Wednesday, March 3, 2010

The VIP Patient– “Doctor, What If I Were Your Mom?”

The Intro to the Intro

For those who were hoping for a sober or analytical piece this Sunday morning, be warned that you have entered a No Wonk Zone. Today’s post, hopefully will make a serious point, but it is seasoned with some levity and a little silliness. Of course, just because I think it’s silly, doesn’t mean that you will agree with me. The definitions of silly and serious are highly subjective. One man’s ‘dead serious’ is another man’s ‘deadpan'. For example, after watching the recent health care reform summit, I couldn’t tell if it was a serious policy exchange or a silly infomercial.  Could you?  Yes, I confess that this is an entirely gratuitous jab at the President's daytime TV health care reform special.

The Intro

Every physician has been asked, “Doctor, what would you do if I were your mother?” The patient, who assumes that the doctor likes his mother, erroneously believes that this is a surefire method of receiving premium medical advice. After all, who wouldn’t want to receive the same medical advice that the doctor would give to his own mother? Extending this flawed logic into the realm of absurdity, the patient could generate a range of medical options from his doctor, simply by using the index question above as a template, and substituting other folks in place of ‘mother’. Watch how this works.

The Hypothetical Patient

A patient comes to the doctor with chest pain (CP). The physician recommends a stress test. The patient wants to verify that this recommendation is ideal. In just a few short minutes, the patient can use the fill-in-the blank template technique to produce a spectrum of medical options. Of course, the inquiry , “Doctor, what would you do if I were your mother?”, should come last so that the patient can readily see by comparison that this is the ‘mother'-of-all-medical recommendations. Any option, possession, idea or medical advice gains currency when it is surrounded by inferior alternatives.

The Template Question in Operation

The patient with chest pain poses 10 questions to the physician using the template that appears below. Each question substitutes a different person in the blank space. As you will see, the physician’s advice is different in each case.


“What would you do if I were your _______?”


    Person                             Physician’s Medical Advice

Congressman.....................Sorry, fillibuster is in progress.
Quack................................Take a high colonic STAT!
Telemarketer.....................I’ll call you back at dinnertime.
Customer Service Agent....Your call is important to us...                  
Teenager...........................The CP is the teacher's fault.                   
Personal Trainer................No pain, no gain. Drop and give me 10!
Accountant .......................The pain will depreciate over time.
Lawyer...............................I refuse to answer.
Psychiatrist........................Are you envious of your CP?
Mom..................................Answer appears at this post's end.

Serious Point

I have never responded to the ‘mom’ inquiry directly, but I try to provide the patient with the reassurance that is being sought. Patients ask the mom question to give us doctors a few moments to reflect on our medical advice. This is their version of, “Is this your final answer?” But, of course, the medical advice never changes, and it shouldn’t. Consider this vignette.


Physician: “I think you should have an ultrasound of your gallbladder because your symptoms sound suspicious for gallstones.”

Patient: “What would you do if I were your mother?”

Physician: “Oh, in that case, I think you should have a colonoscopy.”

I am amused when a referring physician notifies me in advance that a patient being sent to me is a rich executive or some other version of a VIP patient. Am I supposed to ramp up my medical quality as if I have multiple standards depending upon the prominence of the patient? Should I make sure the colonoscope is extra clean for all corporate CEOs or high government officials? Do I have 2 different sets of textbooks (remember textbooks?), one for ordinary patients and better ones for special customers?  There have been many commentaries and medical journal articles that point out that VIP patients don't reliably receive 'VIP' medical care - particularly when the patient is a physician.  In these cases, standard medical practices and procedures are often bypassed and corners are cut.  Medicine works best when there is a single high standard of care for every patient. 

I am not my mom’s doctor. I couldn’t possibly answer how I would treat her medically, in response to a patient’s inquiry, because I am her son. I don’t have the necessary objectivity to advise her, and I wouldn’t want the role in any case. There’s a reason that physicians shouldn’t treat their own family, or even close friends, in my view. It’s just too messy and it can contaminate the personal relationships.

The Answer

So, when a patient asks me what I would do if the patient were my mother, I always offer the same response. I’d tell my mom to speak with her own doctor.

My Mom


18 comments:

Anonymous said...

Oh dear. Apparently you haven't spoken to any actual psychiatrists in a long time. Their response would NOT be a psychodynamic question reflected back to the patient; it would be an rx for some costly, ineffective, dangerous neuroleptic. And a follow up med management appointment. Ad nauseum. Yes, I work with far too many psychiatrists in my line of work.

South Loop Connection said...

I gave your comments on the NYT editorial this morning the thumbs up. What a horribly slanted and dishonest piece of propaganda.

Who was scaring who? Wasn't it the president who scared us by saying doctors would rather amputate our feet or take out our tonsils because they can make more money doing so without any command of the fact? In reality he wildly distorted the facts, but this somehow is ignored by a media outlet like the Times.

I live in Chicago and our senators refused to hold town hall meetings over the summer for fear of looking bad not being able to answer any questions regarding the health care bill.

It's crazy. The new war cry should be "repeal!"

Jackie Fox said...

Great topic and as usual, you handled it with wit while making your point. I've been thinking about this a lot from the patient side. When I was diagnosed with breast cancer, my family doctor told me what he'd want me to do if I were his wife. My oncologist told me he couldn't do any better for me if I were a family member. For the record, both their comments were unsolicited. I didn't interpret them as, "Oh, now I'll get better care." It was just comforting and human, and nice.

In Dr. John Link's book The Breast Cancer Survival Manual, the one clunker for me was when he said he's insulted by the "what would you do if I were your wife" question because it implies a different standard of care. So I asked my surgeon, who gets asked that a lot, if he found it insulting and he said not at all.

Maybe it isn't so much that we think we'd get better care as wanting to know how you'd handle it if our diagnosis affected you personally. Because it sure feels personal to us.

InteractMD.com said...

I read this post this morning, then saw a patient who asked me, "What would you do if I was your wife," so I said, wanting to put my new learnin' to good use, "I would have her see another doctor, since it's too hard taking care of your own wife," and the patient said, "So maybe I should see another doctor."

Thanks a lot, MDWhistleblower.

Michael Kirsch, M.D. said...

@InteractMD: I guess MDWhistleblower is not an effective physician marketing tool! All comments appreciated.

Anonymous said...

It occurs to me that, when my doc wants to try some fancy (pricey) imagining study or rx some state-of-the-Pharma-art script, I am much more apt to ask him "what would your mother do?" In many day to day medical encounters, homespun common sense (like you'd get from you mom or grandmother's generation) goes a lot farther than testing/treating until we find some zebra or induce some iatrogenic sypmtoms from the process. Wondering how you'd feel if faced with that question from your patients: What would your mom do in this sitution...?

Dr. Mary Johnson said...

Hello, Michael. Good post. I hope you got my e-mail. A cyber-stalker has put a crimp in my style at Housecalls.

VIP patients are a very sore subject with me.

And here's why:

http://drjshousecalls.blogspot.com/2009/03/part-two-parent-i-should-havecould-have.html

InteractMD.com said...

Just kidding, Mike. The lady, I think, wasn't being serious, nor was I! :)

I think there's an ongoing process of introspection required when you're a doctor, and reading blogs like yours helps that process along. It's also good to be reminded that sometimes office visits are not just difficult for me.

I was entranced by the concept of "Mindful Medicine," as outlined in the excellent Epstein article in 1999. I wrote a little about it here:
http://interactmd.com/content/minor-classic-mindful-practice

Regards, and keep up the good work!

Mike

buy viagra said...

I think there's an ongoing process of introspection required when you're a doctor, and reading blogs like yours helps that process along. It's also good to be reminded that sometimes office visits are not just difficult for me...

Anonymous said...

In reality he wildly distorted the facts, but this somehow is ignored by a media outlet like the Times.

Anonymous said...

hi

Marie said...

Just popped over from Grand Rounds. This is a great post.

I have found lately that the whole "I would recommend this if it was my ____" is almost a cliche now for some doctors. As though they are anticipating the question so they are pre-empting you with a meaningless bromide. I always want to say "well, I trusted you until you said that".

The notion of preferred levels of care is preposterous anyway. One of our local doctors, someone who is respected and well liked, had his intestine perforated when he came into the hospital where I worked for a routine colonoscopy. Oooops. Yet he was getting the 'best' care there was to offer.

My mother is a narcissistic nightmare. I'm relatively certain her doctors' treatment of choice for any ailment would be a lethal injection. lol So I would never ask that question.

And by the way, your mother is gorgeous. :)

Michael Kirsch, M.D. said...

I have forwarded your comment to my mom, whom I know will be exhilirated to read it! Thanks.

Sharp Incisions said...

Great post! I have more trouble with my mother asking me for medical advice (and I'm a first year student!). I suggest she talks to a doctor, and she tells me that she is - me. No, a *qualified* doctor, Mum!

Anonymous said...

This is truly a good topic and I can see where there are some who disagree. When someone is not well and they are talking to their physician, I believe that it is the doctor's job to handle them gently. I'm not suggesting having them move them move into the office with you, but if they are seeking some form of comfort that makes them feel better about what is happening to their bodies, there should be a kind and gentle manner of providing that.

When my mother was dying of cancer, my brother in law was her physician. He was an enormous help to her, both physically and psychologically. He never lied to her, but he also put things in such a way that did not dash her hopes completely. My brother in law also helped to keep my father around for a several extra years by changing meds constantly (sometimes on a daily basis). Sometimes, dad withheld fluid and others he was dehydrated. If his weight was off one way or the other, the dosage was changed (well, his BP was also considered). I believe that doctors have such a special gift and it goes beyond simply saving lives or giving people more productive lives. There is also those spiritual moments and to distance oneself from that is sad. Maybe, instead of telling patients to ask your mother, you could let them know that you would love to answer all of their questions, but that you do not treat your mother because that is the best way you and your family have found in life.

I'm not coming down on how you do things in your family. I'm just thinking of times where I have been not feeling so well and I really just wanted some compassion. The doctors I return to are the ones who showed me their compassion.

icar said...

interesting!

Anonymous said...

I wouldn't treat my mother. Who wants to get blamed for something... O my

Anonymous said...

I'm afraid I've been guilty of this phrase when talking to doctors. I've also offered the "It's what I would advise my mom to do in this situation" to patients as a nurse, while also telling them to do their research and get a second opinion or more until they are comfortable with all aspects of thier decision, whatever it is. In my opinion, all people are really saying is, "Please look at me as a person, not a chart or a disease." All to often it seems the medical commnunity is in such a hurry, rushing from patient to patient, that we get left feeling very impersonal and unimportant. It feels like they are rarely even looking into our eyes, just at the paper or computer screen...
T

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