Standardized Propaganda
I am often asked to reconcile my love for the Marine Corps and my support for our troops in Iraq and Afghanistan with the tenets of the Hippocratic Oath which, by conventional wisdom, seems to preclude a doctor from calling in an air strike.
There are many versions of the Hippocratic Oath and it is continuously edited to suit the demands of political correctness. One thing on which everybody can agree is that the oath enjoins us to “First do no harm,” meaning that nothing we do should intentionally make the patient sicker than he was when we first met him. I agree with this concept completely but, and forgive me if this is obvious, this only applies to one’s patients and not to the whole world. Only a small subset of the population, those whom we formally accept into our care, are our patients. The rest are strangers and to them we owe no obligation whatsoever. Dropping a laser-guided bomb on a nest of islamofascist vipers is as acceptable as providing them with their annual physicals. It’s the context that’s the thing.
(Hippocrates himself, as a Greek living in the 4th century BC probably owed some military obligation as a Hoplite for his polis and may have been involved in a campaign or two. Even philosophers, playwrights, poets, and others who would eschew military service today served in the phalanx when necessary.)
I mention this because it is not a requirement that physicians be social activists or professional busy-bodies. In fact, as much as doctors becomes these they dilute the only real authority they have, the authority to make medical decisions on behalf of the small subset of the population who are their actual patients. This is the fallacy of “community medicine” and every recent effort to turn doctors into organs of the dependocracy. The community, various ethnic groups, and even families are not your patients, the individual patient is. Even then his role as your patient is as limited as your responsibility for him. You can’t follow him home, you can’t pick his friends, you can’t heroically throw yourself between your patient and his pie, and you certainly have no influence on him outside of the quick talking you can do when you attend him in the clinic or the the hospital.
You can’t, in short, profoundly influence your patient’s lives even though that’s the paradigm being taught in medical school where nebulous concepts such as “wellbeing” are stressed to the exclusion of old-fashioned clinical and diagnostic skills. Not only will you not have the time but in many ways, your patient’s wellbeing isn’t even your business as it depends on many factors, over only one of which you have even a semblance of control. If the patient himself can’t get his life’s house in order, it is completely unreasonable to expect his doctor who sees him for twenty minutes every other month to do it. We have no special powers of persuasion denied to the general population. You’re just a doctor. Not a magician
Under various guises however, and in classes of different names at different medical schools, you will be taught to regard patients with an almost insulting paternalism predicated on the belief that they are helpless creatures who, if you only learned the art, can be hypnotized by your magical doctor voice to make good decisions. This is essentially what is taught in most standardized patient encounters.
For those of you who don’t know, a “standardized patient” is an actor pretending to be a patient against whom medical students are pitted. Apart from learning the mechanics of the patient interview, most standardized patient exercises are constructed to allow the student time to explore psycho-social issues they would be wise to avoid, both because there is no time in the real world to explore the intricacies of your patient’s convoluted lives and because there is nothing you can really do for him anyways outside of attempting to manage his medical problems (the successful achievement of which would be a small victory all by itself).
Medicine is not social work and you are not training to be a case manager. To believe you are is to fall for the propaganda being disseminated by the usual primary care culprits who, if they just stuck to the basics, would find justification enough for their jobs without dragging the profession into a sloppy bog from which it will never extricate itself. Society and your patients already expect too much from their doctors, goods that you cannot possibly deliver in the confines of a doctor-patient relationship.
Wow.
Right on.
It seems like the ‘rescuer’ personality is the dominant type in medicine, so much so that we students are constantly pushed to mimic that behavior in our work. Hell, you can’t even get into medical school without at least feigning that mindset. I occasionally feel like an impostor in that I don’t have the same self-denying drive that is so valued by my faculty and fellow students.
I tell myself that it is enough to just act decently to others, try not to cause too much suffering, do what I can and accept what I can’t, and take care of myself as best I can along the way.
By the way, you may have coined a new and unique word–dependocracy. A google search only brings up your blog. Sounds like a great book title to me. I’d read it.
you are so right. in my practice we deal with some significant social issues, the major one being child abuse. we are asked to make determinations if a fracture was or was not caused by abuse. my standard answer is “it is not for me to say, but children who do not walk don’t break long bones without some sort of trauma. it is for DFS to determine if it was abuse.”
i did have an odd discussion with a rotating med student (may be it is one where the brain washing worked) who felt is was the physicians responsibility to change the communities “bad habits” to effect obesity, heart disease, and diabetes. he was unwilling to budge in his opinion. i will refer him to your blog.
I can’t list how many times my fellow students have freaked out when they find out not only do I hunt, as well as own my own shotgun, but (HEAVEN FORBID) I own a handgun as well. I have seen many faces fill with compassion as they look on my poor soul, so filled with inner-conflict that must be present if I can own firearms, hunt, and be learning become a physician all at the same time.
There are some parts of the world where I think every cluster bomb dropped will actually have the net result of saving lives. So I favor dropping more! See, I’m compassionate! I think it’s an obvious offshoot of germ theory, really.
Was Moose attempting to be sarcastic?
Panda–Great post, as always. I wonder what you think about the “do no harm” tenant and MDs that participate in executions?
The guy you execute is your patient, therefore you shouldn’t participate in executions. See my point?
And this is why I love this blog. Straight forward, no nonsense, facts and opinions. Panda, if I were a religious man I’d have a new god.
My last patient encounter criticism-
“The doctor seemed more interested in my medical problem than me as a person.”
Getting the diagnosis right from a 20 year old Miami street person pretending to be a businessman wasn’t important.
What’s your opinion on physician-assisted suicide? If you’ve written on this already, please refer me to the post.
I am most strongly and completely opposed to it just as I am opposed to physicians taking part in executions (but I am not opposed to the death penalty for certain types of convicted rapists and murderers).
People are not animals who we can put down. There is a difference between withdrawing futile medical interventions and euthanasia.
“There is a difference between withdrawing futile medical interventions and euthanasia.”
I would counter that there is also a difference between PAS and euthanasia, at least the way you phrased it (i.e. being “put down”). The key word in “physician-assisted suicide” is suicide. Obviously we don’t just go around euthanizing people. If letting someone die when the medical interventions have become futile is a beneficent act, let PAS be the logical extension of that beneficence.
Well said PB.
A. PAS is profoundly reprihensible.
B. Execution is a different matter completely: It is judicial in origin and scope.
“the tenants of the Hippocratic Oath”
Are those the guys who live in the school library the week before exams?
(Good call Prowler, corrected-PB)
I recently ran headlong into that whole “can we truly affect a patients life” while interviewing a recent vet with severe PTSD. My dad is a Vietnam vet with PTSD and although I understood it a little from growing up around him, I never really saw the acute side until the VA. I recently wrote a post about it on my blog. I must admit that I really have come to a new view of this world of medicine and I don’t think we have lasting effects on the majority of our patients. We may touch a few, occasionally and we should cherish those opportunities. In general though, I feel that my mission to make the world a better place is going to happen on abscess at a time in the middle of the night in some county ED. When I interviewed this vet it was obvious that although I maight be able to calm him with some meds, help him sleep or perhaps prescribe an SSRI, I was NOT going to be able to take away his demons. If he stands a chance he needs to fight this battle in his own head and heart. Of course, I feel it is our duty to be there and support him when and where we can. to offer him the tools we have, but we can’t walk his walk.
I like Graham (Over My Med Body) and I link his blog because it is very good but he can certainly twist and contort himself into tortuous rhetorical knots to try to refute the obvious fact that patients are going to shovel pie into their slobbering gobs despite the best efforts of their doctors.
Can I produce a study to show this? No, but I can’t produce one to show that weasels suck eggs, bears shit in the woods, or the Pope wears funny hats either.
Hey Panda,
Great stuff as always but everyone would not agree that ‘First do no harm’ is part of the Hippocratic oath. In fact is more correctly attributed to the Roman physician Galen.
Best Regards,
Tom
No, I’m not being sarcastic. I’m being a little inflammatory, but not untrue. Some countries just need the application of a 2000 pounds of truth and light regularly.
“first do no harm” is at odds with modern medicine, period. At least 50% of what we do in this profession violates that tenet. Just handing out baby formula at hospitals for the last 50 years has likely played a huge role in the IQ drop/illiteracy/incompetence problem we seem to be having.
The phrase needs updating.
how about, first, let’s hope we don’t do any harm;…second, we lessen harm by being more selective about invasive procedures and drugs;
third, we inform patients very very crystal clearly about risks versus benefits and KNOW the risks versus benefits and actually KNOW the indications.
In 2005 I had an assymptomatic third molar extracted and had to be on 1500 mg of clindamycin for weeks, miserable, shaking, deathbed feeling all around. Found out that they aren’t doing that procedure for that indication in most parts of the industrialized world. Hmmmm……..
And this month in Portland, at the center for integrative medicine, three people died from overly concentrated IV colchicine for back pain. IV colchicine for back pain? CAM looks better than that. They could have been flogged with sassafrass leaves by a shaman in a hot dark clay sauna and survived happily.
The sad thing is that those patients, I bet my bottom dollar, never tried amitriptyline, or cyclobenzaprine, or codeine, (or even marijuana) because the source of such mundane drugs didn’t have a fancy skylit waiting room with jade plants and a big sign: natural.
The drugs, 10x stronger than labelled, oops, came from a compounder called Apothecure, (french accented e, no less), an outfit complete with a swirling logo.
Once again Panda, I can see there’s a lot of truth here, well-spoken. The spots where I disagree with you are fairly predictable… and boring. When we agree, it’s a beautiful thing.
What advice would you have, I wonder, for someone who has yet to begin the charade of standardized patient encounters? I doubt that my instructors will appreciate me saying, “Dammit, Jim, I’m a doctor, not a babysitter!” …no matter how true or apt it might be.
And they’ll really hate it if I rely on my years of acting training to take apart the “patients” on their performances, or my years as an ER tech to predict which ones will actually follow up as instructed, or fill both the Percocet AND the Bactrim.
Maybe during the happy sunshine classes where we pretend we can make patients’ decisions for them, I’ll sit in the back with a smuggled-in book on physical diagnosis.
semper fi, oorah, hua, and whatever the air force says. served 6yrs and proud and ‘vipers’ they are.
I love this post. I am a Marine having served as an 0311 during the late Clintonian Pax Americana era and have since spent my post-warrior life either wandering around the country or sequestered in academic-villages. I am now preparing to matriculate in a PA program this fall and will re-enter the military under the HPSP program—this time as a Navy PA.
Anybody who gives you shit about the military and medicine being irreconcilable is dead wrong. The military providers (whether they are Army medics, or Navy corpsmen, IDCs, or physicians) not only save the lives of their troops, but also provide free health care for noncombatants and refugees in regions where the indigenous docs have long since flown the coop. What’s more, military docs even provide for enemy combatant prisoners: The terrorist becomes the patient. How could anyone treat the wounds of one who has been murdering his brothers? At first glance this may seem to be a moral dilemma. In the civilian sector a provider could back out on the grounds of “conflict of interests†and go about their daily life with a free conscience. However, duty comes first in the military. I would posit that those who have the character and fortitude to volunteer in the military in the first place will have the moral/intellectual equipment to treat illness and injury regardless of race, creed, class, or color.
If anybody is interested in combat medicine they should check out CDR. Jadick’s On Call in Hell: A Doctor’s Iraq War Story. Its about a Navy physician and his team’s experience in setting up a forward aid station during the Battle of Fullujah in the spring of 2004.
You may be a cynic, but not always a realist, since fiction, not fact, frequently fuels your conviction. Approximations of reality, although amusing to read, if left unchecked will sclerose your brain. You need treatment.
Don’t confuse legal authority with respect. A medical board bestows the first kind. The other kind of authority is given by the patient, and if they do not respect you, then I would argue an empty office dilutes your authority even more. Sincere involvement in community affairs expands the authority that the patient sees within you. Your version is backwards.
(Dude, don’t be a condescending ass. I know as well as you that the Hippocratic Oath is not legally binding and is merely a tradition. However, as various interpretations of the oath inform the convictions of many who believe in medical mission creep, I believe it is relevant to point out that the oath applies to one patient, not to a cohort of them or society in general. I think you confuse your convictions with fact. My conviction is that the role of a doctor is to diagnose and treat medical problems of the small subset of the population who are his patients. Period. Your convictions seem to lead you to favor a more expansive role which is fine, more power to you and knock yourself out, but it’s just your weltanschung, nothing more.
And if you think education is going to keep people away from their bad habits then have at it. In the real world, very few physicians have the time to devote to the herculean task of seducing the patient away from his pie, let alone thier heroin, crack, or even cigarettes.-PB)
If you have good rapport with patients, then you most certainly can persuade more effectively than the general population, and you can be a teacher as well as a doctor. PhDs in influence research also support this observation objectively. Education is a critical component of preventive medicine and a part of ordinary practice. Therefore the assertion, “you’re just a doctor”, weakens your ability to be an effective doctor. Ironic also, since your intent is to persuade. Again, you get reality backwards.
Given some apparent departures from reality and your wariness of the Hippocratic oath, I thought I would correct one more misconception implicit in your statements. The Hippocratic oath is a tradition, not a requirement, and the NIH fact sheet on it indicates most modern medical schools don’t require the Oath. So rest easy. The only oath you need to worry about is the one you take in court, just before a trial lawyer begins his malpractice suit against you.
Also, please go re-read Pie Will Out but this time without viewing it through the prism of your deeply held biases. “Teacher as well as a doctor blah blah blah.” In the real world, it is almost impossible to teach somebody out of a crack habit, for example, because for the addicted, nothing can compare to the transient euphoria of their last hit. People will sell their children, steal from their friends, alienate every non-junkie person they know and sacrifice their jobs and fortunes for their drugs. They will, if required, surrender their self-respect and become outcasts from the productive world and you think a good talking to is going to make a difference? I think your PhD friends need to get out more.
Dude. Just getting a patient to lose weight is a major victory. Not saying it can’t be done but, as I said, the level of involvement in the lives of the patient is economically prohibitive.
Oh the stories I could tell.
Best advice I ever heard in med school was from a sage GP, who, giving us a lecture the first month of school, told us:
“Don’t let anyone fool you into thinking that doctors are gods. The only thing I can really do is give people advice. Most of the time they don’t listen. Every now and then they do.”
I once told a thirty eight year old he had diabetes and he needed to lose weight and eat better and to see me in two weeks for “formal” diabetic education. I saw him nine months later, a assymptomatic piece of steel with no trace of any chronic disease. That was nine years ago and as I see him every couple of years for a cold, he is still going strong. Like a hole in one or a couple of turkeys at the alley, it only takes one patient like that every decade to keep me going. For young docs reading this, realize that everyone gets to go to hell in their own way. You are a tool for the patient, they have to be the carpenter. Very few will use you in that way, but those that do will make you feel, well like a doctor. Also, because they use you the way you should be used, they will only see you rarely, so enjoy those visits when they come.
By the way, about that oath. All cynicism aside, when you stand up in front of your teachers and swear you will never intend to do harm to your patient and you won’t put money first, it either means something or it doesn’t. Crossing your fingers is all about you as person and nothing about the profession