10 June 2008

Conundrums

It's a common perception that, being an ER doctor, everybody and their brother must bug me for medical advice at all times. Strangely, I have found that not to be so much the case. It's in fact quite rare for someone I know only casually to ask my opinion on anything medical. They may ask for "freaky ER stories," but not about themselves. In truth, I also try very hard not to let people know what I do for a living. My standard line is that I "work in a body shop in [name of town]."

My family and close friends do occasionally ask for opinions regarding their own health, but these are all people I am really close to and have a very trusting relationship with, so it doesn't bother me. I may or may not be able to help them or answer their questions, but I have no qualms about discussing it and venturing an opinion when appropriate.

I recently found myself in a somewhat dicey variation on the theme. A high-profile, powerful individual who I knew only professionally called me and asked for some advice. This is a person I have interacted with on multiple occasions, but don't really know very well, and though I am well-disposed towards her, I would not say we have much of a relationship at all. But we do have enough of a relationship (and she is important enough) that it would have been impolitic of me to brush her off.

Worse, her concern was regarding chest pains she had been experiencing. Clearly, after some information-gathering, these were quite unlikely to represent anything serious. But as all ER doctors know, unlikely things do happen from time to time.

So I had to decide: what should I tell her? I could just abdicate all responsibility and tell her to get in to the ER. Safer, simpler, and the "textbook" answer. But I could tell that she did not want to go to the ER and I hated to think that if I sent her in and she endured a negative work-up, she would be annoyed at me for wasting her time and money and disrupting her busy life with a worthless hospital stay. Would her opinion of me suffer? Not an appealing thought. On the other hand, I could reassure her, quite honestly, that the symptoms she was experiencing were probably not serious and doing so, effectively give her permission not to go in. (Which was what she wanted.) She'd be happy with me, and truth be told, she almost certainly would be fine. But such a response just feels intrinsically dishonest, and as a fundamentally paranoid ER doctor, that nagging "what if" in the back of my mind is hard to ignore.

Ultimately, this is what I told her:
You need to understand that I am not going to attempt to diagnose or treat you over the phone. I will, however, give you some background information. The symptoms you describe, in a person such as yourself, are highly unlikely to represent any serious disease. There is, however, a small but measurable possibility that these pains are caused by your heart or some other dangerous cause. If you go to the ER, they will do tests X and Y and Z and will be able to give you a better assessment as to whether you are at risk or not. If you choose not to go in, that is a reasonable choice in this setting, but you need to consider your own willingness to tolerate risk before making that decision.


There was a long silence over the phone. Clearly she was not thrilled with what I had done -- put the onus of the decision back on her shoulders. She thanked me and ended the conversation.

A short time later she sent me a text saying that she was going in.

The next day, at work, I was tempted to look her record up in the computer, to see what the tests had shown. But I was unsure whether that was kosher -- would it have been a violation of her privacy? She had trusted me enough to call me and discuss her medical condition -- does that entitle me to "treating physician" status? I decided probably not, at least not worth the risk and potential bureaucratic headache. I figured I would find out next time we met, which I did, and she was fine, and in hindsight she was quite glad for my advice because it had helped her make the decision that was right for her.

So a happy ending for both of us.

5 comments:

  1. Your bias as an ER doc shows here, in the sense that you perceived this as a dichotomy; a situation with only two acceptable courses of action (go to the ER or don't go.) What about adding, "I think you ought to consult with your personal physician about these symptoms." (And that if she didn't have a personal physician, she ought to, perhaps using this as the impetus to establish that relationship.)

    I find it sad/frustrating/appalling that this option didn't even occur to you.

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  2. Oh, give me some credit (and get off your high horse). Of course there was PCP involvement, in fact she already had an appointment set up. That was not why she was calling me. What she wanted to know was "do I need to do something about this now, at 8pm, or can it wait?"

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  3. I have the same problem as an attorney, and I was recently put into a similar position when my boss (I'm now a teacher) called me at home for legal advice. I basically did the same thing. It's uncomfortable. And people I barely know ask me for advice all the time if they know I'm an attorney.

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  4. I thought that was nicely handled. Letting the kind of, sort of, patient make the decision is better for everyone.

    From the way it was written, I presumed that it was not during office hours.

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  5. I thought your answer was just about perfect. You left the decision in her court, but you gave her the information needed to make it.

    Why should you assume the risk? Ultimately, the patient ought to be responsible for their own health. Obviously, in emergency medicine that is often not possible, and a dr. has to assume responsibility for some decisions. But I never expect my personal physician to be responsible for my health. I'm the one who will be making the daily decisions that affect my health, after all. What can he do if I don't follow his instructions? And what can he do if he doesn't have all of the information he might need, through no fault of his own?

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