Continuing today’s theme
Tuesday, March 3 2009
Today’s theme, apparently, is stupid, stupid patients.
With more on that, let’s turn to the NY Times’ Well blog, where Tara Parker-Pope asks, “Are Patients Ready for Health-Reform?” The slugs includes a link to her column, “A Hurdle for Health Reform: Patients and their doctors“. Note subtle change from “patients and doctors” to just “patients”; also note the fact that every expert quote in P-P’s column talks about patients and doctors, except this one:
“Doctors believe the industry propaganda that new drugs are better than old ones, and that for every ailment there is a drug,” said Dr. Marcia Angell[...]
But, of course, the real question is whether patients are ready for health reform – not that doctors have anything to do with it.
Dr. Mintz picks up the ball to run it into the end zone:
her sentiment is right on target. If we want to lower health care costs, then everyone can’t get everything. In certain cases, some degree of rationing is going to have to occur. However, in many cases just using good scientific evidence will do the trick.
He goes on to offer a list of things “patients can do to reduce health care costs right now”:
1. Don’t demand antibiotics
2. MRI doesn’t necessarily mean the best test
3. Patients have to accept watchful waiting
4. Spend out of pocket money of things that work
5. Reform malpractice insurance
Dr. Mintz seems to practice medicine in a universe where patients are making irresistible demands of their physicians, who get steamrollered into agreeing to all sorts of expensive and unnecessary treatments. Am I the only one who thinks this is insane?
1. Could doctors stop prescribing antibiotics, and take the time to explain that they don’t work? It’s not like patients get these OTC. (I suspect this is a pet peeve of Dr. Mintz’s – something he occasionally sees and it drives him nuts, but he can’t figure out how to explain the difference between viruses and bacteria to his patients.)
2. Do doctors have any say in who gets an MRI? Again, patients are not buying these machines for themselves; if patients are climbing into them, it’s because their doctors are ordering the test.
3. Is “watchful waiting” too often a euphemism for “I’m too busy to deal with you”, or “I don’t want to address your problems”? I am happy to wait watchfully, so long as I feel my doctor really is out of options. But if it’s just a dodge to keep him from having to write for the pain meds I need, to hell with that.
4. Might the reason patients spend out-of-pocket on money on things they hope will (but in fact don’t) work be that what works is often beyond our ability to purchase at any price? See #1, re: doctors and prescriptions. I can’t go into CVS and buy the TPN that I know would help me stay well-nourished and energetic; so instead I take a gummy-bear multivitamin that probably does nothing (but at least it’s a gummy bear). That gummy bear is the very least of what’s wrong with our health care system.
5. Are doc-bloggers contractually obligated to mention malpractice every time they get on the subject of reform? Seriously, are we still on this? To his credit, Dr. Mintz suggests that we need a better system to compensate patients when things go wrong; but here’s the thing: there is nothing keeping the medical profession from implementing such a system all by itself, and meanwhile Dr. Mintz knows “malpractice reform” is codeword for changes that would strip patients of necessary protections.
By all means, let’s nobody examine the role the medical profession has played in creating and sustaining dysfunction in our health care system. Let’s all ignore the effect of physician licensure rules, prescription drug laws, and training that inculcates physicians to believe they are their patients’ superiors; let’s ignore all the myriad ways medicine disempowers and diminishes patients, and gives them over to alienation and disaffection with the medical profession.
Instead, let’s blame them for being stupid, stupid patients, and demand they give up even more – more money, more control, more privacy, more dignity – to ensure the viability of our medical system. Let’s all demand that patients change their behavior – so doctors won’t have to.
I came across your website from Kevin MD’s blog. First off, very well written. Secondly, I rarely come across patients as well informed as you. You realize you are an anomaly? Because the majority of patients I see are scared, sick, tired ,in pain etc, they are often not doing cost comparisons for their care. It is the doctors and nurses responsibility to teach their patients, and to prescribe the appropriate treatments. Patients may “demand” a drug they see on TV for example. It is up to the doctors and nurse practitioners to patiently explain why it is not right for them. The art of conversation has been lost in medicine. Some doctors and nurses are afraid to converse with their patients because of time constraints or because they do not know the answers to their questions. As far as the every present malpractice threat, patients who respect and have a good relationship with their doctors, rarely sue.
@Reality: Welcome, and thanks. Yes, I am very much aware of my anomaly-ness, in part because I know my particular circumstances are rather unusual; but I do think my perspective puts me in a position to help other patients be more proactive and responsible in their own care. I agree that we need to reintroduce the “art of conversation” into medicine, and I respect the difficulties faced by many doctors (including yourself) in their practice. I guess the question is, how do we address those difficulties in a way that is not punitive towards patients?
Uhhh… I hate to break this to you, but doctors ARE superior to patients when it comes to the practice of medicine. If I have belly pain, i have no clue whether its autoimmune hepatitis, appendicitis, perforated colon, or gastritis. I need the doctor to diagnose me and tell me about treatments.
Also you overestimate the willingness of patients to listen to their doctors when they get news they dont like. If you are convinced you need narcotic pain meds, then the doctor could spend an hour telling you why narcotics are a bad idea but you arent going to listen, you are just going to “doctor-shop” until you find one that agrees with you.
Same thing with antibiotics. People dont want to hear that they might have to wait a couple of weeks for a virus to run its course. They want INSTANT relief, and if you dont offer an instant relief, they will keep going to urgent care clinics until they find a doctor who will give them what they want.
@anon305: Yes, doctors are superior – that’s kinda my point. Doctors are granted a lot of privileges and latitude within the medical system, at the expense of patients – yet Dr. Mintz seems to be arguing that patients should give up even more. But health care reform won’t work if it’s all about strengthening doctor’s position against patients. I think we’re starting to see quite clearly that the practice of medicine alone is not enough to keep Americans healthy; one of the the ways we can fix that is to stop treating doctors like they are the solution to the problem of illness. You wonder why patients don’t like bad news from doctors: because we’ve been trained by the medical system to think that doctors have a solution for everything (usually a pill). And where are these doctors who have an hour to spend talking at patients? Is it so much to ask them to spend some of that time listening?
You seem to be reasonable and informed. I agree with most of what you have said above. BUT I have patients that have a sore throat for one hour without fever that want antibiotics. Patients that state, “I have a cold and need antibiotics.” I explain to them why they do NOT need antibiotics. They then call me daily for the next 7-10 days begging for antibiotics until they finally are better. I do not cave in. Many patients have left my practice because I stick to my guns. Many have given me poor ratings on websites too. Luckily I own my own practice so I can do as I wish. Many employed doctors are pressured by their administrators to make the patient happy, even at the expense of good medical care. The other day a patient insisted on an MRI for their back pain of 3 days. I refused. They went to the ER. No MRI done there either, but what a waste. You seem to understand the bigger picture of health care. Most of my patients want it all and they want it now. They also want it for free. I have patients that refuse to take cholesterol medicines for high cholesterol because it is too expensive, but will pop about 12 vitamins a day.
Many of my patients medical problems would resolve with weight loss, exercise, a healthy diet, drinking in moderation, restructuring their stressful lives, and quitting smoking. I counsel this all day (even though insurance pays nothing for that kind of service). Insurance pays for me to order tests and give them drugs. No one wants to work to maintain their own health.
@stargirl65: For all the comments I’ve gotten here (and elsewhere) about it, I admit that maybe I need to learn more about the antibiotics issue. But let me point out that jerks and idiots get sick, too, and nothing is going to keep them from being jerks and idiots. That said, I think most people don’t want to be jerks and idiots, and I can’t help thinking that at least some of the unrealistic expectations your patients bring in were taught to them by the medical system. So I applaud you for sticking to your guns, but I don’t think you can win it all by yourself. Patients need to learn not to look to doctors for easy solutions to all their problems. Doctors can help teach this, but it needs to be part of a process of patient empowerment. Unfortunately, a lot of doctors resist this because they fear it will diminish them, either in status or salary. I think there’s room for healthy compromise.
Nowhere is this more apparent than in obstetrics. Add to it the philosophy that pregnancy and birth do not need to be pathologized in the first place and that the practice of medicine is best reserved for when it is actually needed and you get a century old struggle of responsibility between woman and doctor. http://tinyurl.com/c7e2a5
Great post and I loved your subsequent post on advice for patients.