I was interested to read the column of Dr Des Spence (a British general practitioner/family physician) in this week’s British Medical Journal [1]. He has chosen this week to lament the fact that modern medical practice has become more “tyrannical, hierarchical, controlled, intolerant, and dogmatic.” There is pressure on doctors to ‘follow the evidence’ even though the evidence may be deeply flawed and biased due to considerable conflicts of interest. Another concern is the fact that doctors are remunerated for doing certain things, which can make it difficult for them to take a truly objective stance of some of what they do.
Patients who dissent and question or refuse treatment are openly scolded. There are many potential examples of this, but mammography and treatment with statins readily spring to mind.
The end result is that patients can end up being exposed to interventions for which there is little indication or evidence of benefit. Worse still, they can feel pushed or cajoled into things that they feel are not right for them. Dr Spence asks: “Are patients really getting the doctors they deserve?” As usual, Dr Spence demonstrates an ability to think for himself – a quality that is I think is not as widespread in medicine as one might imagine.
I think it’s right that, as Dr Spence points out, doctors can sometimes do too much. However, it occurs to me that they can sometimes do too little as well. I have heard time and again from patients whose concerns and thoughts about their symptoms have been all-too-readily dismissed by their doctors. Here’s a couple of examples:
A couple of weeks ago I was visiting a friend. She told me she had been suffering from a very sore tongue. I asked to look at it and it, to me, had the characteristic of what is sometimes referred to as ‘beefy’ tongue – dark red, smooth and shiny (quite like a piece of beef). This observation was helped perhaps by the fact that I know my friend has been vegetarian for 20-odd years, and for much of this time has been vegan. The relevance of this is that beefsteak tongue is a recognised symptom of B12 deficiency, and vegans (and to a lesser degree vegetarians) are at risk of this.
She went to see her doctor, and asked if her tongue issues might be caused by B12 deficiency. She told him about her dietary history too. Trust me when I tell you none of this line of thinking is implausible or illogical (if anything, the reverse is true). Her doctor’s reaction? He said nothing. On looking at her tongue he said that she had oral thrush (a yeast infection) as a result of the steroid inhalers she takes for her asthma. She remarked that she did not take a steroid inhaler for her asthma, though. No comment from the doctor on this. She asked him what he thought of the idea that it might be B12 deficiency, and he replied that it wasn’t that.
Now, exactly what caused my friend’s doctor to put intellectual barriers up to her reasonable suggestion is unknown to me (and maybe him). One possibility is that he knows little about B12 deficiency and its signs, and does not want to make this evident (there’s a tendency for doctors to ‘be down on things they’re not up on’). Another possibility, though, is that we doctors have a habit of liking to be the ones make diagnoses and be in control. Even unconsciously, we can reject ideas that come from our patients because, well, they have come from our patients (and not from us).
Another friend of mine was telling me recently about some bladder symptoms she was having. She had googled her symptoms and felt them to be a very good match with the symptoms of a condition called ‘interstitial cystitis’. For what it’s worth, I believe she made the correct diagnosis. She took her symptoms and a printout on the condition to her doctor. Her doctor would not entertain the diagnosis at all, though, and did not want to look at the literature. Instead the doctor told my friend that symptoms were coming from a scar from surgery from a long time ago (highly unlikely, in my opinion). Again, I have no idea what caused this doctor to reject an entirely logical and plausible potential diagnosis, in favour of something far less likely.
Particularly in the information age, individuals have much more access to medical information than they used to have. While doctors can be dismissive of ‘Dr Google’ I, for one, am not. The fact is patients often have more time and more motivation to research their health issues and arrive at plausible diagnoses. Whatever insecurities we doctors have about the fact that the patient may have made the right diagnosis (and not us) need to put to one side, I think.
In my experiences, patients are not infallible, but rarely do their ideas have no merit. Usually, they are highly useful. My personal view is that patients should be listened to when they offer their views on the cause of their symptoms. And even if they don’t, my experience tells me that perhaps the most useful questions a doctor can a patient is: “What do you think is going on?”
References:
1. Spence D. What happened to the doctor-patient relationship? BMJ 2012;344:e4349
Patients don’t just Google symptoms, but also write about their experience online. Here’s one that doesn’t make personal attacks, but looks at the general trend of development in the health service and patient behaviour:
http://suzanneloomscreativity.blogspot.co.uk/2011/03/patient-has-gone-awol.html
Nina
This is what Ivan Illich, a philosopher, called “the expropriation of medicine,” the subtitle of his insightful 1975 book, “Medical Nemesis.” It is a scathing account of institutional medicine. Doctors have stolen our knowledge of ourselves and our bodies. Worse, medicine has become “clinically iatrogenic,” that is, the enterprise itself causes harm (statins, anyone?). “Unfortunately,” he writes, “harmless but futile care is the least important of the damages a proliferating medical enterprise inflicts on contemporary society. The pain, dysfunction, disability and anquish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents …and make the impact of medicine one of the rapidly spreading epidemics of our time.” Thirty-five years later, things have only gotten worse. Our salvation may reside in the information now available to us on the Internet, and wise practitioners like Dr. Briffa.
Illich’s book (with a preview) is available on Amazon: http://www.amazon.com/gp/product/0714529931/ref=kinw_rke_rti_1 It deserves to be widely read.
Thanks for your news letters.
I enjoy reading them although I live in Sweden .
I recognise many aspects of your article – Perhaps the most useful question a doctor can ask a patient (2nd July, 2012) – and the comments.
Here are some stories about people close to me. They made me look for information about drugs/side effects etc. Thanks to the Internet I also “discovered” many Enlglish/American books, sites etc. It started in 2003 and I learn something new everyday.
My father (1)
Melleril, Aricept etc.
In 2003, my 95-year old father was drugged during a one-week-stay at a nursing home.
I became very angry.
I had just been connected to the Internet and looked for information.
It did not take me long to find out that Melleril (antipsychotic) was withdrawn in England because it could cause serious heart problems/sudden death. The list of side effects was very long.
They had also given my father Aricept (for dementia).
I saw, on the Internet, that its efficiency was being questioned, that it had numerous side effects and that you should be careful if you had asthma. My father had suffered from that since he was about 35.
My father had 12 different drugs before his visit at the nursing home. Drugs that had been renewed,year by year, without proper evaluation.
He had no signs of dementia but was old and had just gone through a bacterial infection
in one of his arms (wrongly diagnosed as overuse, and plastered, to begin with).
My mother told a visiting nurse about my Internet-search on Melleril and Aricept.
She sent a message to me – don´t believe in what you read on the Internet!
P.S. Melleril was prescribed for another year in Sweden.
When it was withdrawn it was totally silent in the media.
My father (1, continued)
Melleril, Aricept etc.
I wrote several letters to the prescribing doctor asking for a stop of the two “new” medications and a total evaluation of the rest.
After some weeks my mother received a phone call from a nurse at the doctor´s office.
She was told that she could stop giving my father Aricept, but the rest of the medications, including Melleril, should continue.
After some months my father died and I received a reply to my letters.
The doctor motivated the Aricept-prescription with the words – I thought about your father`s future!
why oh why do so many docs take the lab ranges as gods say so? Why do lab techs have the overall say so which tests will be carried out? Why when we are desperate and offer to pay for ‘tests’ are we frowned upon and asked ‘WHY’? And why are people like me left until the cause becomes so bad we end up needing hospital treatment when the ’cause’ could of been maybe sorted before things end up in costly treatment and hospital stays? What happened to prevention is better than cure?
My mother (2)
Zocor = simvastatin
After a small heart attack, my mother was prescribed Zocor (=simvastatin) , aspirin and Toprol (=metoprolol) at the hospital. After some time she started to have sleeping problems, cramp and weakness in her legs etc.
She phoned her doctor and asked if it could be side effects. My mother doesn´t like to “bother” her doctor unless it`s absolutely necessary.
His answer was no – and the conversation ended.
One day, when I visited the library, I saw the front page of a health magazine.
It was a special cholesterol-number and I started reading.
I learnt that there were doctors/scientists who disagreed with the “Cholesterol Hypotesis” and that some of them had formed a network – thincs.org.
I discovered Uffe Ravnskov – and his books (some translated into English/other languages).
I also read books by Duane Graveline, Malcolm Kendrick and Anthony Colpo.
I found patient stories on spacedoc.net, askapatient.com, medications.com and peoplespharmacy.com. Many of the stories were similar to my mothers.
I offered my mother to come along on her next appointment, but she refused.
I offered to write – she said no.
But I wrote a nice letter to her doctor telling him that I only had my mother´s best at heart and wondered if she could lower her Zocor-dose and eventually stop.
After several weeks I received a reply. He didn´t think it was a good idea.
I wrote again and included many American patient stories.
I told him that I realised that it was impossible for medical staff to keep up with all medical information and that I was not giving him critique.
After several weeks I recived an answer.
He did not think it was a good idea for my mother to stop because Socialstyrelsen (=The National Health Institute in Sweden ?) had decided that even lower cholesterol numbers should be treated.
I translated five patient stories at a time for my mother and gave her Uffe Ravnskov`s books.
Then I left it. It was up to her to decide.
A year passed and I asked – are you still taking Zocor?
Oh no, she answered.
She had phoned the nurse and asked her to tell the doctor that she wanted to stop with Zocor. The nurse had returned the call telling my mother that it was okay.
I am convinced that my mother, now 92, would not be in such good shape had she continued with Zocor (or any other statin).
@nonegiven,
thanks, that’s truly helpful! I wonder is a your inspired definition worthy of a minor refinement?
‘Oligarchal collectivism,’ to me says one size fits all and the oligarchy dictates the size, even if it fits no one, but where there are other benefits and rewards to be enjoyed by the oligarchs.
The farm gate price awarded in return for a litre of raw milk in the UK seems to work to the rules oligarchal collectivism.