The other day, I had cause to sit in on a medical appointment. I’ve sat in on lots of medical appointments over the years, but this was one of those relatively rare times when I was there because of my relationship with the patient, not in a professional capacity. Though it’s impossible to dissect away my medical persona from the rest of my psyche, I experienced the visit more from her perspective than as a doctor.
During the history-taking part of the appointment, the medical provider asked a few pointed questions about the patient’s social situation, which had no direct relevance to the reason for the visit. Hearing these questions, my thoughts diverged. As a physician, I knew immediately why the questions were asked, and what the medical provider was trying to accomplish by asking. She wanted to know that the patient was “well” in a more general way than just pertained to the proximate medical concern. I understood the goodness in her intentions. But I also could see that the patient found the questions both invasive and condescending. Further, as much as I could grasp the reason for the questions, I suspect that was only because I’ve been on the other side of the provider-patient relationship. For any given patient, the questions would (and did) seem to come from out of the blue.
It was this vein of questioning (albeit about the unrelated subject of gun ownership) that rankled Ken at Popehat a little while ago, and in response I went to bat for asking them. I haven’t changed my mind about asking questions related to social situation and risk factors and all the rest of it in the few short weeks since I wrote that piece. If we are meant to treat our patients as complex and multidimensional human beings instead of a collection of medical problems, it is important to have a sense of their lives as a whole. As a pediatrician, part of what I’m supposed to do is offer anticipatory guidance about keeping kids safe and healthy. Indeed, as a specialist in adolescent health I ask about specific kinds of risk behaviors in a confidential manner, because it’s both directly relevant to my patients’ health and often something they don’t tell other people for fear of being disciplined by disapproving parents. (I’m not so naive as to believe they always tell me everything either, but at least I give them a space to do so “safely” if they’re inclined to be honest.)
I think the importance of asking questions intended to mitigate risk of injury or disease must be balanced against respect for our patients’ ability to take care of themselves. There seems to me a tendency within the medical community to view ourselves as all-purpose dispensers of invaluable advice, which if taken will obviate problems our patients would otherwise not know how to fix. We must ask about everything, because we must be prepared to instruct in all things.
This is, of course, arrogant hooey. I was a happy dispenser of this kind of advice for several years before I had a child of my own, and have (half-)jokingly commented many times since getting the Critter that I feel like I should call several years’ worth of parents and apologize for being so bloody worthless. A startling number of areas in which I was wholly ignorant surfaced, despite having handy answers provided by the AAP. A lot of the advice I give now is informed by my experience as a parent, not as a physician, and could have just as easily been given by a kindly aunt.
I try to keep my advice limited to a few discrete topics for each stage of development. I remind parents of small infants that their children could start rolling over soon, so to be wary of leaving them unattended on flat surfaces. I make sure I discuss concussions with any patient who plays tackle football. I review contraception with all of my adolescent patients. Etc. And obviously I give advice about specific subjects when I’m asked. I would be doing a half-assed job if I didn’t, and (to paraphrase America’s greatest avatar) I like to think I use my whole ass when I’m working. To take a “see no evil” approach (which is, frankly, how a lot of pediatricians deal with their teenage patients) is to be a lackluster doctor.
But the other extreme is to be avoided, as well. With this pervasive tendency in our society at large to medicalize every problem or quirk, seeking a medical solution when the answer (if there is one) lays outside the doctor’s office. I think much of this comes from unrealistic patient expectations, but physicians and their professional organizations play no small role either. (There will never be a more perfect example of this tendency taken to a ridiculous extreme than the lamentable calls to redesign the hotdog.) We don’t have all the answers, and can be just as susceptible to faddish nonsense as anyone else. (You can color me skeptical about all the health claims currently being attributed to vitamin D, which I strongly suspect will be the “oat bran” of its time.)
Should we give helpful advice? Of course. Should we ask questions of our patients to better know their lives and better understand their health? Certainly. Should we probe our penlights into every last little crevice of their habits and households? Perhaps not.