More on Paternalism

EKR at Educated Guesswork writes about my paternalism rant – When is paternalism justified?

I think DB is missing something important here. Sure, if you want high quality medical care and you’re not medically sophisticated you want to be under the supervision of a doctor. The problem is that it’s legally mandated. There’s no law against me working on my own car, but when I have a transmission problem, I don’t drop the tranny in my garage–I take it to a mechanic. (To tell the truth, I take it to a mechanic to have the wiper blades changed). So, I think if you want to have mandatory paternalism, you really have to explain why people aren’t able to decide for themselves whether they want close monitoring. In my view, DB doesn’t do that satisfactorily.

Let me try again. Many patients make their own decisions regardless of our recommendations (and remember, we prescribe we do not force feed medications). I guess a well educated patient might be able to figure out a complex medication regimen. But it really is unlikely. I guess I could treat myself – but we do have a saying about that – “The doctor who treats himself has a fool for patient”.

So I must endorse this form of paternalism. Physicians have the training and experience to juggle the multiple conditions and disease manifestations. We should include the patient in our decision making – but we should recommend and recommend strongly a treatment course that best fits the available evidence. For that I do not apologize!

The Proximal Tubule on Paternalism in Medicine

Paternalism In Medicine – Part II: Gatekeepers

Trent McBride writes a long rant about the influence of prescription drugs on the doctor patient relationship. First, I love the blog’s title – I love renal physiology. Maybe I should rename my blog the Countercurrent Mechanism. Or that could be a great name for an alternative band!

Trent hypothesizes that making patients come to the doctor for prescriptions represents the ultimate form of paternalism. I will disagree to some extent on his proposed solutions.

Yes, prescribing medications is paternalistic. But then I do not assume that all medical paternalism is bad.

If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).

So to provide the highest quality care, I believe that I must be paternalistic. In that sense paternalism is not a bad attribute.

Narcotics might be the exception. I do not really know how much pain a patient suffers. How can I judge the best method for treating that pain? Should I worry about narcotic abuse? Wouldn’t we be better off if we just let patients buy their own pain meds and suffer their own consequences?

Trent does mention antibiotics – and he is correct. But I will gladly argue that many conditions which I treat require complex decision making and adjusting of multiple medications. I accept that paternalism and I believe the great majority (>90%) of patients want that paternalism.

Caveat ahead – even when one must take a paternalistic stance, one should still discuss the rationale for each medication with the interested patient. When choices are available for treatment, we can and should discuss those choices with the patient.

So as usual, I am a bit wishy washy. I agree with some of the Tubule’s argument. But I believe he goes overboard. But after all, that is what blogs are for – to stimulate our thinking and challenge accepted thinking. And therefore he succeeds.

On hypochondria (or somatization disorder)

A New Era in Treating Imaginary Ills

They make frequent doctors’ appointments, demand unnecessary tests and can drive their friends and relatives � not to mention their physicians � to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation’s staggering annual health care costs.

Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room.

Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective.

“The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment,” said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women’s Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.

If these patients do not induce “heart sink” then you are a different physician than me. These patient’s name on your daily list causes anxiety, depression and thoughts of illness.

The biggest challenge is sorting out their hypochondriacal complaints from real disease, because even a hypochondriac can get sick.

I once had a patient who came to me after having 17 negative HIV tests. He had not had any sexual relations in over 6 months, yet thought he needed another test.

I saw this patient for around 9 months. My greatest feat was getting him back to see his psychiatrist, as he also had major depression. Over time with reassurance, calm, scheduled appoints and medication he was able to regain a productive life.

As I read the article this morning, I saw most of his personality and problems. We (physicians) would all like a consultant who wanted to see these patients, as most physicians and psychiatrists shun them. I certainly hope that these initial positive reports are confirmed.