Medical Associates Clinic

 Quality Care Close To Home

     When a medical student starts their education, the usual first course is anatomy where a student dissects a cadaver and learns about all the different structures in the body.  The students are examined on every muscle in the arm and the leg, the back etc.,etc..  The instructor wants to know what the muscle does, what bone it is inserted into, what nerve goes to it, where its blood supply comes from and what its relationship is to the surrounding structures. Students study very hard to learn and remember all of this detailed information.  But I absolutely promise you that a very short time after the course is over, most of the information is forgotten.  And then there is biochemistry and a mind boggling detail of chemical reactions that go on in the body.  These too are soon forgotten.  It isn’t until the junior year in medical school that practical, applicable information is presented and the students have a chance to apply that information.  Then they learn about diseases and how to use drugs and surgery to help people.  At that time, whether the patient really wants to have any medications or surgery really isn’t something the medical students think about very much.  Students have enough trouble trying to remember what drugs to use for which disease and how to recognize the diseases.  What the patient wants just does not seem to be that important.

     After the medical student graduates, there is a year of internship in which the young doctor works in a hospital taking care of very sick patients.  There follows one to five years of additional training depending upon which specialty the young doctor enters.  Every step of that training is directed to how to recognize a disease, what the natural history of that disease would be, and how medical or surgical treatment might benefit the patient.  Residents and fellows in training change assignments frequently and rarely have more than a year’s contact with the patients they care for.  Thus, the young doctor in training does not develop long term relationships with patients such as occur in the private practice of medicine in the small towns of South Dakota.  The doctor in training is repeatedly drilled and trained on how to care for sick patients.  But they do not get taught to pay attention to what the patient wants.

     In my memory, there is not even one time in the ten years of my medical education when a professor devoted time to what I call “medical truism”.  Unfortunately, a young doctor has to learn these medical truisms through experience and enough interaction with patients to recognize the truism’s application.  I have never seen a list of these truisms.  Thus this and next week’s column will be devoted to medical truisms.  I promise that their recognition and application by healthcare providers and patients will reap as much benefit as medical or surgical treatment ever offered.

     Medical truism #1:  “The predominant driving motivation for human behavior is freedom of choice.”  As our society has been more sophisticated and educated, people continue to want detailed considerations regarding their health, the various choices available to them, and most importantly the freedom to make their own choice.  So many times, the healthcare provider will tell a patient “You’ve got to take this pill”.  That is just a flat lie.  No patient ever had to take a pill.  They have the choice to take it or not to take it.  A whole bunch of times, the patient will say that they are taking their pill when they are really not in order to avoid conflict with the healthcare provider.  Good patient care critically requires the patient making the choice based upon their own values and concerns.  Refusing to proceed with a surgery or a medication is a patient’s right.  Healthcare providers may feel very strongly about the importance and value of the given treatment but they have neither the power nor the right to impose that treatment upon the patient.  It is always the patient’s choice as to what they will do.  As an additional comment, it benefits the healthcare provider-patient relationship when the healthcare provider respects the patient’s choice whether agreed with it or not.

     Medical truism #2:  “Nobody every does anything wrong.  People always make the best decision considering the problem, the premises, the time and circumstances.”  I  lose a lot of people when I say this but it is absolutely true.  Life is not like a spelling or an arithmetic test in which answers are either right or wrong.  To be sure, some decisions a person makes result in a more favorable outcome than some other decisions they might make.  But nobody considers a situation and then on purpose makes the choice that they consider to be second or third or fourth best.  Intrinsically, people make a decision that is best in their opinion at the time.  That decision may come out with a most unfortunate result but at the time that the person made the decision to act in the way that they did, in their mind it was the best decision that they could make.

     Medical truism #3:  “It is not wrong to be wrong, it is just wrong to stay wrong.”  After a decision is made and a result comes out very unfavorably, the important step at that time is to change the behavior to avoid further unfortunate outcomes.  And yet so many times, people need to protect their ego by denying that they have made an unwise choice and had a bad outcome.  If they acknowledge that what they did had a bad outcome, people seem to feel that that will make them appear to be “wrong”.  No one ever wants to do something wrong.  So it seems that one of the better ways to avoid being wrong is to deny that you were wrong to begin with and keep on doing the same thing.  A willingness to change to another behavior is a critical part of a healthy lifestyle.  Sometimes, I wish the word “wrong” could be deleted from the English language.

     As an extra note here, a person benefits by recognizing that “when what they are doing does not work, do anything else.  But do not keep doing what has already been shown not to work.”

     Medical truism #4:  “The meaning of your message is the response that you get.”  A person naturally believes that what they mean is what they said.  That speaker is looking at what is said (the message) from the speaker’s (writer’s) side of a two way communication.  On the other side of that communication is the other person who is going to receive “the message”.  The meaning of the message is not decided by the person who sent it; the meaning of the message is decided by the person who receives it.  This is the root of misunderstanding.  As an example, I remember one night when a friend and I were going to an awards banquet where he was going to be honored.  His wife had been struggling with her weight and was very sensitive to her personal appearance.  When she came downstairs to leave, he turned and genuinely honestly believed that she was beautiful.  He said, “That dress fits you perfectly.”  The message she heard was, “He still thinks I am too fat for this dress.”  Now granting there was some history here and my friend’s comment might have been better chosen, he was in no way prepared for her turning around, going back upstairs and refusing to go to the banquet that night.  No matter what my friend intended, the meaning of his message was the response that he got.

     As a second example, the patient asks, “Do I have to take all of these pills?”  The healthcare provider says, “Yes they are important, you have to take them all.”  The patient heard, “He is trying to run my life.”; I’ll show him.  I don’t have to take all of these pills.  I can quit any time I want to.  The healthcare provider was simply trying to emphasize the importance to the person’s health that they take their medicine. That is not what the patient heard.  The meaning of the message is the response that occurs.

 Medical truism #5:  “Right is more important than fast.”  Our society today is fixated on fast.  Computers go faster, cars go faster, everything has to go faster.  While a student is in school, they are constantly pushed to improve how much they get done and students are invariably assigned more to do than they can possibly get done.  This generates corner cutting and coming to conclusions prematurely.  When a healthcare provider tells the patient one thing and then has to come back and say, “Oops! I have to make a new diagnosis and a new treatment because the first one wasn’t right.”, the patient looses confidence very quickly.  The second times this happens, the game is usually over and the patient seeks another healthcare provider.  Waiting until decisions can be made in a firm basis is critical to patient confidence and healthcare provider integrity.  One of my favorite questions to ask medical students is, “If you don’t have time to do it right at this time, when are you going to have time to do it over?”

     Next week, I will add in the other five medical truisms that help healthcare provider-patient relationships.