Doctors, Patients and Fools

I like the Happy Hospitalist a lot. Most of his economic analyses of medical care are quite accurate, although, like Panda, he sometimes resorts to hyperbole to make his points. Still, his essential observations that patients need to assume more financial responsibility for their care and that medical liability needs to be seriously re-worked are spot on.

And I'm not mad at him.

However, his disclosure a few posts back of his diagnosis with primary hypothyroidism and his intention to manage it himself raise another issue I believe worthy of discussion: the doctor as patient. HH himself quoted Sir William Osler:

The doctor who treats himself has a fool for a patient.

yet he didn't seem to feel it applied to him in this case. Frankly, I agree with him.

Primary hypothyroidism is not difficult to treat; certainly less so than diabetes, which patients are often taught to manage, and self-monitoring of anticoagulation, a procedure that also has its proponents. Yet it occurs to me that it might be the beginning of a slippery slope; a shallow one, perhaps, but with the potential for some problems along the way.

At the other extreme, for example if he needed surgery, a cardiac cath or other invasive procedure, I don't think HH would hesitate to place himself in the care of a trusted colleague. Even for certain conditions he can and does easily manage every day -- pneumonia, kidney stones, COPD (though I agree he's probably at the same ridiculously low risk of that particular ailment as I and other non-smokers) -- I believe he and most other physicians would agree that self-management is not appropriate.

The problem is the middle ground. What about acute, self-limiting conditions: bronchitis; Bell's Palsy; UTIs? How about chronic conditions like asthma, diabetes or migraine? I think answers to the question, "Should a physician treat himself for these ailments?" would be all over the map. Some would agree that a doc could safely and effectively manage the illness himself, where others would feel strongly that he should not. Specialty matters here. I think neurologists are probably quicker to treat their own migraines and pulmonologists likely to self-prescribe for their asthma. Doesn't anyone else have a problem with this? I think Dr. Osler did.

How about this twist: should a rural oncologist manage his own chemotherapy? He's perfectly competent; he does it every day; it would be so much more convenient not just for him and his family, but also for patients he could continue to treat. I think it would be a bad idea, but it wouldn't be up to me.

What about self-limited but painful conditions like shingles or sciatica? No need for MRIs or other extensive testing. Everyone knows it will get better on its own, but how do you feel about doctors self-prescribing narcotics? Suppose HH knows he has no personal or family history of addiction issues; he's perfectly capable of managing narcotics. What's the big deal? The problem, of course, is that although plenty of doctors have done it safely, some have gotten themselves into big trouble; even some who thought they knew better.

As things stand now, these decisions are made by individual physicians on a case by case basis. I don't deny that everything works out fine the vast majority of the time, but I believe there are suboptimal outcomes frequently enough to prove Sir William correct. So without denying HH's ability to successfully manage his own thyroid replacement, I respectfully suggest that he consider the wisdom of taking this opportunity to forge a relationship with a primary care physician of his own. He may not really *need* one for this, but the benefits of consulting with someone else -- who may, perhaps, some day, who knows?? know certain things he might not -- are real, even if he can't see them right now. If nothing else, it is the opportunity to avoid becoming a fool at some point in the future.