Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, February 14, 2010

What Patients Really Want

Once again, the incomparable OncRN nails it:
nurse - 'wait, why are we offering this super difficult treatment to this super old person with super crappy disease?'
doctor - 'because she wants treatment'

i so desperately need a game show buzzer for my pocket....because we're sorry - that is incorrect
i have yet to meet a patient who wants treatment.
patients want an outcome.
big difference.
Seldom have I ever seen the point made so cogently. By and large, patients have little to no idea what "treatment" really entails. From chemotherapy, to breast reconstruction, right down the line to the nasty side effects of antibiotics; no one really wants to undergo any of these treatments. They just want their disease to go away, and never come back. They want to feel better, though they may settle just for feeling a little less crappy than they feel now. Rarely will any of our treatments make anyone feel better while they are undergoing them. Patients are taking us at our word that once they recover from the treatment, they will feel better than before. That is why it is so important that we as physicians make pretty damn sure that they will, before we undertake the surgery; the chemo; the radiation; the medications. And we'd better be damned sure to do everything in our power to mitigate the discomfort of the treatment, which starts with recognizing it. Because OncRN has it right: No patient wants treatment.


At Sun Feb 14, 04:08:00 PM, Blogger kg said...

This is so important and needs to be spread around the blogosphere and in real life! Could you make sure it gets into Grand Rounds?

At Sun Feb 14, 08:40:00 PM, Anonymous Anonymous said...

Stated answer, "she wants treatment" which as you said she has no idea what that involves. Real answer, which you will NEVER hear out loud, "because we can bill for it."

At Tue Feb 16, 05:15:00 PM, Blogger Thoughts on Life and Millinery. said...

As my Onc/bone marrow transplant/now Hospice intake nurse daughter put it: The reason they nail the coffin shut on a deceased cancer patient is to stop the doctors from trying just one more horrible treatment.

I'm noticing how many obituaries thank the hospice team for all that they did for the patient and the family. Yet my daughter tells me Hospice nursing is still considered somewhat of the black sheep of the medical world. That people still think that hospice is to be called only hours before death, when really hospice can make remaining months a much pleasanter experience for everyone if they are called into the situation while there is still good quality of life.

At Wed Mar 24, 12:30:00 PM, Anonymous karanya said...

I recently had the pleasure of about a dozen visits with an older (in his 70s) ophthalmologist due to a rather severe case of optic neuritis. I didn't want treatment and I knew that the outcome was really just a matter of time. TBH, I was there for a referral to a neurologist because I knew what I really needed was an MRI.

However, he insisted that I take 100mg of prednisone daily for four months, despite the fact that oral steroids are now contraindicated in optic neuritis... he insisted I take them, and I did, despite my own misgivings. "Your vision is everything!" he said.

A few of months into this questionable therapy, he expressed his disgust with EBM, saying that "Those ivory tower people, they say we should do nothing in a case like yours! But I can't do nothing! I have to try doing something to help, no matter what the studies say!"

When my vision stopped improving after reaching 20/400 in the affected eye, he wrote up a massive list of vitamins and supplements I should take and explained what each was for. I remember that of these he said was "improves your overall system" and a couple of others were "good for eye problems". After looking up one of these herbal supplements, I found that it had been studied for macular degeneration, but nothing else, and I wondered if I should have asked him if I should have cataract surgery because it's "good for eye problems".

He kept telling me the same story about a dentist with bilateral optic neuritis that he had treated with oral steroids, and who had regained 20/20 vision in both eyes after six months. I think he got desperate when my bad eye just would not improve beyond 20/400, and eventually when I walked in -- obviously Cushingoid -- he decided to stop treatment and let the neurologist take over.

As much as I liked the old guy, he was terribly misguided, and it appears that his lengthy delay in referral while he tried desperately to save my eye might have caused an even longer delay in diagnosis and treatment of the underlying problem -- possibly years, unless I can dredge up the money to drive hundreds of miles to somewhere with a decent MRI machine.


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