Doctors Helping Patients

by James Channing Shaw, MD

Keywords: Doctor’s Responsibility; Helping Patients; Hippocratic Oath; Physician Charter; Doctor-Patient relationship

We diagnose, we treat. We try to do no harm. But what do we do when diagnoses evade us, or treatments fail? Do we physicians have an obligation to keep working with the patient after a diagnosis or cure eludes us? Some doctors might say no, that it’s perfectly acceptable to tell a patient “there’s nothing more I can do for you”; or discharge the patient without answers or directives, rationalizing that “I’ve done my part.” This especially applies to specialists. Patients, on the other hand, expect their doctors to keep trying.

Enter: the concept of helping patients. To help the patient could be considered a primary goal—if not the primary goal—of doctoring. Going all the way back to Hippocrates, placing the interests of patients above those of the physician is the well-known requirement for fulfilling medicine’s contract with society. ‘Patient-Centered Care’, a term coined in 1988, emphasizes shared decision making and the emotional needs of patients. Both are important. But what if the patient is still having the symptoms he/she came to you or me to diagnose and treat? What does ‘helping the patient’ mean beyond Hippocratic oaths, Physician Charters¹ and patient centeredness? ² I submit the following list.

1. More than anything, helping patients starts with addressing each patient as a human being worthy of our respect and attention, from corporate CEO to illiterate vagabond.
2. It means never talking down to patients (pediatric patients sometimes excluded). Patients know when they are being patronized.
3. It means respecting family or friends who accompany patients into the examination room. The patient brought them. Their support makes our job easier.
4. It means teaching patients, when possible, about their illnesses, through discussions or with nurse educators and printed material.
5. It means combining evidence-based knowledge with experience to tailor each treatment to the tolerance and needs of each patient. In some cases, patients won’t be able to accept best therapies at first. Keep trying while using second best therapies.
6. It means frequently going beyond what we learned during our training. Search the literature before the patient’s next follow-up visit. Results can be enlightening.
7. It means learning to use new drugs if the literature (not drug reps) supports their use, or at the very least, referring patients to someone who knows how to use newer drugs.
8. It means prescribing off-label drugs if those are the most appropriate for a patient. To use only FDA-approved drugs limits our treatment options to drugs that ‘passed’ well-designed phase III trials. Many effective older drugs never went through the process.
9. It means being more concerned about treating the patient than about our own legal liability. Documented discussions in the patient’s medical record reduce liability to near-zero.
10. It means prescribing narcotics when indicated, even when we suspect drug-seeking behavior. The risk for the physician, of a one-time prescription, is nil.
11. It means being available, personally or through on-call arrangements, to take responsibility for complications of treatments originating in our offices.
12. It means being willing to admit failure with one treatment while trying to find an alternative.
13. It means never using the phrase ‘there is nothing more I can do for you’, which translates to ‘I am not interested in spending any more time on your problem’.
14. It means knowing that even if cure cannot be achieved, the caring, teaching, hand-holding and outlining of expectations of treatment are important parts of doctoring.
15. It means knowing when to stop treatment (e.g. chemotherapy for terminal metastatic cancer) and switch to palliative measures.
16. It means rethinking difficult cases that don’t make sense. Start again from the beginning. Go to the books. Go to the literature.
17. It means getting help through referrals to doctors with more expertise, not for the purpose of getting rid of patients, but to help arrive at a diagnosis and treatment.
18. It means taking extra time during any given day if an acute problem demands it.
19. It means not allowing one’s own beliefs or moral convictions (abortion; narcotics; same-sex issues, pre-marital sex) to stand in the way of proper patient management.
20. It means providing treatment sometimes, even when there are relative contraindications to the treatment being considered. Almost no treatment is risk-free.
21. It means assisting the patient with an unexpected urgent problem outside the realm of one’s specialty by facilitating a referral to another specialist, having a discussion with the primary care doctor, contacting home health nurses, calling an ambulance if necessary.
22. Finally, helping our patients means never forgetting that no matter how specialized some of us may be, we are doctors first, specialists second. It’s our responsibility.

References:

1. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a Physician Charter. Ann Intern Med.2002;136(3):243-246.
2. Barry MJ, Edgman-Levitan S. Shared Decision Making — The Pinnacle of Patient-Centered Care. N Engl J Med 2012;366:780-1.