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I recently wanted to prescribe a medication called Prevacid for a patient. It's a proton pump inhibitor that shuts off acid production in the stomach.  It's used to treat a wide variety of gastrointestinal complaints, most commonly heartburn, which is the malady I was aiming to treat in my patient.  She was strongly resistant to starting it, however—not so much out of concern about its safety (it's quite safe), but because, like many people, she simply didn't like taking medication.  I was sympathetic but also felt that Prevacid had the greatest chance to help her feel better.  A long discussion ensued after which she agreed to try it.

And then her insurance company refused to cover it.  I ended up having to spend two hours over two days making the argument that the treatment was medically indicated.  I hung up the phone after I'd finally gotten them to agree and found myself thinking how stupid it was that I'd had to talk with them at all.  If a physician writes a prescription for a patient, doesn't that mean, by definition, he or she thinks it's medically appropriate for their patient to take it?  Why should doctors have to spend any time explaining the appropriateness of their actions in those instances where their actions explain themselves?

In the course of caring for patients from day to day, some obstacles bother me far more than others.  Having to take the time to explain to my patient why I thought Prevacid was a good idea for her and having to listen to and address her concerns about it, for example, didn't bother me at all.  It's entirely reasonable and even desirable for patients to question the interventions doctors want to make with them.  It leads to dialogue (or should) that can often result in important changes in the doctor's plan that benefit the patient.  I welcome the particular challenge of working with patients to increase their compliance with treatments I believe will benefit them.  I like patients to think, to ask questions, to assume ownership of their own health.

I don't, however, like having to repeat myself to insurance companies.  I understand their desire to contain costs.  But forcing doctors to justify the prescribing of FDA approved medications makes little sense.  It's not a challenge I welcome at all.  It's an obstacle I'd rather avoid.

We all know to expect obstacles whenever we take aim at a specific goal.  But what my conversation with the insurance company made me realize is that those obstacles are rarely the ones we want.  We can't help but anticipate the kinds of fights we have ahead of us when we embark on a plan to accomplish something.  But when those fights aren't the ones we expect we're likely more than anything to become annoyed.  This, in my view, represents a serious problem.

When we anticipate an obstacle, we can't help but mentally cast our minds forward, envisioning how we might handle it.  Often we develop possible avenues of attack, which makes the obstacles seem less daunting.  Surmountable, even.  We may even worry less (preparation, as I wrote in a previous post, prevents poor performance).  But when we come up against an obstacle we didn't anticipate and become annoyed, we become far more likely to attempt to avoid it than overcome it.  Because of this, we're more likely to be defeated by unexpected obstacles than expected obstacles, even if the expected obstacles are far more formidable than the unexpected obstacles.  We're simply more likely to complain about stupid fights than to actually fight them.

The real threat unexpected obstacles pose, then, is to our attitude—and attitude is everything in sustaining one's resolve to overcome an obstacle, large or small.  Hence, the real risk of failing to achieve a goal doesn't come from the most implacable obstacles; it comes from the least expected ones.

The solution?  Expect the unexpected.  We can't, of course, predict the specific nature of unexpected obstacles but we can predict the fact we'll encounter them.  So when unexpected obstacles arise, as they invariably do, and you find yourself annoyed and thinking of them as stupid (as I did my encounter with the insurance company), force yourself to recognize what your mind is doing so that you can prevent it from having a deleterious effect on your attitude.  In this way you can prevent unexpected obstacles—even small ones—from stripping you of your most effective obstacle-buster:  resolve.  Don't be discouraged by having to face stupid obstacles.  Don't let them wear you down.  Ignore your own indignation and calmly attack—even those obstacles you don't think you should have to—like a lion trapping an ant.  Remember, it's not the strongest opponent who's most likely to defeat you, because that one you can prepare for.  It's the one you underestimated, because that one you can't.

About the Author

Alex Lickerman, M.D.

Alex Lickerman, M.D., is a general internist and former Director of Primary Care at the University of Chicago and has been a practicing Buddhist since 1989.

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