I saw an exceptionally malignant patient with back pain a few days ago. Readers who work in an ER know exactly what I mean just from that statement; for my lay readers, let me try to paint a picture. He was a 50-something, shabbily dressed guy in somewhat of a constant state of disrepair. There was a musty odor of tobacco about him, and when the nurse entered the room he sneered "Oh, there you are. So there IS someone actually attending patient needs today. Get me a damn soda, I'm thirsty." He had been triaged, registered, and taken to a room within 25 minutes of arrival. His wife piped in, "Make it a Coke for him and a Mountain Dew for me. We don't do Diet."
I walked in the room to a hostile environment. His wife was tapping her foot on the floor impatiently, lips pursed, and apparently we were fresh out of Mountain Dew. He had his arms crossed and began to lay into me before I could say a word.
"I want an MRI. I hurt my back lifting something a couple hours ago, I've had a bulging disk before, and I've been waiting now for the better part of 30 minutes to see ANYBODY who is competent around here."
I took a mental breath, calmed the raging inner demons, and introduced myself. I apologized for not seeing him earlier as I had been performing CPR in another room and broke away just as soon as I was free.
I'll cut the story short here and get to the chase. He left the ER with a diagnosis of back sprain sans MRI, shouting at staff, extremely angry... but it was clear from our first interaction that this was inevitable. Interestingly, he didn't come to the ER for pain control - he came because he wanted an MRI, and was livid that I wouldn't give him what he wanted.
This gets to the crux of the matter at hand. There has been a rising emphasis on patient autonomy in medicine, a deliberate shift from the paternalistic attitudes of physicians of old. It is one of the four central "pillars" of medical ethics; Autonomy, Beneficence, Non-Maleficence, and Justice. Most of the time, it is a good thing. I involve patients and family members on their medical decision making as often as possible. If I'm waffling about admitting a patient to the hospital, I'll ask them, "do you feel comfortable going home tonight? We can try home therapy first and you can always come back if you aren't doing well." I am often surprised by how adept patients are about making these decisions for themselves.
There is, however, a group of patients we'll call Generation WebMD, who think that 5 minutes of Googling has given them a provisional electronic doctorate. This guy got it into his head that he wanted - no, needed - an MRI to diagnose his back sprain and wouldn't take no for an answer.
A scenario like this plays out every minute of every day in every ER across the country. I have had furious mothers physically escorted from the premises by security guards over whether or not their child should get antibiotics for a cold. Drug seekers have thumbed their switchblades at me when I inform them I will not be providing them with their fix. One of our regular COPD patients has a strict "only three breathing treatments per day" policy to prevent him from overstaying his welcome, happily puffing on albuterol while lighting cigarettes and tampering with the smoke detector.
It's a huge issue. Physician reimbursement nowadays is often linked to patient satisfaction scores. Physicians at a neighboring ER, for example, have 25% of their entire salary directly tied to phone surveys. That's a huge incentive to make sure people are happy - and people are happy when they get what they want. Unfortunately, what people want when they come into a medical setting is often not what they need.
Here's the thing. If all you do is constantly acquiesce to patient demands to make them happy... well, you aren't really a doctor, are you? You're just a puppet medical license with a DEA number for hire.
I got into a huge argument with a woman a few weeks ago about antibiotics for two days of sinus pain. She started screaming so loudly at me that a police officer walking down the hall peeked his head in. She finally asked me a simple question, "JESUS, doc, why are you being so damn obstructionist about this? All I want is some fucking AMOXICILLIN for my sinusitis! It has worked EVERY OTHER TIME. It's not like I'm asking for a prescription for medical marijuana! WHAT IS THE HARM?"
I've thought a lot about her in the past few weeks. Every single patient I have seen dying of multidrug resistant bacteria, every news article I see about superbug TB, every case of clostridia difficile colitis - I have mentally told her, "This. This is the harm. The harm comes in physicians prescribing things that aren't needed, doing tests that aren't indicated, giving therapy just to say we did. One day we will look back from the brink and realize we should have been more careful."
I could go on, but I've made my point. It is so easy to roll over and give people what they want. I fight this temptation every single shift. Mom wants amoxicillin for her kid's "ear infection". Guy wants Vicodin for back pain. Family wants me to "do everything" for the 95 year old demented nursing patient.
With a click of a button I can easily do all these things, even when I know I shouldn't. And I'll get paid more. And I'll avoid lawsuits. And my patient interactions will be far more pleasant. I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.
And sometimes, despite violent opposition, that means simply saying no.