Friday Reflection #19: A Pledge That Can Be Hard to Honor

TR is an 84-year-old man I see for an initial clinic visit. After reviewing his concerns, his medical history and his medications, I asked him where he is from. In short order we figured out that we had grown up in the same city (he lived on the same block as one of my high school girlfriends), that he attended the high school that was the primary rival of my school, and that we graduated from the same small college.

The Declaration of Geneva is recited by many physicians upon receiving their degree. Roughly a third of medical schools use this declaration rather than the Hippocratic Oath. One of the pledges included in the declaration is:

I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.

I cannot imagine any doctor arguing with the sentiment of this pledge. Fulfilling it is part of what makes me love my work. I take pride in serving the diversity of my patients: old, young, rich, poor, black, white, religious, atheist, saint, sinner.

A favorite story of mine comes from the operating room after the attempted assassination of Ronald Reagan. Before being put under, Reagan said to the surgical team, "I hope you are all Republicans." Joseph Giordano, one of the physicians (and a Democrat) replied, "Today, Mr. President, we are all Republicans.”

In striving to fulfill this pledge, one standard I aim for was set for me by my own internist 25 years ago. One morning, while in my office, I diagnosed myself with appendicitis. It was not a difficult diagnosis. I’d been having abdominal discomfort for a few days. I’d been unable to eat my usual two hot dogs at a Cubs game on Sunday. And then, at work on Monday morning, I developed right lower quadrant pain and tenderness. Even though I knew what I needed to do, I called my doctor. His assistant answered the phone, listened to my concern, put me on hold, and within 90 seconds the doctor was on the phone. He directed me to the emergency room where he met me -- a few hours later and in the minutes between leaving the CT scanner and receiving 25 mcg of fentanyl.

Of this whole experience, my doctor’s availability and responsiveness is what I remember most.

Most days, I feel like I achieve this standard with every patient. My patients have multiple ways to reach me. I answer my messages before I leave every night. I’m willing to provide care well outside the walls of the office. I’ve diagnosed and treated polymyalgia rheumatica in Paris and rheumatoid arthritis in Moscow. I’ve managed gout in Mississippi and giardia in Montana. I’ve consulted with doctors seeing my patients in dozens of states and a handful of foreign countries. I am certainly not unique in any of this.

When I do fall short in my care of a patient, it has nothing to do with who the patient is.

Yet, I do not care for all my patients in the same way.

TR and I developed a relationship unavailable to most patients. Few people will ever connect with a physician in this way.[i] Sharing a personal history is certainly not necessary to build a productive relationship, but it was remarkable how quickly it changed the tenor of our visit. Our interaction went from a cordial, attentive, business-like interaction that most people would hope for and expect during a visit with a new physician to something more – friendly, comfortable and collegial.[ii]

Other times, a special connection is based not on a shared history but on a common present. The members of my community, my neighborhood, my profession -- the people that I see at faculty meetings, school open-houses, and the gym – also share a special connection. For those who know the area, my shorthand for this is the difference between patients from Hyde Park and those from Hammond. Hyde Park, my neighborhood in Chicago, and Hammond, a town just over the Indiana border, are only 24 miles apart. Each is home to dozens of my patients. Although I offer the same access to people from both places, the Hyde Parkers are less hesitant to use every means of contact. They reach me by email, MyChart, and through my nurse freely. This differential persists despite my recognizing it and understanding that I need to work to provide equitable rather than equal access.

Lastly, there are those patients whose relationship with me is shaped not by a common history or a shared present but by how they treat me. I do not need to like a patient to provide my best care – it would be unacceptable to care for, or only provide good care to, people I could see being friends with. The challenge of caring for someone who is unpleasant is oddly attractive to me.[iii] That said, there are a small number of patients who treat their doctors truly terribly. We have all seen people treat someone they consider “an anonymous, low skilled, service worker” poorly. I have been treated just as badly.

I understand where this behavior comes from. People can feel uncomfortable with, and unused to, the feelings of helplessness, worry, fear and powerlessness that come with being a patient. While some respond to the patient role by regressing or becoming overly agreeable, others become true misanthropes. Even knowing this, I cannot help but be affected. I may delay a call, cut short a conversation, avoid a particularly difficult topic because of how devalued and disrespected I feel.

Do any of these differences, differences which are mostly relational ones, affect care – affect the outcomes of my patients? I don’t know, but I can see how they might. Perhaps a patient is less likely to open up to a doctor they feel more distance from. Maybe a patient holds back embarrassing but important details from a doctor who is also a colleague. Maybe my delaying a call for a few hours because “I just can’t handle getting into it with her right now” could have negative consequences.

I’ve thought about areas in my practice where these differences might have measurable effects. One is around dementia treatment. I rarely prescribe the medications donepezil and memantine, but I do prescribe them more frequently for the “more connected” of my patients. Why is this? My read of the data, and my clinical experience, leads me to think that these medications are not particularly effective. I have certainly seen them (donepezil in particular) cause adverse effects – adverse effects in a patient population particularly unprepared for them. Thus, in an older patient with cognitive impairment, already on multiple medications, I will seldom encourage their use. However, I also do not resist prescribing them when a particularly empowered, connected family requests them. This might be an example of patients with a “more privileged” relationship getting (what in my professional opinion is) worse care.

I expect there are even more subtle differences I am unaware of. Given the relatively small numbers of patients in a single doctor’s practice, I don’t even think actual data could detect those differences.

Our pledge to care for everyone equally, without regard to who they are, is core to the practice of medicine. Like all promises, however, it is a challenge to keep.

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[i] This alone is an argument for greater diversity in the medical workforce.

[ii] I guess this feeling is what leads to homophily, birds of a feather flocking together.

[iii] The fact that I feel the need to martyr myself to feel genuinely happy would probably keep a therapist busy for some time.