Above comments are right on the mark

Moral education is important and should be a priority in any professional training . The comment I make really pertains to the world which includes training and post training.

There is no bitterness against academics ( it is fun and correct to think about acid base disturbances, pathophysiologic processes, and treatments while helping those acutely ill in the hospital or to get paid a stipend to teach and lecture. )

But as the above commentor notes the private practice world is quitea different climate, where the physicians attention is pulled continuously away from the patient and forced to negotiate beuracratic ,legal and
financial obstacles.

The distinction from the hospital/academic ward is seen in the DB’s comment

“we cannot care for the patient if a patient does not care for himself”

In academics, this is true at the obligatory end of the ward rotation, where trainees and teaching attendings change services and patients face fresh new docs.

In non academic settings, the patient will come back to you again and again and again and again with ailments and the physician cannot “rotate off”.

The non interested diabetic smoker with hypertension will
come back to you with the consequences of the silent MI and the community doc WILL have to intensify the therapy and provide close follow-up until they decide not to follow up again or take their meds and 9 months later the ER calls you at 10:00 pm and notifies the community doc of the new stroke or out of hospital cardiac arrest. then you WILL spend the next morning explaining on the phone to the daughter just how it is that her hero father is critically ill.

in the post training community world

” we MUST care for the patient if a patient does not care for himself”

I do not misread your comments, I simply provide another view.

Moral values can be re-inforced in training and community based physicians try their best to work
against a system which places profits over care.

in fact the last comment of DB underscores again the gap
in academic medicine from commnuity medicine

DB writes “we cannot care for the patient if the patient does not care for himself/herself”

in the community we do it everyday and everynight

OK Db, you are right. I am not responsible for the
patient who is not responsible for themself.

now for my rant

it just seems that I am responsible
1.when the insurance company do their routine chart audits making me explain why their members did not have a colonscopy or mammo. (curious why they do not call the patient directly) sure, I don’t personally respond, my nurse does. I have to pay my nurse to do this so I am financially responsible.

2. when the fed government is poised to pay less if I cannot make patients reach certain lab value goals.
……so I am financially responsible

3. when case managers of insurance companies send me
notes expressing their concerns that “their” high risks patient needs closer office follow-up. Sure I don’t respond but my nurse does, so I have to pay my nurse to do this. so I am financially responsible

4. that doc’s spend a lot of time documenting (not providing care) so lawyers cannot find fault with the physician. recently I read about a 3 million dollar suit lost by a physician for not ordering a PSA on a 50ish year old man. He noted that the pro’s and con’s of PSA screening were discussed but lost the case becuase the standard of care is to order PSA’s. The AMA (in 2004) news detailed this and the lawyers found medical expert “witnesses” to support the notion that evidence based medicine is just a con job to save insurance companies money. how does that make me feel…all my male patients get PSA’s and if they are overdue I send them a letter to get it done. ( I pay for the letter)

5. Pharmaceutical management companies send letters to me monthly asking for me to explain to them why patients are not filling their scripts monthly. Sure I don’t respond to these letters but my nursing staff does. (which I must pay them for…

6. when the hospital case manager asks me as to why Mr. Jones is still in the hospital after 6 days ( because he smokes still and has end stage emphysema) she does not ask him, she asks me. (DRG pressure)

5. when I fill out endless short term disabilty forms for people whose personal lifestyles they miss work. (last year I refused to fill one out and I got a call from his attorney saying that I was abandoning “my responsibilty”
as his physician .

etc.

so yeah your right I am not responsible, I just feel like I am.

(and don’t get me wrong academic medicine is a national treasure.)

Whine, whine, whine! When will you understand that you’re not treating “patients?” You are treating PEOPLE with lives of their own, stress, work, financial problems, kids with problems, marriage problems, full-time job, several part time jobs, work and school, aging parents, a brother in jail, who knows what else! Or maybe it’s the rich lady who appears to have everything and yet is so lonely she’s thinking fondly of driving off a bridge someday soon. Are YOU spending enough time to learn why your patients are not complying? Everyone has problems. Everyone has barriers. If noncompliance is interfering with the health of your patient then you absolutely ARE responsible for breaking those barriers and finding the best way for your patient to comply.

This disgusts me: “Community doc’s pick up the pieces whether or not the patient follows a prescribed medical regimen. Community doc’s face the consequences of patient’s failings. In truth true care reverts to the community doc.”

Bull! If your patients aren’t following the “prescribed medical regimen” then YOU are NOT doing your job! Do you honestly think your nurses are EXPLAINING the “prescribed regimen” to your patients? You know you’re not doing it, you’re already on to the next billable bag of symptoms.

How in the world can you think that a person chooses to be unhealthy? Are they really choosing not to follow your regimen? Or, are they simply not undertstanding your instructions? Or my favorite, have you given them guidelines that they can reasonably follow within the confines of their budget, job, family and social responsibilites?

“Go on a diet,” “Quit smoking,” “Stop drinking so much.” Yeah. Uh-huh. How? Have you lived the patient’s life? Do you know what kind of stress he deals with on a daily basis? Do you know what kind of stress has been in his life since birth? You’re whining that YOU have to deal with the consequences of him not following your health plan? Seriously? Do YOU have to feel the pain that wracks his body every time he moves? Are you sure you’ve made the proper diagnosis? How will you check that? What if he doesn’t show up for an appointment? You send a bill, good! But WHY didn’t he come in? Doesn’t he need treatment? Has someone called to check on him?

Paying for a letter to remind a patient about a test that he PROBABLY DOESN’T EVEN NEED because you’re afraid of a law suit? Are you kidding me? How about spending a little more time with your patient to ensure that his health under control? Respect him, treat him with dignity no matter what his station in life is and he will not sue you no matter what.

Shocking that you must pay a nurse to follow up with a high risk patient. Perhaps your patient hasn’t been in for care because her life is a shambles? She may not know where her kid’s winter boots are going to come from! Not only can she not afford to buy new, she has no time between her three part time jobs to get to the Salvation Army. Even if she had time, how can she get there? No car! She has to deal with her life. Does your prescribed medical regimen fit into her life? And puh-lease! YOU don’t deal with her consequences! You condescend and “tsk, tsk,” write another prescription. Then, you lament on your big fancy computer about your burden of having to deal with the consequences of your patient’s failures. You know, how about instead you pray to whatever higher power you hold sacred that you will never have to live her life.

Moral? Humanitarian? Not unless you’re doing it for free. Think about this doc: When that call comes in at 10 p.m. and you have to “deal” with that “noncompliant” patient, you’re gonna get a paycheck. Your patient is suffering in ways you never even bothered to imagine, they’re laying in PAIN in that hospital bed. No paycheck for him.

When you answer that call about Mr. Jones, you KNOW you’re getting a paycheck for that. Poor Mr. Jones is dying and can only find a little comfort from the nicotine that he’s ADDICTED to God only knows how long. No paycheck for him, he deserves that smoke if it makes him feel better and he deserves that tiniest amount of respect for his life that it would cost you not to JUDGE him without even knowing him well enough to understand how to help him cure his addiction.

Your patient’s name keeps appearing on the schedule and you can’t diagnose her problem and somehow that’s her fault? No one else can solve the problem, you’re off the hook because she must be a kook, right? How are you going to tell her that even though she’s in pain every day, since you can’t find what’s wrong with her, there must be nothing wrong with her. She’s still sick. She FEELS sick every day. Are YOU “dealing with consequenses, or is she? Are you really satisfied with that?

And finally, your good intentions will NEVER cure a human being. Yes, in a perfect world all your patients will have the resources to follow your instructions. Last time I checked, this is still NOT a perfect world.

Noncompliance is obviously a problem. Who is working to solve it?

I’m saying that a lot of people actually have WAY fewer choices than the more priviledged citizens of the world realize. If you were able to afford college prep, college and medical school, I believe it’s fairly safe to say that you never personally spent more than one or two days of your life worrying how you were going to find enough money to put food on your table? Distracting? You better believe it. Until you understand the kind of distraction that comes from desperation, I’m pretty sure you and I will continue to disagree. But just in case you’re willing to learn from the poor and distracted, read on:

Not once do I mention enabling or absolving the patient of their responsibility. I’m saying, spend the time to understand the patient and help them find a way to take care of themselves using strategies that they can actually manage given the condition of their day to day lives. It’s unbelievably easy to do and you’d be shocked to learn just how effective it is to spend even an extra 5 minutes per patient listening to the reasons why they’re not following your instructions WITHOUT JUDGING THEM. Aren’t you responsible for communicating with your patients?

There are no excuses, only reasons. I believe it’s your job to learn the patient’s barriers and help them work around. I guess I’m always just looking for the inherent good in people. I wouldn’t categorize someone that I barely know as irresponsible or a blame-shifter just because they haven’t done what I expected from them. Especially if I haven’t taken the time to learn how in the world this particular person has “chosen” to disregard instructions that will supposedly improve their health. I think that if a person is choosing pain and suffering over following instructions that will make them well, there’s got to be something pretty powerful behind that. Maybe that’s the process you should be treating. Is that really not your responsibility?

I believe that generally speaking the trouble with all society is that just about every human on the planet feels that every other human on the planet should think and feel just like they do. And yes I think you summed up my thoughts perfectly when you said, “If you lived my life, you’d smoke/overeat/neglect your health, too.” The difference is our perception of the statement. You perceive that as an irresponsible attitude that a person chooses to have. I believe that it’s an attitude that has evolved over time and circumstance and is unique to that person. Perhaps introducing new circumstances such as a nonjudgmental, caring, helpful doctor is just what that patient needs to change that attitude.

I wasn’t griping about unneccessary tests, the previous poster was. I was only saying that whole problem can be solved by spending the time with the patient and explaining in a language that they can understand what’s really needed and what’s not.

“Our medicolegal processes, third-party payors and even patients want the doctors to own the problem. They can’t and shouldn’t be expected to.” What? The patient’s health is not your problem?

With all that said, of course I acknowledge that not all doctors are the same. I personally know some extremely kind and caring doctors who are regularly able to help their patients find and embrace strategies that help them live healthful lives within their means, circumstances and modes of understanding.

And finally, it was not my intention to SHIFT blame. I believe there is plenty of blame to go around. I think that if you take the time to talk with your noncompliant patients you will learn exactly how DESPERATE they are to comply and be healthy. If they need your help to get over some barriers, then they do and it’s your job to take care of that. You have chosen a lifestyle which makes you responsible for patients’ health.

there’s a lot of emotion out there and a lot of grandstanding as well.

The truth is that the vast majority of patients are good people and so are the doctors.

a similar rancor occurs with politics . Harris poll recently released a poll data showing that a large majority of patients were happy with their doc’s but were quite frustrated with the system.

Most politicians get good marks from their constituents but there is widespread dissatisfaction with politics in general.

absolutely we have cultural faults that lead to road rage,
drug use,greed, poverty, disenchantment, crime,you pick your cause… and medicine is not immune from these forces. Doctors are easy scapegoats as well as patients who abuse themselves.

are some doctors just plain bad ?

are some patients just plain bad ?

yes and yes.

Common sense :

if the patient doesn’t like the doctor, the patient can see someone else. The physician likewise can , with proper notice, ask a patient to receive care elsewhere.

The MAJOR problem I see is that the shortage of physicians makes it harder for patients and doc’s to allow for good fits. This will certainly spell trouble for patient and doc alike.

unfortunately too many med students in the U.S. and canada are choosing sub-specialty care and bypassing primary care. So medical care will is like many other enterprises. There are roofers, dry wallers, plumbers, masons,electricians, carpeters, painters, septic, wall paperers,etc… if you find a good overall handyman…you better keep him/her happy .

is their ultimately someone to blame for the world’s unhappiness. ?

it all goes back long long ago in a garden called Eden…

“If you were able to afford college prep, college and medical school, I believe it’s fairly safe to say that you never personally spent more than one or two days of your life worrying how you were going to find enough money to put food on your table?”

Spoken like a true relativizer and dissembler. This is a sly class-based argumemtative fallacy. To wit: “you, doctor, obviously come from such a different and more privileged background (true or not), so what you think couldn’t possibly be true for someone from a different background. Others (the poor, perhaps)have such a tough time in their daily lives that they couldn’t possibly find your understanding of their problems relevant, never mind your solutions. You have to reach down to them and understand them at their level.” Please. That is the language of the enabler and poverty pimp.

Betty, you really don’t know much about the medical profession, and certainly not as much as you think you know. I am not even convinced you are able to reason very well.