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When ends justify means

The patient probably didn't need the antibiotic -- she simply had a viral infection. What she did need was a sense of control over her own care.

September 18, 2006|John A. Vaughn | Special to The Times

AFTER a thorough examination, I reassured the patient, a young woman who had stopped into the urgent-care center on her way home from work, that her upper respiratory infection was caused by a virus. I recommended that she take an over-the-counter decongestant and expectorant until her symptoms resolved.

As I half-expected, she launched into an emetic outburst that ended with the indignant admonition that she wasn't paying a $50 co-pay for nothing. She wanted an antibiotic.

Like all primary care physicians, I'd given in to this demand more times than I'd like to admit.

With insurance reimbursements declining, operating costs rising and the specter of malpractice liability constantly hanging over our heads, we can't afford to make people unhappy. We give people what they want because if we don't, someone else will. There just isn't enough time to earn their trust when the only way to keep the doors open is to see more and more patients.

This time I refused.

Perhaps it was the haughtiness of her tone, but I suddenly found myself fed up with trying to make people who were young and healthy enough to get good insurance -- the "worried well" -- feel as if they'd gotten their money's worth while watching elderly people cut their blood pressure pills in half to make it through the month.

It was true that the best thing I could do for her really was to do nothing, but I had simply had enough of propagating a healthcare system that subsists on giving some people what they want while denying others what they need.

So again, I told her that I would not give her an antibiotic.

And an amazing thing happened. She began to weep.

"I know I need an antibiotic," she said. "I just know it."

Her intensity and desperation shocked me. I walked out of the room in stunned silence.

A medical school professor had once told me that no matter how much the economics of healthcare may change, medicine will always come down to the bond between doctor and patient. Apparently not this time. External economic forces had destroyed our relationship before it even began.

She had seen me in the first place only because a change in her insurance plan had eliminated her family doctor from the list of preferred providers. Meanwhile, a constant barrage of pharmaceutical advertising had told her that a pill to cure any problem could be had simply by "asking your doctor if it's right for you" without preparing her for the possibility that he would say it wasn't.

Even the urgent-care center at which I saw her, with its focus on convenience rather than continuity of care, had undermined our ability to forge a relationship.

After giving the situation a few minutes to cool off, I went back into the room and offered her a compromise. I would give her the antibiotic prescription if she agreed not to fill it unless her symptoms worsened or didn't improve after a week. She quickly and very gratefully accepted.

To me, the irony was painful. Practicing good medicine would make her hate me, but providing good customer service made her thank me as if I'd just saved her life.

At the time, I felt like a failure. But that was four years ago, and my view of what I'm doing for my patients has changed considerably.

What I saw as her infuriating selfishness was, I came to realize, genuine anxiety. Even though she had nothing more serious than a cold, she perceived it as a potentially serious threat to her health at a time when she was cut off from her trusted physician. By giving her that prescription, I put some control back into her hands. Maybe she didn't run to the pharmacy after all; maybe just knowing that she could is all she really needed.

She's become a regular patient, or customer, since then, coming in to see me for various acute illnesses when she can't get an appointment with her new family doctor.

I'm always glad to see her; the trust we fought so hard to earn the first time we met has made it much easier for me to guide her along that tightrope between what she wants and what she needs.

The lesson she taught me has served me well. I do my best to avoid ordering medications or tests that I know aren't going to help, but I now realize that to ease people's suffering, I sometimes have to make interventions that aren't technically indicated.

I'm sure it's a move my professor wouldn't have approved of, but by conceding the contest, I at least gave us a shot at a rematch. And next time, the stakes could be much higher.


Dr. John Vaughn is a family physician in Columbus, Ohio. He can be reached at johnvaughnmd@yahoo .com.

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