When most people think of "Defensive Medicine" they envision what physicians do to cover their backsides rather than really help patients.
I think of being a medical student working in the ER when a drunk patient comes in complaining of chest pain. My attending physician asks - "what does that patient need?" I answer - "He needs a rally bag, some food and a place to sleep for about 12-18 hours."
She then says - "but you know what we're going to do right? He's going to get a CBC, CMP, UA, BAL, Chest X-ray and an EKG - and that's just for starters."
And that's how it goes. We know what's wrong - or least we're pretty sure. But we have to cover ourselves legally - because what if???
Can a drunk guy with chest pain be having a heart attack? YES
It's like they say: "Every Hypochondriac eventually dies from something."
My residency director often said: "A man with diseases can have as many as he pleases."
Just because someone uses drugs and has a personality disorder doesn't mean they can't have epilepsy. Yep - just because someone has pseudoseizures doesn't mean they can't have real seizures too.
And that's why we do it. Yeah - we don't want to get sued - it's true.
We would probably be correct and save thousands and millions of dollars if we treated people how we REALLY think they need to be treated. But we don't get to make that call.
Psychiatrists have it even worse. I wish I could just look at a depressed patient, or an anxious patient, and give them what they need. I could give them the medications that are most likely to help them and get them the therapy that is most likely to have a lasting effect - but I have to do more than that.
Every patient I see - I have to look at their medication list and ask myself - "If they took every pill in their medicine cabinet - would they survive?" "If they tried to kill themselves - have I given them the tools to do it?"
I always have to worry about suicide. Always.
I can't just treat symptoms, or even diseases. I have to practice defensive medicine - meaning I have to defend the patient from themselves.
It's an impossible task. I don't control their free will. I am not their parent or their conscience. I am merely their psychiatrist.
Yet somehow - when I get that call - the one where some ER doctor tells me that my patient just attempted suicide by overdosing on the pills I gave them - I'll feel responsible.
Maybe I can get used to it. Is that what makes a good shrink? Being able to handle things like that?
Maybe that sinking pit of guilt, despair, and regret at having facilitated a patient's suicide goes away?
Maybe it should.
Maybe it shouldn't.
3 comments:
I do not envy your job. So hard. If only there were a better way to regulate how they took their pills...like magically locking pill bottles that dispense one pill a day and cannot be opened until the next....hmmmmm....sounds like an invention for you, Matt! My prayers are with you!
Good read, Matt. It is far too easy, particularly with electronic medical records, to just click and prescribe. Everything has side effects, regardless of whether they are apparent in a given patient or not, and I can't tell you how many times I've been reviewing someone's chart only to discover they are on medications that shouldn't be taken together, or are contraindicated because of comorbidities.
Thankfully, I rarely have to worry about my patients attempting suicide with what I prescribe to them, but I sure as hell worry about them selling the narcotics. You have to send percocet home with someone who is 3 days s/p cesarean, but those bad boys are at least worth $50 each.
I'm post call. And rambling. But this was still a good read. :)
Thanks Brenna and Chelsea. It's tough because I really want to trust everyone. Most patients reward my trust and do just fine - but every doctor has been burned before - and the old adage of "once burned, twice shy" rings true.
Post a Comment