Dinosaur Doctors and the Death of Paternalistic Medicine

By: Carolyn McClanahan Physician/Financial Planner/Forbes contributor discussing all things money and medicine

The traditional practice of medicine is a paternalistic affair – the patient goes to the doctor, the doctor tells the patient what to do and the patient does as ordered (or more often, doesn’t do exactly as the doctor ordered). The doctor plays the part of parent. Over the past century, this accepted medical practice did much to foster the “god complex” many doctors are perceived to have to this day.

Healthcare delivery has morphed through the decades, and we are in the infancy of a new and exciting phase – the age of patient empowerment. What exactly is this? Let me first share a story of what is not in the realm of physician-patient interaction.

My husband just turned the big 5-0. Although I am a physician and he is an engineer type, we both tend to be “minimalists” when it comes to healthcare. This means our idea of good health is accessing the healthcare system as little as possible, yet being very active in maintaining our health. The foundation of this is a healthy lifestyle and a very pragmatic approach to preventive care – if there is an intervention where the benefits significantly outweigh the risks, we will most likely agree to that intervention. For example, I have decided not to have mammograms until I am 50 years old – the benefits for me before age 50 do not outweigh the risks of having a mammogram.

One intervention that begins at age 50 is colon cancer screening. After weighing the pros and cons, my husband and I decided this is a worthwhile intervention. We made an appointment with our family physician for his age 50 physical and a referral for a screening colonoscopy. It really didn’t matter to us which doctor he would see for the colonoscopy since it was theoretically a one-time thing. Therefore, we did not question the referral to the large gastroenterology group in town. What is the worst that can happen?

My husband and I like to go to our rare doctor appointments together. Four ears and two brains are much better when processing the large amount of information sometimes thrown around when discussing healthcare. Plus, he is the analyzer and I am the decision maker – we complement each other because I am not fond of the detail work and he can have “paralysis by analysis” when forced to make a decision. So, as simple as a screening colonoscopy seems, I accompanied my husband to meet the doctor who would perform this lovely procedure. My husband was concerned about anesthesia, and wanted to have the procedure with as little anesthesia as possible. In all honesty, he really just wanted to be awake to see his beautiful colon directly.

The visit did not start out well. The appointment was running thirty minutes late and the waiting room was kept in sub-zero condition. I tweeted incessantly and did standing squats to stay warm. The medical assistant finally stepped out and called my husband’s name. We both got up and she promptly stated, “The doctor wants to see the patient alone. He will call you back later.”

My husband and I were both a little stunned but went along with the request. My husband is really good at speaking up when something doesn’t sit well with him, yet he does not become a squeaky wheel too early in any situation. I wish all patients without a medical background had his confidence and courage when speaking to medical professionals.

About fifteen minutes later, the physician called me from the waiting room. Once all three of us were situated in the exam room, the physician went through why my husband should get colon cancer screening. My husband then asked about anesthesia, and was told that he would receive conscious sedation. This caused a bit of confusion for my husband, as he thought this meant he would be awake and be able to see the procedure. I explained to him that this would knock him out and he would not be able to see his colon on the screen. My poor husband was visibly deflated.

Knowing that my husband was not happy, I tried to mollify the situation. I asked the physician, “Can I be in the room with him?” In an annoyed tone, the physician stated, “Absolutely not. I do not work like that.” And now I was annoyed.

My husband asked if the physician would do the procedure without anesthesia. He was promptly told something to the effect (but with bigger words I do not remember,) “And have you release catecholamine and factors that will cause your colon to go into spasm? That increases the risk of complications.”

By then, I was incensed. This dinosaur knew I was a physician and apparently thought I was stupid and didn’t do my homework. Or maybe he doesn’t know the truth. Anesthesia during colonoscopy increases complications. Lack of anesthesia decreases complications.

I kindly asked, “Do you know anything about patient-centered medical care?” I already had an idea about how he would answer, but just wanted to see the workings of a dinosaur brain. He said, “I don’t know that term. Is it where you let family in the room when you code the patient?” I answered, “It is a move towards patients being the decision makers, and a movement away from the old paternalistic style of medical practice.” I then asked the physician, “Do you know anyone who will do the colonoscopy without anesthesia?” In a very smug and annoyed tone, the dinosaur stated, “No.”

My husband can tell when I am moving toward my “Tasmanian Devil” mode. It doesn’t happen often and it isn’t pretty. At that point my usually indecisive husband made a hugely uncharacteristic move. He stated, “I think we’re done here.” He stood up, the dinosaur looked amazed, we shook his hand, and then we left.

So what really happened in this scenario? It basically was a breakdown in communication and expectations on both sides. You’ve heard the patient side. Let’s be fair to the physician and give him the benefit of the doubt for a moment.

1. He has to see a lot of patients to earn his keep, which for the average gastroenterologist is a salary of about $330,000.
2. He has probably done a colonoscopy without      anesthesia, and it took more time and discussion getting the patient through the procedure. More time equals fewer colonoscopies equals smaller paycheck.
3. He probably had a complication during the procedure at some point in his career. Dealing with complications is easier if you don’t have to deal with the patient’s questions and discomfort at the same time.
4. Medical practice has changed dramatically since he entered the profession. I estimate that he is in his mid to late 50’s and is in the cohort ready to hang it up because the new challenges are too much for him to take.
5. I’m most certain he was never offered the “bedside manner” and communication class we taught in the family medicine department. This should be a requirement for every physician.

The patient empowerment movement is very young and has spent the past couple of decades learning how to crawl then walk. The internet and social media has accelerated this movement far beyond anyone’s expectations. It is exciting and dangerous. The patient is like a teenager with a new Ferrari and too many physicians are driving the old AMC Pacer.

Where do we need to go from here?

I often write about the need to hang out with diverse people and place ourselves in situations different from our usual state, yet my hypocrisy was made clear to me by my interaction with the dinosaur. I am so involved with patient empowerment and surround myself with those who believe as I do that I did not realize this old guard still exists in practice. This needs to change, but how?

First, patients need to learn how to drive the Ferrari. They should understand:

1. Their own medical decision making personality. See “Your Medical Mind”      for details on this. By knowing how patients make medical decisions, the health care providers can tailor information in a way that complements their decision making process.
2. What resources are reliable? There is so much junk present on the internet. The medical system needs to lead the way on providing clear, concise, complete, unbiased, and patient friendly information. For now, patients should steer toward sites with the least conflicts of interest.
3. How to communicate using a collaborative process. Communication that comes from a place of openness, kindness, and the desire for good outcomes for all parties is the key. Putting physicians on the defensive from the beginning doesn’t foster great communication.
4. The limitations of medical care. Medicine is still art and science. Very little in medicine is black and white, and we have to weigh probabilities when making decisions. Outcomes are not definitive and patients need to accept some responsibility. If medicine truly moves to a team based approach, this should open the door to quality tort reform and shared responsibility of medical decision making. We have a long way to go on this one.

Physicians are changing, and I have a feeling the old guard in place today will be gone in a decade or two. If not, they will eventually be pushed out or forced to change by many outside factors clamoring for a new style of practice. Here are a few to chew over:

1. Obamacare promotes the creation of patient centered medical homes, a move toward prevention and wellness, and rebuilding of our primary care system.
2. Payment provisions in Obamacare will move medicine away from being paid more to do more. Instead, providers will be paid based on how well they deliver care. This will include being nice and listening to patients.
3. Patients are creating a force of their own. Websites such as Patients Like Me are providing patients with additional resources to manage their care. In fact, Aetna just announced a new collaborative project with Patients Like Me. In this pilot program, Aetna members can connect with other patients to help understand and manage their illness. This is a big move that side steps the physician community and empowers patients with information. If doctors are not careful, they may be relegated to prescription requests.
4. Organizations such as the Institute for Healthcare Improvement focus on bold and inventive ways to improve the health of individuals and populations. I      attended their last national meeting and was blown away by the brainpower      dedicated toward improving patient empowerment.

These are indeed exciting times. Aren’t they all though? If we work together – everyone, including the dinosaurs – we can take patient empowerment from the teenage stage to full adulthood, and we will all be better for it.