Patients as friends

I'd like to submit this article from today's USA Today into the Annals of Worthless Journalism. (Yes, I realize this is kind of like criticizing the McDonald's Dollar Menu for its lack of seasonal produce. Sue me.) From the headline "Ethicists debate doctors who keep it personal," you might expect documentation of an actual debate. Instead, you get a couple of token quotes from some randomly-chosen ethicists, and several soft-focus profiles of nice, caring doctors that stitch up the neighborhood kids during episodes of SpongeBob. (Seriously.)

For example:

Sometimes going beyond the bounds of normal practice standards isn't a matter of emotional choice but simply about saving a life, says Samuel Weinstein, director of pediatric cardio-thoracic surgery at the Children's Hospital at Montefiore Medical Center in the Bronx, N.Y.

While performing open-heart surgery on a boy in El Salvador two years ago, the child needed blood but had a rare type not in supply at the hospital. Weinstein, like the child, was B-negative. He says, "I scrubbed out, donated a unit of blood, then scrubbed back in and finished the surgery with my colleague."

Weinstein says he did not intend to be a hero. "It is just something you have to do," he says. "You do everything you know how to do to help you put your head on your pillow at night. If he'd had a bad outcome, I would never be able to stop thinking about it."

While I'm a wee bit curious why Weinstein didn't donate the blood before he scrubbed in in the first place, I have a hard time imagining an ethical question about this.

On the other hand, while I hate to crush all those pretty elf houses on Lollipop Lane, there are a couple of real, legitimate concerns with the Rockwellian docs the article eulogizes.

1) House calls sound great on paper, and we all lament their passing, right? Sure. Fine. But they are very, very time-consuming. Medicine is, let's all remind ourselves, a business. The money office visits generate pays for the staff, supplies and administrative costs of keeping the practice open. Unless the house calls are done on the doctor's own time, they cut into the revenue stream in a way that doesn't make sense when you look at the big picture. In the time it would take me to drive to a patient's house, see the patient, drive back, and document everything in the record, I could see half a dozen patients in the office. Plus, is it fair to the other five patients I could have seen that I went and saw the one in her home? Cold? Maybe. But I think people, on balance, would prefer we keep the office open.

2) Apparently one of the doctors does minor facial surgery for his patients in his living room, with his 11-year-old holding a flashlight. I don't think this is admirable, I think this is crazy. All it will take is one lousy outcome or one crazy, lawsuit-happy parent, and St. Surgeon will be back to 100% office-based care.

"Tell me, doctor," asks the malpractice lawyer. "Were you able to guarantee sterile conditions there on your coffee table? Did you notice the problems with those stitches in the poor lighting?"

Should we all don sackcloth as we mourn the passing of a less litigious time, when Donna Reed undressed babies in their home office for Carl Betz to examine? Fine. And we also miss the dodo. I guess when you're chief of pediatric plastic surgery at UCLA, you're confident enough not to have these concerns. Lesser mortals like yours truly? Not so much.

Now, with that being said, of course I take the time to answer friends' questions if they call. I did minor wound care for one of my nieces this summer when she cut her foot. I dispense free advice in church all the time. I do all of this gladly and without reservation. Being helpful is its own reward, and I imagine most of my colleagues feel the same. But any time there are actual medical management decisions in question, I counsel people to speak with their own doctors. This has less to do with boundary issues and more to do with not wanting to manage someone else's patient, which does neither the doctor nor the patient any favors.

All in all, an inane article. It's nice to be nice. But doctors practice medicine the way we do, by and large, because we have to given the legal and fiscal demands of contemporary medical care. You'd never know it from USA Today, however,