An excerpt from Treating a Broken System: A Physician’s Cure For the Healthcare Crisis.
I remember the event clearly, even though it was more than forty years ago. I was a fairly new faculty member in a Philadelphia university medical center, having finished my residency in internal medicine a few years prior. My wife, Terry, and I had been married for six years, and we had two kids at the time, ages five and one. The youngest started running a fever and seemed to be pulling on one of her ears. Terry and I were concerned, and she asked me to bring home my otoscope so I could see if she did have an infection and then prescribe an antibiotic for her. I demurred, telling her that I was out of practice in looking at kids’ ears. Terry kept persisting, and I finally said that the baby had a pediatrician and that we should utilize his expertise. She finally agreed, though she was not happy about it.
The real reason that I didn’t want to look into the baby’s ears was that I was never very good at it in medical school. It was one of many considerations when I was trying to decide on my residency (training after medical school). The resident on the pediatrics rotation that I was on indicated that I should go into internal medicine. When I asked him why, he said that I wanted to play with the patients, not care for them as a physician. He was probably right, and I was blissfully happy as an internal medicine physician for forty years. But there was something more that was bothering me at the time, one that I couldn’t put my finger on. But as I went along in my practice and research, the reason became known to me.
In order for a physician to appropriately ask a patient questions about the symptoms of their illness, fully examine them, make a tentative diagnosis, and then order the appropriate tests and treatments, the physician must be able to maintain objectivity. Certainly, every physician has certain biases that can impact that objectivity. This is true regardless of who the patient is. For example, in 1984, we published a paper examining residents’ likelihood of initiating CPR (life-saving attempts when the patient’s heart and breathing have stopped) when they faced two patients in potentially fatal situations but only one “code team” was available. When presented with various sources of bias, residents were more likely to initiate CPR for a patient without drug or alcohol abuse, dementia, severe psychiatric disease, or a history as a violent criminal than for a patient with one of these conditions. But interestingly, among the hypothetical patients used, those who had some relationship with the housestaff were more likely to receive CPR. Thus, a positive or negative bias can exist that can cloud a physician’s decision-making, especially when dealing with family or close friends.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Other issues may play a role in obscuring the information that the physician needs in order to make a correct diagnosis and initiate appropriate treatment. Let’s say that a patient who is the physician’s sister-in-law asks for advice and treatment for a problem she is having. When asked what it is about, she tells the physician, “I am having some burning and discharge from my vagina.” In order to narrow down the possible culprits, the physician would need to take a complete history, including a sexual history. This would include not only the patient’s marital sexual history (with the physician’s brother), but also whether the patient was having sexual relations outside the marriage and, if so, whether those individuals could have sexually transmitted infections. Further, a pelvic examination and cultures would be required. These questions would not likely be asked of the patient, and the physician would not likely examine his sister-in-law. This increases the risk of a misdiagnosis and mistreatment.
It is for this reason that we wrote a paper about caring for a loved one. I unfortunately did not adhere to my own reluctance to act as a physician to a loved one in one situation, and although no physical harm ensued, there was psychological trauma to myself and my children. After Terry had had the initial surgery for her brain tumor in 1997, she underwent adjuvant radiation therapy and then started chemotherapy in September. By December, she had undergone three cycles of chemotherapy and, at that point, was to undergo a follow-up MRI to ensure that the treatment was working. We had planned a vacation in Scottsdale, Arizona, over Christmas in order to have a break from everything. But in order to ensure that we could relax and enjoy the vacation, I decided that I would call radiology, tell them I was Dr. Farber (they knew me from all of the patients I had referred for studies), and ask for the results of the MRI. Much to my dismay, instead of showing that the tumor had not returned, the MRI indicated regrowth despite the chemotherapy. I was devastated but determined to ensure that both Terry and the kids had a nice vacation. So I hid the information from everyone until Terry was to have her follow-up appointment with the neurosurgeon in January. When we had the visit, he informed us of the results. I was miserable during the vacation, thinking it was the last time we would have a vacation with Terry. And though I didn’t tell them, the kids knew something was up and therefore were unhappy as well.
Had I been smarter, I would have just waited until we saw the neurosurgeon in January, when he would have told us the results. But because I was concerned, I acted in some ways as Terry’s physician, and it caused some psychological trauma for us all. From then on, I let Terry’s physicians act as her physicians, and I appropriately thereafter acted only as her caregiver.
Neil J. Farber is an internal medicine physician.
