A.J. Smith, a pseudonym of course, walked into my office today, unhappily. Most of her topical medications for acne caused too much irritation. The ones that didn’t, weren’t working. The doxycycline caused photosensitivity in the past. But her friend’s dermatologist gave her isotretinoin, better known as Accutane, and she completely cleared. As such, that’s what my patient demanded. There was only one problem. The degree of her acne didn’t warrant such an aggressive approach. I explained the risks at length with her, and I explained politely why she wasn’t a candidate. This fell on deaf ears. She wanted what she came in for.
As a medical provider, I never downplay a patient’s complaint and how it affects their lifestyle. A minor malady for one patient can be the equivalent of cancer for another. If I have a patient whose livelihood depends on their appearance, it’s my job to make my patient whole again, judgments aside. I do, however, need to adhere to the Hippocratic oath. First, do no harm.
In the digital age, a side effect of this thinking is that of a negative Yelp or Healthgrades review. With a negative review comes decreased patient visits and, by extension, decreased revenue. As most of us realize, today’s medical corporate culture puts more emphasis on volume and dollars generated than it does on well-being restored. Hermes and Hippocrates would have surely found another vocation, had they been alive today.
The struggle, as medical providers, has never been more tense than it is today. We constantly find ourselves in a battle between good customer service and doing what’s right for the body. Empowering patients through knowledge is intrinsic to healing. As a provider, I refine my approach on a daily basis so that I may explain, in the simplest terms available, a complex disease process. My patients and I are partners in healing and we need each other to achieve this end. I fear, however, that the balance has shifted too far in the other direction. With information comes strong opinions, beliefs, and demands. Due to outside pressures, including societal expectations, Dr. Google and direct-to-consumer advertisements by pharma companies, we medical providers find ourselves in a mental tug-of-war. The healer and the consumer have become opponents instead of teammates. We, as medical providers, know that there’s no substitute for experiential knowledge, but often, our patients don’t understand this. Knowledge from the school of Google becomes gospel, and to go against it is blasphemy.
When faced with this conundrum as a provider, what do we do? Do we abandon the oath that we took and, instead, indulge our patients so that we’re seen by the “customer” in good light? Do we indulge in our own instinct for the short-term gain of approval, to avoid the pain of disapproval? Do we strive to avoid the meeting with the business owner to discuss the bad Yelp review that’s mostly based on the human tendency toward negativity bias? After all, it takes less energy to complain than it does to compliment. Or do we risk their wrath to do what’s best for the long-term well-being of the patient?
In the end, I used as much persuasive logic as I could to explain to my patient that such aggressive treatment as isotretinoin was not in her best interest. While generally tolerated well, the potential side effects outweighed the benefits and, as such, I could not justify prescribing it. While my mental discontent to avoid the negative review remains, I know viscerally that I did the right thing.
While I don’t have a concrete answer on how to restore the balance between patient expectations and medical realities, I do hope to stimulate discussion about it. I feel that one solution would be to decrease the unsustainable time constraints that we experience. Having more time to explain and illustrate why medication A may not be right would be immensely helpful. Another possible solution would be to incorporate more instruction on communication and the psychology of persuasion into our medical training. With great knowledge, but lack of efficient communication, healing cannot occur.
As someone who prides themselves on good bedside manner, I feel that medicine has become, predominantly, a consumer-driven service. In addition, our system has become one of automation. Insurance companies have resulted in medical practice becoming algorithmic. They expect something as complex as the human body to behave in ways that can be minimized to that which can be printed on paper. In dealing with this way of concrete thinking on one extreme, and our patient’s expectations on the other, the artistic practice of medicine ceases to be an art, but instead a source of conflict, with the provider feeling like the prey being pulled apart by two lions. Unfortunately, the easy way out, to move on to the next patient thereby avoiding getting too far behind, can be to give in to the patient’s demands.
The philosophy of fast-food franchises is to produce the most food possible in the least amount of time with the least amount of thinking to satisfy the largest number of customers. The system runs the workers, not the other way around. This philosophy has expanded to the practice of medicine. It has done so at the expense of the spirit of healing that brought us into medicine. We no longer have the time or freedom to create an individually tailored treatment plan. The purpose of medicine, once with the simple goal of making a fellow human being whole again, now appears to have a new slogan: Welcome to McMedicine, may I please take your order?
The author is an anonymous physician.
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