A Primary Care Doc Walks into a Bar
Struggling to uphold the distinction between doctors and bartenders.
Posted May 16, 2011
Reading Frank Bruni's recent review in the New York Times of Provocateur, a chic bar in the meatpacking district, got me thinking about an argument I'd had recently with a family practice doctor. It's true the argument had driven me to drink, but that wasn't the essence of the connection between the bar and the argument in my mind.
I'd run into this doctor while guest-teaching a bioethics course on the challenge of making sure the resources of medicine are truly directed at patients' well-being, and not merely at the upholding of social norms around appearance. The physician put to me that she had no interest in running interference between her patients and cosmetic surgical procedures, even though she seemed to agree with me that such procedures unnecessarily introduce risk to patients, to the medical profession, and to democracy itself. (Summary of my argument about this available here.)
I'd put forth the question of what a physician should do if she believed a patient were depressed and latching onto an almost certainly false hope that breast enlargement would alleviate her depression. The physician's response was laissez-faire. "Who am I to get in the way of this desire of my patient?" she asked.
I was a bit taken aback. Who are you to get in the way? "You are her physician," I answered, surprised I needed to explain what that was supposed to mean. "If you believe your patient to be ill - in this case, ill from depression - is it not your duty to try to guide her towards treatments that will help, and away from those that will introduce harm without helping?"
I gave her an analogy: Say the patient came in with the claim that she was low on energy, and she knew a friend who had been low on energy and had been put on thyroid-boosting drugs, and who felt much more energetic as a result. The patient wanted a script for the same drug as what her friend was taking. Would this physician simply listen to this patient and prescribe the thyroid-booster the patient felt she needed?
The physician responded that depression is a squishy kind of diagnosis, and breast size is an issue of perception, whereas thyroids come with hard numbers attached. I reminded her any thyroid test has a margin of error to which the patient could appeal, and in any case, what was the difference between the one laissez-faire attitude and the other? Both seemed to treat that patient as just as expert as the physician, and to treat the physician as just as irresponsible to the patient's well-being.
The physician was annoyed with me. She asked what I expected the physician in such a case to do. I answered that, in both cases, I expected the physician to first do no harm. I said I would answer the patient this way: "I understand you do not feel well, and I want to help you with that. But I have no reason to believe that the intervention you are proposing will treat the problem we think is underlying your concern, and so it would be irresponsible of me to help you obtain that intervention. My professional duty is to take care of you, not to simply write you a prescription or a referral for whatever you want."
The physician declared me dreadfully paternalistic. I replied I thought of myself as old-fashioned in the sense of believing a physician to be more than a car salesman, more than a hairdresser. I thought autonomy required, um, facts. A weighing of evidence?
Now I rather wish I had come upon Bruni's review of Provocateur before this encounter, because then I would have used a different analogy from the thyroid booster. You see, Provocateur has apparently been offering a special "menu of spring and summer cocktails, jointly created by a bartender and a beauty vendor, that purport to smooth skin, plump it up or improve it in other ways."
Bruni went and tried these out. His conclusion? "Sip by sip I was getting blotto, not beautiful."
In retrospect, I'd like to ask that primary care physician, "What if the patient had said to you, 'Better looking skin would leave me less depressed, so I want you to explain to my husband that I have to go to Provocateur and drink lots of expensive cocktails as a way of treating my blues'?"
In the meantime, I'm left with this question: Where are we when we find a tipsy reporter for the Times thinking more critically about supposedly appearance-enhancing interventions than a primary care doctor?
And it gets worse: this was a Canadian doctor. At the end of a 12-week bioethics course.
Now I really need a drink.
(This essay originally appeared in Bioethics Forum. My thanks to Susan Gilbert for editing.)