As Physicians Today, We Must Both Represent the “System” and Disregard it

Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.

Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.

I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.

On the other hand, if we work within the traditional healthcare system, we must strive to understand it well and present fairly the merits of the establishment’s usual approach to our patient’s problem. When our own educated opinion differs from mainstream medicine, it is our professional and ethical duty to tell our patients what we understand about their options and make it clear that this is not at this point in time the typical approach. I have done this for decades, warning patients that low fat diets promote heart disease by often inadvertently increasing intake of refined carbohydrates and telling patients that a Mediterranean diet has been shown to reduce heart attack risk at least as much as statin drug therapy. Medicine has always been an evolving science and to think it won’t continue to change is naive.

But if we disagree with everything conventional medicine does, we need to follow our conviction and move outside the system. If we do, we could be throwing the baby out with the bath water. And we could confuse and jeopardize patients by not informing them plainly enough that we aim to withhold accepted therapy because of our own dogmatism.

Our duty as guides is to walk with our patients in the direction they wish to go and to know more than one way of getting there; some people want the scenic route, others the fastest – some patients want better health with fewer medications and some want every intervention they can get.

It isn’t professional to only offer one approach if you know several. Let the patient choose.

3 Responses to “As Physicians Today, We Must Both Represent the “System” and Disregard it”

  1. 1 Eva Hnizdo March 1, 2020 at 6:02 am

    Yes, a sensible article. Also, we are not always right. When I used to each young doctors, I used to have several points in how to make a dg and plan of treatment. The most important question they needed to ask was : ” What if I’m wrong? ” If being wrong would mean a disaster, there needs to be a way of making sure the mistake doesn’t happen. With a patient with chest pain, the way would be send to hospital for cardiac enzymes and ecg. But in fact, ” What if I’m wrong?” is useful i all parts of life.

  2. 2 William Houghton March 1, 2020 at 7:55 am

    It takes guts and perseverance. If you feel that your company is short-changing the patient, first you can talk with the patient, and then do you need to talk with the company? If it’s a recurring problem, I’m afraid you do. What if your company doesn’t want to hear you? Then you are confronted with how much you compromise for the sake of both the company and the patient. I tended to go with the patient, and therefore had to drop out of pretty many companies. The same is true with professional organizations – – I was very disappointed that the American Psychiatric Association did not agree with me in 2011. Still, I soldiered on, and have continued my membership with the APA. Life is a series of compromises, I guess

  3. 3 James Noble March 7, 2020 at 7:06 am

    There’s a great scene in Star Wars (1977), when Obi Wan and Luke meet Han Solo to arrange passage on his ship. When Han quotes a high price, young Luke is outraged and says to Obi Wan “We could buy our own ship for that!”

    The Han Solo rejoinder – “But who’s gonna fly it, kid? You?” can be used, successfully, in dealing with “the system” and the various foolish and greedy schemes now in constant use to exploit patients and rob us of our autonomy.

    Every time a benefits manager, a “care” manager (actually, a manager of non-care), a prior approval drone, or one of the other leeches feasting on the pool of employer or government money intended for the care of the sick tries an intervention, you can and you should deploy “Fine. Write the orders”, our highly useful equivalent of “Who’s gonna fly it, kid? You?”

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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