The job of a doctor isn’t to diagnose, prescribe, or examine. It isn’t to be well read, efficient, or punctual. The job of the modern doctor is to convince.
We now have radiological studies whose theoretical discernment limit is subcellular. We can not only map clear and obvious genetic errors of metabolism, but also minor variations of the normal. In a few years, the majority of codes in the procedure manual will probably be laboratory evaluation codes. There are few disorders left that given enough money and studies remain elusive.
Patients walk in my door with their diagnoses. They have COPD, or hypercholesterolemia, or degenerative disc disease. They come bearing boxes of records from dozens of doctors. They provide me lists of treatments, some effective, most not. Occasionally I add a few diagnoses, or parse out which of their problems is the culprit, but for the most part I know what they have when I first see them.
Once the patient and I agree on a diagnosis, the doctoring begins. Based on nothing other than my words, I have to convince the patient to take poison, do something that may hurt a lot, or go see another doctor who will cut them with sharp objects. Based on a single conversation, I expect strangers to change their lives, expose themselves to unknown dangers, and then usually not see me again for a month.
I enter all of my patients’ medications from all of their doctors using my electronic medical record system. Almost every prescription is flagged, usually with 3 or 4 interactions. If drugs weren’t poisons, they wouldn’t be useful. Their purpose is to change what your body naturally. Medications that won’t kill you if taken in bulk are rare. Many of the drugs that I write for have unpleasant side effects that are worst when started. All of them come decorated from the pharmacist with dire warnings on the outside of the bottle and written instructions reminiscent of the fine print of the Affordable Care Act.
I am a rehab doctor. That means I often decide that the best treatment is exercise, usually of an unpleasant variety. Musculoskeletal pain frequently promotes avoidance behavior with consequences in posture and activity that must be trained out, through the restrictions and pain that produced the problem. Frequently, I’m trying to get the patient to accept therapy to improve the problem, not eliminate it. After all of the painful therapy they still will have some of the pain.
Sometimes, it’s my job to tell the patient that what they’re afraid of the most is the right thing to do. The patient comes in after years of injections and therapy and medications, determined to avoid the surgery that their brother said ruined his life. Then, it’s my job to tell them that all of the failed therapy to avoid surgery increased the chances that they would need surgery, and that now they need surgery.
After telling the patient all of this, I send them out the door with my instructions. They may or may not fill the prescriptions, or go to the therapist, or go to the surgeon. They certainly will ask their pharmacist, friends and family their opinions of the treatment. They will then do what they want.
Bureaucrats paid and unpaid need to understand the fundamental limitation of research based guidelines. That limitation is that people who are paid behave differently than those who are not. All of the instructions and electronic monitoring will change nothing if the provider can’t convince the patient to do the recommended treatment.
If the job of a doctor becomes that of a data entry clerk who matches the recommended diagnoses with treatment guidelines, how effective will the doctor be at convincing patients? I have enough trouble getting patients to do what I actually think should be done, much less providing instructions that are changed yearly by committees who never see patients.
“Tiredoc” is a physician.