I went into medicine because I wanted to learn about the craft, become proficient at healing disease and easing suffering, and because I genuinely liked getting to know more about my patients and hearing their stories. These reasons for going into medicine as a career and staying in medicine as a vocation have not changed significantly through the last three decades.
The problem we are faced with pretty often nowadays is this: the demands that patients (and through them insurance companies, pharmaceutical companies, families, and other third parties) make are often at odds with what were taught to do. I’ll give you a few examples.
Patients will come to me and ask for a specific diagnosis. Why? Because sometimes their insurance will not pay for a less severe diagnosis (an adjustment disorder versus a major depression), they do not want to be perceived as being in treatment for an alcohol or other substance abuse problem (no matter how valid it is), or they need to be seen as having a particular problem because their attorney told them that it “would look good” for their disability case or another lawsuit.
Patients will come to me asking, or sometimes outright demanding, that I prescribe a particular drug for them. Telling them that I do not prescribe narcotic pain medications in a mental health clinic is easy enough. When they ask for benzodiazepines like Xanax, Ativan, Valium, Librium or Klonopin, the area might be grayer. Some patients might benefit from those drugs or even need to be on them long term, but they are the exceptions nowadays. “If you won’t given them to me, then I’ll just go to Dr. Jones down the street!” they exclaim, thinking that this is somehow a threat to me. Or, “I know that you give them to Ms. X from across town. Why won’t you prescribe them for me too?”
Direct to consumer advertising on television has not made this any easier, since patients will come in asking to be prescribed powerful antipsychotics for insomnia or pain medication for panic attacks. What they are asking for often makes little sense clinically, but of course, since they saw it on television it must be true, and I should get out the prescription pad.
Some patients come in demanding a particular kind of treatment that they think makes the most sense for them. Aunt Sara may have told them to ask for it, since she took Psychology 101 in college and has the power of the Google search behind that vast amount of training, or they have read about it in Vanity Fair, or a friend of a friend of a friend had the particular treatment years ago and it worked for them.
Some will want long term therapy when it makes little sense to drag things out for years when weeks or perhaps months will address the problems at hand. Some will want outpatient treatment when it is quite clear that they need to be admitted to the hospital. Others, already on an inpatient unit, will want to stay there for weeks, when the right thing clinically is to discharge them to an outpatient clinic. Some will ask for “counseling” when it is imperative that they enter drug rehab for a heroin problem that they do not want to acknowledge.
Some patients want a specific kind of relationship, that is, they would like to consider the doctor their special friend, not their physician. Others like to consider themselves the medical, diagnostic and therapeutic equal of their physician, since they can and do research everything online, sometimes in real time on a smartphone while they are sitting in the exam or consulting room! Some, of course, want a clinical relationship to move to a friendship and then perhaps an even more intimate relationship, which is never appropriate in my opinion. I was taught, once a patient, always a patient, and I still subscribe to that maxim today.
It is hard to do the right thing, in medicine and in life.
So what is a conscientious and well-trained and compassionate doctor to do?
Establish a professional doctor-patient relationship first, before doing anything to treat any malady. This means seeing the patient, getting a thorough history, doing an examination as indicated, establishing a diagnosis and coming up with a treatment plan. No shooting from the hip, sidewalk consulting and doing something for a friend. These will come back to bite you. Although some would not agree with me, I have not made a practice of treating my own family over the years either. If my children were ill, I figured a well-trained, trusted pediatrician was a much better option than a slightly frazzled, worried parent who happened to also be a doctor.
As far as medication treatment goes, I have always been very conservative. If a mother is pushing for a 3-year-old child to be put on stimulants for “ADHD,” I will balk.
If a woman pregnant in her first trimester is pushing for Xanax to help her deal with the marital conflict with her husband because of the pregnancy, I will recommend counseling, not benzodiazepines.
If someone who is not psychotic is having trouble sleeping, I will be much more likely to give them a two-week course of a sleeping pill than put them on the small dose of a major antipsychotic that they heard about on television. What you’re treating, and not treating, is important. Efficacy and potential side effects are important.
It is very important to tailor the treatment to the illness diagnosed, the symptoms that are being targeted and the outcome that is expected.
Lastly, as alluded to above, the relationship between doctor and patient must be held to the highest standard of all. It should be professional, respectful, and collegial. We are partners, but by definition, we are not equals in the process. You know yourself better than anyone in the world. You have information that you must impart, and I have decades of experience and learning and training that I must share with you in order to help you get better.
Together, if we are honest and work together, treatment happens, illness is treated and managed, and patients recover.
It is only then that it is much easier to do the right thing.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
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