With that context, understand my sincerity in asking “What is it with doctors?”

In my writing and my client work, in- and out-group dynamics come up a lot. Doctors are perceived as a very specific constituency in the system… with good reason. The extent to which this perception stands is fascinating:

At lunch recently with a fellow consultant in the health care system said to me: “We seek to inform the doctors, but all we hope is that they don’t actively resist the work we are doing.” Working with a hospital group recently, the historic specter of the doctor vs. nurse divide reared its head. An academic mentor of mine with whom I consulted before launching my practice suggested: “It won’t work if you don’t get the docs on board, and I don’t think you will.”

There are a number of reasons why doctors could view themselves as very removed from the system: degree of training, stature that crosses most/all cultures, different employment structure with the hospital/community system, etc. But do they see themselves as that different? Some may, some may not.

If I were a doctor, I think that I would be proud of my accomplishments, and I might develop an ego. I also might think that it is my job to make decisions and may actually not appreciate what I perceive as challenges from other staff (RNs, RPNs, etc.) who (although they are only trying to help) are trying to make those decisions for me. What if they are wrong? If I were time starved, as many doctors are, I may not be able to take the time to “soften” my message or think about the “how” of my communication skills.

If doctors are removed from the workings of the system, they can take responsibility to “engage” more. If they don’t those working around them can accept the out-group reality and behave accordingly. The right information to save and prolong lives can still get through. Like many things, it is easiest if both sides work together. Some doctors will; some won’t or can’t. It is the latter group that could tip the scale one way or the other. As some of the tougher reforms come through, it will be interesting to see if the perception (and reality) of doctors change.

Both doctors and parents, one can assume, have the best interest of the child at heart. But it may be more complicated than that: I recall hearing commentary on an instance in Vancouver–raised in the above article–whereby the parents of sextuplets refused blood transfusions because their Jehovah Witness faith did not allow the procedure. The commentary (I will try to find the source; you will have to trust me for now) was that in such instances, loving parents need to be legally forced, because it allows them to save the child, while also saving religious face.

If, in fact, both parties are focussed on what is truly best for the child, both are responsible and accountable. Parents need to be ready to make their case with more than just “this is what we want” or, worse “this is what our child wants.” With all due respect, it should not take a psychiatrist to determine that a child is unfit to determine the cancer-fighting procedures that they will receive. The medical profession must be granted some degree of trust and authority to make these decisions for people. This sort of latitude should be granted, but also needs to be earned.

Information is everywhere, and Google could probably help find a source to support that a diet of raw vegetables beats chemotherapy or that alternative care in Mexico will be more effective than Ontario hospital care. If these sources of information are being given the nod over what the doctor says, the doctor has some “selling” to do. Understanding the real concern takes time, and usually requires (1) creating a relationship of trust and (2) asking questions. Did the doctors do this? Did they have the time? the skill? Not everyone is going to take a doctor’s word as gospel; nor should they.

Medical research and past results are not the only forms of evidence, but will only be effective if the other party is listening. Fostering a dialogue can get people to open up to some grim realities. It must be a horrible decision to pick between a grueling medical procedure that might help, and a less extreme treatment that almost certainly won’t. That decision, however, should not be the parent’s, and definitely shouldn’t be the child’s!

This is one issue that I believe is tough to find “neutrality.” As I think is the objective of many editorial pieces, I think it strikes enough core beliefs that you have to be selective of those with whom to discuss the issue.

In the spirit of the right solution being able to sidestep all the noise created by conflicting philosophies and values, I wanted to bring light to the position put forward by a doctor in a letter to the editor by Dr. Susan Piccinin in Ancaster, Ontario.

She talks about insistence on narcotic-based medication being a “red flag” for physicians when talking to patients. The ensuing dialogue in an initial meeting might look something like this:

Patient: I have a back problem and I have been taking [narcotic-based medication] for it. Can I get some of that from you?

Doctor: Using that kind of medication for any length of time is going to build up dangerous addictions and won’t help your back at all in the long-term.

Patient: I am not addicted; it’s just the only thing that works! Please, give me the prescription.

Doctor: Sorry I don’t prescribe these medications, and for that reason we a not a good match.

Note: The last line is a direct quote from the letter to the editor.

There would have to be a fairly involved exchange of information between the doctor and the patient to get to the above dialogue. For this to work the patient would have to be open and trusting with the doctor (Will this happen if the patient feels a danger of being screened out?), and the doctor would have to devote the time to probe the right information, in a fairly sophisticated manner. (Do doctors have the time? Do they have the skill?)

If this doesn’t work, emotions will cloud the exchange long before we arrive at the “I need the drug/You can’t have the drug” impasse, which, I believe, is a legitimate position for the doctor to hold. Objectively, a doctor should be able to refuse care to a patient who will not allow care to be delivered. (e.g. You are not going to listen to me, so why should I talk to you?)

If this is indeed the case, I think the “selecting patients” issue becomes quite simple, although a number of other complicated issues arise, such as “how does this patient get the treatment they need?” The follow-on issues are much better fodder for articles and editorial pieces, which would create more practical discussion.