July 7th, 2011

The Price of Being a Doctor

I saw a patient while I was moonlighting the other night that actually made me question whether or not it was worth it to be a doctor.

The patient was a 56-year-old gentleman who presented to the emergency room complaining of neck pain. When I went to talk with him and learn more about his complaint, he told me that he had a history of neck pain and felt as if it was about to start “rebounding again.” He had no previous or recent injury to his neck, never underwent radiographs, and had no neurological symptoms, but some physician somewhere had felt it was appropriate to give him hydrocodone, and he had been treating his pain “effectively” with this medication ever since. He was taking no anti-inflammatories, had never seen a physical therapist, and had taken no other conservative measures to manage his pain. In fact, he had no primary care physician at all.

As we talked, it became blatantly clear that his “rebounding pain” was running in direct correlation with his dwindling hydrocodone prescription. I readily admit that I believe we, as a whole, under treat pain (for fear of inducing potential addiction, tolerance, and side effects), which is a disservice to our patients and their quality of life. However, as a sports medicine physician, I see my fair share of chronic musculoskeletal pain and, therefore, am comfortable with my treatment algorithm and with who qualifies for narcotic medications.

This guy did not require narcotics.

hydrocodoneIn further discussing his condition and my medical opinion that he needed to treat the ailment rather than masking it with pain meds, he became agitated (as you could imagine) and demanded hydrocodone. “I need hydrocodone 10/325 and I need a quantity of 30,” he emphatically stated. “It is the only thing that works.”

At this point my patience was wearing thin. Not only was this patient misusing the medical system by arriving at an emergency department for what appeared to be a medication refill, he was now attempting to bully me into prescribing him medication I did not feel was medically necessary. To make a long story short, I told the patient that this was not a negotiation and that I was going to treat him no differently than I treat any of my other patients. I stayed true to my clinical criteria for prescribing narcotics, and he left with a script for Mobic.

I was later informed by my nurse that, as he was leaving, he turned to her and asked, “What night does that doctor not work?” as if he was plotting his next attack.

I went back to my desk, irritated, and reflected about how I spent 4 years of medical school, incurred a large amount of debt, trudged through residency, sacrificed family time to extend my training through moonlighting, paid big bucks to take a board exam — not to mention the cost of licensing, DEA, and DPS numbers — and how it was all just lost on this patient because I was expected to do what he wanted.

And to be quite honest, it pissed me off.

There are people in our communities that have capitalized on physicians’ fears of litigation and willingness to practice defensive medicine to get what they want. They feel entitled when they are seen by a doctor. They “know” what is medically best. They aren’t coming to their appointments to get evaluated and treated, but rather, they are using the doctors as suppliers. They are successful because they instill a sense of “if you don’t do what I want, I will report you for failure to treat my pain adequately.”

And if this is how practicing medicine is going to evolve (insert political commentary here), then is it still worth it to be a doctor??

I had this question answered for me on Easter Sunday. I was enjoying a nice Easter service with my family. I had just returned to my pew after communion when, from the back of the sanctuary, a hysterical mother called out, “Is there a doctor in the house!?!?” A silence fell over the congregation and everyone stood frozen in their place — except for me. I arose from my pew and made my way to the mother.

As I approached the woman, I found her 14-year-old daughter lying horizontal on the wooden pew, pale and diaphoretic, with a confused and scared look on her face. She had passed out and was just awakening when I arrived. With the help of some other providers, we tended to the young girl, comforted the mom, and handled the situation appropriately.

Thankfully, the mother’s call for help was for something minor, but, to me, it was a major boost to my failing sense of purpose. To have my “name” called in a moment of personal despair and to realize that, in a gathering of 300 or more people, I was the only physician, made me feel as if being a physician still was something special.

So, is it worth it??

Yes, it’s priceless.

47 Responses to “The Price of Being a Doctor”

  1. Steve Sanders says:

    It is frustrating to me that you seem to extend your feelings about one drug addicted patient to patients in general. You are the one who went to medical school, how dare they question your authority, how dare they bring their own perspectives, how dare they expect to be a co-participant in determining their course of treatment. This kind of attitude is what is driving patients in droves to naturopaths, homeopaths and accupuncturists – quacks who don’t have science on their side, but who are running circles around the medical community in terms of listening and empathy.

    • Steve Sanders says:

      I should add – I don’t disagree with your assessment of this patient who wanted narcotics. But perhaps you should consider that it was another white coat with a medical school degree who got him addicted in the first place.

      • daniela says:

        “But perhaps you should consider that it was another white coat with a medical school degree who got him addicted in the first place.”

        Yes. A little compassion for your annoying patients will go a long way in reducing your frustration.

        You are going to face this situation many, many, many times in your career. Stick to your principles, but just BE NICE. You’d be surprised how helpful it is to say to someone, “I’m sorry. I hear how upset you are about this.”

    • Glen Cadence says:

      Steve you are an idiot!!!! Who gives you the authority to call anyone quack? If you think medicine and its pseudoscience made up by the big Pharma companies is science, think again you Moron!!!!

  2. Ana Pfitscher, M.D. says:

    Sometimes is good to remember on the deep of my heart why I am a doctor and your text made me feel in this way.
    Thanks!

    I´m from Brazil and this kind of thing, sure, also happens here. It´s not only because of “defensive medicine” – only some specialities have this problem here (plastic surgery, obstetrics…), nor because of the money the patient is paying (here most of the health assistance is provided by Brazilian government for free).
    I think that maybe people don´t respect doctor as it used to be. Free and open information (as internet provides us) is great, but sometimes give the false impression of that you REALLY know a subject, and that you don´t need a professional assistance.

    But, anyway it´s a good experience that you shared with us.

  3. AR Kinge, MD says:

    It is Good to stay on your principles. As a physician you should respond to patient needs putting in mind that you “do no harm”. If he doesn’t get the narcotics from you, he will get it somewhere else; as he was already doing. I would say give him what he needs cause you can not treat the addiction by one refusal, start counseling and get family members to help pave the way for rehabilitation.

  4. John GolbergM.D. says:

    Thirty years on , I have those feelings still, almost very week, especially when some insurance clerk tells me how to practice medicine.
    I noticed a clinic the other day where paramedics seem to be the new qualified providers.
    Search every day for the incidents that ‘make a difference”… there will be many,and the rest is best ignored or dealt with in some political forum.

  5. Brian says:

    Great article regarding the mental trials and tribulations of a medical professional that are very difficult to “teach” or even convey. Real world stories contain a wealth of knowledge that have left an impression on the writer and therefore represent the unique challenges of a role as seen through their eyes. Being confident in yourself while allowing inputs from others when necessary is always a challenge. I commend you for having the conviction required to stick to the care plan/procedure you have established. Although open mindedness, flexibility and preparedness all help keep us from diagnosing a overabundance of some biased and “forced-to-fit” illness, it is very critical that we remain confident and true to our beliefs. I believe you did exactly that.

    Thanks for sharing!

  6. Brandon Young says:

    Physicians aren’t the only ones who suffer from this sort of behavior. As a pharmacist I have four years of pharmacy school resulting in a Doctorate of Pharmacy under my belt with comparable student debt. Trust me, it’s no walk in the park. When we run into drug seekers they give us even less respect, and we are not empowered to really do anything to stop them. The last thing a physician who was bullied into a hydrocodone prescription wants is the pharmacist calling with fears of drug seeking. And don’t forget we see them far more frequently when they stop in for refills, advances, pleading for a few pills “just this one time”, or blatant robbery.

    Compound that with a certain lack of respect from other health professionals and we have some very unrewarding days.

    I like the positive ending to this entry, and I will follow suit. I chose to go into health care and subsequently pharmacy and, although there are ‘those days’, I don’t regret it.

  7. Steve says:

    Who was in more need of a physician’s healing expertise? The girl who fainted in the pew or the unfortunate drug seeker who is desperately acting out in response to his addiction? For those of you who do believe in God – they are BOTH God’s children. After 25 years of practice, many of the most difficult and challenging patients, when approached with compassion and understanding, prove to be the most satisfying enconters in the long run. Next time you feel that frustration, ask yourself what it is in you that makes you react that way. Then you will be sure to grow as a physician and person.

  8. Monica T says:

    Dr. Bratton,

    Thank you for sharing your experiences. You know that with this patient you made the correct decisions both professionally and morally. You treated his pain as appropriately as you knew from his history, and you did not prescribe narcotics liberally – especially since he was a first-time patient.

    If he really did have pain that requires narcotics, he needs to re-evaluate his long-term pain goals. Does he really want to be on narcotics for the rest of his life? It seems as though he was not even willing to consider other therapeutic options.

    From a pharmacy standpoint, I get tired of patients who ask for specifically the “Watson 349” Vicodin or that say they are allergic to “the speckled ones” (Norco). These people know which tablets and strengths are recognized on the street and get the most money for them. FYI, these patients often have UDS positive for cocaine. The physicians I work with don’t write narcotic pain meds for patients with positive drug screens.

    Patients have to be willing to help themselves. There is only so much you can do when they destroy their own bodies.

    Best of luck with the rest of your career. I’m glad the positive experiences make it all worth it to you.

    “Whatever you do, work at it with all your heart, as working for the Lord, not for men, since you know that you will receive an inheritance from the Lord as a reward. It is the Lord Christ you are serving.”
    Colossians 3:22-24 (NIV)

  9. Don S. says:

    One’s disappointments in life are directly proportional to his/her expectations. The simple fact is that we cannot control patients, or anyone else for that matter, including even our own family members. We have the opportunity and obligation to attempt to influence their behavior, but we do not have control over the outcome. It is a potentially devastating experience to condition one’s happiness on the decisions they make and the behaviors they choose. I often remark that human behavior is the last frontier. Think about it. We cannot cure most lung cancer, but we know how to prevent about 85% of it–simply by not smoking. Yet lung cancer remains the #1 cancer killer of both men and women, having surpassed breast cancer mortality many years ago. Go figure. Yet many thousands–possibly million–of people have been influenced not to smoke. But the decision to not smoke, or to quit, was theirs alone. Human behavior is the last frontier. It is a rare practitioner who does not see self-defeating behavior, not only in patients but also in our colleagues, on a daily basis. Get used to it. And you won’t escape it by changing professions.

  10. Dr. Nan says:

    Hi Greg!
    After fourteen years in primary care, I still struggle–Is what I’m doing worth it? WHy do we struggle? Because it is HARD! We don’t do nosejobs and eyelifts-we don’t do chemical peels. We treat sick people–and sick people have flaws, some that are compensatory for being sick, and some that show physical illness as a compensation for more psychological illness!Some days I feel more like a pill pusher than an expert in the diagnosis and treatment of serious diseases. I have reconciled myself in that–I am here to treat sick people–they do not always behave as I think they should, but they probably do the best they can. I’m not saying I prescribe a bunch of narcs–I would have done the same as you–but that patient needed someone to say “No”. Maybe he will figure it out–maybe not! But your mission, or passion should not be weakened by one ill and weak patient. I get jazzed about the small things as well. There is no dramatic save to most of what we do. There’s no glory in preventing a heart attack (over thirty years, working on someone’s cholesterol). Most of the appreciation I receive from my patients (and is thus my positive reinforcement) comes from very small actions on my part (or no actions). There are things that may not seem clinically significant to me, yet are important to the patient (perception is everything). You can only be the best physician you can be–stick to your morals, and do not expect appreciation from every patient–much of what patients need–they do not like!!!

  11. chew boon how says:

    Many patients don’t know what they really need, it is the same as many people don’t really know or appreciate salvation grace in Christ.

    However, that is exactly what it means to provide patient-centred care: a process of coming to understand each others (and significant others eg. family members or carers of the patient) and shared decision making with the patient if possible. The process has to be valued and comfortable to the patient. If it does not go well with the doctor, then an informed-referral can be arranged. This may be a more fulfilling doctor-patient relationship.

  12. George Kent says:

    Such experiences are not limited to the practice of medicine. Almost any job will encounter obnoxious, manipulative jerks.

  13. Rafi Ahmad Masoodi says:

    I have innumerable reasons not to love India and just two to love it.One of the two reasons is the angelic attitude and behaviour of an Indian Doctor.When it comes to the WORTH of a doctor what matters more is how you treat,esteem and evaluate your patient and not the other way round. The PATIENT could not coerce you into something not befitting a doctor makes you “THE DOCTOR”.

  14. William Schuler M.D. says:

    I have had many similar situations in the past 30 years, some of them barely a few minutes apart. My wife tells me, “behind every upset there is an unmet expectation.” The longer I live, the fewer expectations I have. I think it really helps to read authors who have a better and wider appreciation of the human spectrum than your typical medical author. Professor Einstein once said that he got more out of Dostoevsky then out of the stuff written by his colleagues. I would also recommend Walker Percy and Flannery O’Connor–they seem pessimistic to the world but they are far more charitable than strict materialists; some of whom have made the typical intolerant remarks that we have come to expect from what passes for discourse at the present time.

    I am pleased that the Journal Watch directed me to this site. In spite of “church” being mentioned. Will wonders never cease?

  15. Anonymous says:

    The breadth of the reactions here is quite striking. It amazes me the different perspectives from which the responses come. The article, in my opinion, is right on the money. Some responses are, indeed, quite difficult to take.

  16. Alejandro says:

    Ours is a difficult profession. Sometimes really hard, specially when our patient is not improving and we do not really know what is happening. Sometimes, I suppose we all think that better if we were lawyers or something like that. But I feel proud of being a physician and I try to do it the best I can.

    Besides, maybe I am lucky because I believe in God.

  17. Naveen kansal says:

    In India, after the consumer protection act (CPA) was extended to be applied, during last 2 decades, number of students desirous to be doctors has decreased dramatically (this is according to a recent survey in the leading newspaper ‘Hindustan Times’). Medicine is considered as toughest, and longest to be a professional, still less paying & less satisfying than others like engineering or management. Moreover, we study for 8-10 years to become a specialist, but may be taken by patient as a new doctor (i.e. doctor with less knowledge. Still, if a patient says ‘thank you’, it gives satisfaction but now it’s much less than older times!!! However, I think it’s priceless to be a doctor.

  18. Raman, MD says:

    Dr.Bratton:
    Recently in a formal discussion with my senior residents, I was told that these pain medication issue is very recent (2 decades) to american society. To increase the sales of Oxycontin / Oxycodone heavy marketing strategies were followed to educate the physicians regarding appropriate pain control and at the same time too many commercials to ask for pain medications kind of changed the culture of over treating the pain. I noticed that younger physicians (<6-8 yr of graduation from residency) has high threshold to treat the pain with high doses of opiods. Please comment: Do you think physician community need re education about pain management??

  19. W.L. (MBBS) says:

    Preventing the Misuse of National Healthcare Resources
    i) National guidelines wrt analgesia must be developed and circulated both nationally and institutionally.

    ii) A national medical records system (public hosp) needs to be developed so the attending physician can immediately view the pt’s electronic med Hx and document current care clearly to prevent healthcare$ wastage/ abuse.

    iii) If the pt’s condition is complex and warrants specialist attention then such consultations should be documented in his/ her electronic med records. Any Jr Dr seeing pt for urgent drug refill/ treatment may give Rx X 3/7 at most or other such reasonable duration until until the pt next sees his specialist.

    iv) The specialist concerned should publish within the pt’s electronic folder his current management wrt pt’s condition and a brief summary wrt EVERY specialist visit so emergency care physicians can understand the patients true condition.

    This would certainly go towards improving the patient/ physician healthcare experience as well as prevent misuse/ abuse of health care systems.

  20. MARIA BECERRA says:

    I am a Colombian doctor,i have just finished my pediatric residency and sometimes i wonder the same…
    , is it worth it to be a doctor??
    and i think the same as you…
    Yes, it’s priceless!!!
    We study this because we feel it deep in our hearts…is our life mision….hope you understand my english =) bye

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