error, I still have to pay for the error and have to pay for someone to fix the error.

        • Payne Hertz

          No country’s medical profession is error-free.

          No country’s police force is free of police brutality, either. This is a poor excuse for the epidemic of medical errors in the US and the medical profession’s refusal to take full responsibility for it.

          The question is this: are people better off with or without medical care?

          That isn’t the right question(s), but it is an interesting one. The right questions are: can the problem of medical errors be dramatically reduced given current science and technology, and if so, is the medical system doing all it can to utilize these tools to reduce errors. The answers are yes and no to those questions, and those answers need to be reversed. Ideally, medical errors should only occur with any degree of frequency in those situations that are largely beyond the control of anybody. They shouldn’t be a routine occurrence with things as mundane as writing scripts.

          Are people better off without medical care? That is a hard question to answer and it would have to be answered on a case-by-case basis. Obviously, doctors do save people’s lives every day and many people do benefit from medical care.  On the other hand, if the widely quoted statistics on medical errors are correct, that would make doctors the third leading cause of death in America. If this is true, it is hard to make the case that medical care overall is a net benefit, particularly given its massive cost. As a chronic pain patient, I can say without question I would be better off today if the medical profession either didn’t exist, or I could have treated my own pain without having to deal with it.

          There have been a number of studies that have shown that during prolonged doctor strikes, the death rates in affected hospitals has gone down. Less medical care shouldn’t equal less death.

  • http://www.facebook.com/profile.php?id=813719062 Mikki Melinda Anderson

    As a massage therapist of nearly 35 years, I can understand Dr. Segal’s frustration with patients who KNOW what they should or shouldn’t be doing and maintain the unhealthy behavior anyway and then search for a magic pill or potion from their physician to fix them.  I work both in a wellness spa and in a hospital.  The folks in the wellness spa actually take more responsibility for their wellness than do the patients in the hospital for the most part.

    However, I follow my passion and go after the type of work I am most drawn to.  Therefore, I suggest to Dr. Segal that he find more of a wellness or integrative medicine environment where the patients are invested in their own healthcare.  Become a member of a wonderful healing center part time if you can’t just make the leap into the unknown…life is too short to be unfulfilled.  Furthermore, we can all give more when we ourselves are happy.

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    I think this is a great post and list. This clearly brings to light the disconnect going on between patients and doctors right now. Patients feel that doctors should have all the answers and doctors feel that patients need to do more to achieve their goals. The answer is somewhere in the middle, but changes with each patient. The goal is not for this equation to be one sided, but an equal partnership between both. I think that patients clearly undervalue their own roles in their health and doctors overvalue their specific advise. The challenge (and the opportunity) is to allow both doctor and patient to feel that they are working together. I think this is best achieved when doctors focus on developing rapport with their patients very early in the doctor/ patient relationship and for patients to have a vested interest in their own health. Lacking both aspects often leads to where we are right now–disconnect and disenchanchment.

  • http://www.facebook.com/profile.php?id=1517049577 Linda Galindo

    There is a definite need for this plain and clear agreement. “To Err is Human” came out 10 years ago and without personal accountability for the doctor / patient relationship being owned on both sides, we will get what we have always got. Evidence? 10 years later…number of errors is higher and it’s costing more! Dig deep people – personal accountability has to be distinctly different from legal liability to transform our destructive “world class” healthcare system.

  • http://pulse.yahoo.com/_HMQJ7TQCHJGXOMGKU6RSL3Q3TM Michael Matheson

    Gee, if every patient did all of this, what would be the need for doctors? People who don’t understand their condition and whose doctors do not take the time to listen or cogently answer their questions make this very simple sounding “contract” much more complicated.  We have been through dozens of doctors who don’t uphold their end of this utopian vision of health care. Dr. Kevin, how about a doctor’s contract too…where s/he is committing to understanding, coping, LISTENING, actively participating, STUDYING (especially when the patient’s condition does not fit into the pigeon holes that most physicians insist that it must). THAT would be something. 

  • Terry M

    I’m going to try to stay on topic here…

    Dr. Segal’s article advocates a model of care in which the patient assumes some responsibility for their own health instead of sitting there disinterested or passive.  What is so controversial about that?

    You may or may not agree with the individual points in his “contract” (I happen to not agree with all of them myself), but I hope you do agree that a patient needs to be actively involved and invested in what is going on with their body/mind.  More than occasionally, patients walk into doctors’ offices or clinics expecting quick fixes to chronic problems with minimal effort and minimal sacrifice.  Yes, some patients actually have no idea what medications they are taking on a daily basis or why they are doing so.  Is this right on the patient’s part?  Absolutely, unequivocally, no.

    Should a patient expect that their doctor will try to the best of their ability to work with them to the betterment of their health?  Absolutely, yes.  Nowhere in this blog post does it say that a doctor should not be held to a standard of responsibility to his/her patients.  Of course that should be an expectation that goes along with the job.  The responsibility and accountability needs to go both ways though.

    • Anonymous

      I have found that accountability doesn’t go both ways.  I was that patient that Dr. Segal longs for…educated, involved, honest, forthcoming, fit and a foodie, etc…and my doctors did very little to improve my health, one problem was ignored and became a permanent disability, and in a separate incident, was harmed by my medical team.  Not one of the doctors in my care took any responsibility for what happened.

      The doctor I see now gets the filtered version of my health because I feel it’s a waste of time and money to spend talking about all these issues.  I know my conditions, the prescriptions I take, the supplements I take. I know how the medications and supplements interact, what problems I need to be aware of.  I know how to coordinate my own care.  I know every test that was done, what the result was and what it means.  I know all my options, and if I decide I want to smoke, I have weighed the risks and benefits of my actions.

  • Anonymous

    So if I have a 27 point contract with my family doctor, and a 27 point contract with my sleep doctor, and another with my pelvic floor physical therapist, and another with my therapist, and another with my pharmacist, and another with my dentist, and another with my women’s therapy group, and one with my CPAP DME and respiratory therapist.  One might think these would all dovetail, but they don’t, particularly financially.  And of course the 27 point contracts I have by proxy with my mother’s healthcare providers and the management of the dementia unit where she resides, by virtue of me being her healthcare power of attorney.  And then there’s my minor son and his healthcare providers.  And then another 27 point contract about my financial health with my banker (since financial stress has a big impact on health), and 27 point contract with my auto mechanic.  (Gotta have a car to get to the doctor visits on time.)  And the 27 point contract with my cohousing homeowner’s association.  (Being homeless is terrible for one’s health.) And the 27 point contract with my employer.  (Being unemployed — ditto.)Hmmm.  Do each of my pets get a 27 point contract, or do I have a single one for both of them with the vet?  And I have to ask, if stopping smoking was this “simple”, why did the ultrasound technician who did my cardiac ultrasound a few years ago smoke? 

  • http://twitter.com/USMCShrink Kevin Nasky

    Efforts to reduce medical errors are abundant! Do you have any idea the amount of time and energy that goes into patient safety? Sure…it’s not perfect…we’re not there yet, but the medical profession (physician and nursing community, alike) is more attuned to this issue than anyone. Have you ever been to an M&M conference? Do you even know what one is?

    Seriously…if you don’t think our profession is tuned into the problem of medical errors and patient safety, you’re completely clueless.

    • Payne Hertz

      Being “tuned in” and taking responsibility for medical errors are entirely different things. Yes, there has been a lot of lip service paid to the problem of medical errors and some token efforts undertaken, but overall, the evidence is that these efforts have been few and far between, and have produced scant results. Those are the facts, make of them what you will. Read the links I posted. Doctors’ handwriting errors alone are said to kill 11,000 Americans a year. This is a remarkably simple problem to correct, particularly with modern technology and e-prescribing software and devices. If doctors were as “tuned in” as you claim, this problem would be near non-existent.

      As far as taking responsibility for medical errors,  the usual result of a medical error is the doctor and or hospital denies it or covers it up, and the patient has to pay the bill or risk having collection agencies destroy his credit rating and garnish his earnings. Patients often find themselves blacklisted and denied medical care for no other reason than they tried to get compensation for their suffering. The AMA is on record as supporting a controversial website that was set up to identify and effectively blacklist patients who had filed malpractice suits, though the site was forced to close over the controversy. In a perverse way, medical errors increase profit for the system on the whole, as victims are not only forced to pay the same for botched procedures as for successful ones, but often incur hundreds of thousands of dollars in additional expenses over a lifetime to treat the resulting medical problems.

    • http://www.facebook.com/people/Ailan-Medici/1409476759 Ailan Medici

      Unfortunately some medical errors are swept under the rug.  What’s that hospital maxim…’if it isn’t charted, it didn’t happen.’  Or pretend it didn’t happen.  Nurses on All Nurses forum have reported witnessing fudging with the record to obfuscate the facts, especially when something hasn’t gone well with the patient.

  • http://twitter.com/livewellthy Stewart Segal

    Michael Matheson asked a great question, “Gee, if every patient did all of this, what would be the need for doctors?”  Yes, the contract sounds straight forward and simplistic. Yes, life is complex. And, yes, Mr. Matheson is correct. If patients took this contract seriously, there would be far less need for doctors.  That would be a good thing!   Wait time in the doctor’s office would decrease.  Doctors would have more time to take care of the seriously ill patients.  Patients would be able to take a much more active role in diagnosis and treatment.  Less crowded lobbies with better informed, responsible patients would give docs more time to listen.

  • Anonymous

    This post pushes three of my (wait for it …) hot buttons.  

    First is the Personal Responsibility hot button, where on one side, there are companies who can and do use highly sophisticated behavioral modification techniques to promote various things (smoke! eat! drink! gamble!) so that they can make money off of them.  And on the other side is the individual who is supposed to resist all of these forces and live a healthy life, and it’s their own fault if they don’t.

    The second is the Faith Based Science hot button.  Didn’t you know that faith trumps science?  For example, almost every one of the Republican slate of candidates says so, about global warming, about evolution, just to pick two.  What’s the point of studying anything, of learning facts about anything?  

    And the third is Global Warming.  Humanity has been served notice.  If we don’t “stop smoking” — in the form of burning fossil fuels — great swaths of the Earth will be uninhabitable by 2050.  That’s 40 short years from now.  And in the face of all of the evidence, and the study that many people have done, the so-called adults in the room are  continuing to smoke, as unbelievable horror gets closer and closer.  Isn’t this the single patient who continues to smoke writ large, with planetary devastation as the equivalent of lung cancer, emphysema, heart disease, premature aging etc etc etc?  What is the difference?  

    And Dr. Segal, if it helps you to take a slightly longer view, in 40 years, it really won’t matter whether any of your patients smoke or not.  And I’m not saying that flippantly or snarkily.  I’m dead serious.

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