Respectful Insolence

An uncomfortable question

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgWork called last night. (It happens.) Basically, I had two deadlines for two big things (finishing reviewing the grants assigned to me for study section and a major writeup for a project for my job). Unfortunately, both of them were today. I realized as I perused old posts that I hadn’t reposted this one in over five years. So, unless you’re a long time reader, it’s definitely new to you. More importantly, it reminds me that I don’t write about thins like this much anymore. Certainly I rarely do personal anecdotes or straight medical blogging much anymore. Maybe I should do more.

[NOTE: This story is loosely based on a real patient encounter from several years ago, but some details have been changed.]

The patient list for the day had simply the words “abnormal mammogram” next to her name. That used to be the most common reason that of breast patients came to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal. The next thing they know, they’re sitting in one of my examining rooms. However, the patient list is quite brief. It’s just meant to be a quick capsule of what patient has what basic complaint. These days, because at my current institution so many more practitioners order breast biopsies, most of the patients I see are already pre-diagnosed with breast cancer. Be that as it may, nothing on the list prepared me for the woman I greeted when I walked in the examination room.

This woman was enormous, and I do mean enormous. Morbidly obese, she told me she wasn’t sure how much she weighed, but that it was at least 450 lbs. As she sat in a wheelchair massive enough to support her, rolls of fat hung over the armrests, and her breath wheezed like a mortally wounded Darth Vader near the end of Return of the Jedi, right before he took his helmet off and revealed Anakin Skywalker beneath the mask. Indeed, on the same theme, I could not help but be reminded of Jabba the Hutt. Yes, I know that physicians aren’t supposed to think that way about their patients, and, honestly, I tried not to. However, we’re human, just like everyone else, and even our years of professional training can’t entirely suppress our baser thoughts. At least I managed to keep enough self-control to restrain myself from voicing such thoughts to my nurse or any of the clinic staff at all, not just where the patient couldn’t hear. Not all clinicians exercise such self-restraint, and, I’m embarrassed to say, there have been times in the past when I didn’t either. I like to think that experience and maturity have provided me with the self-restraint to reign in my sarcastic tendencies.

Normally, dealing with a patient with suspicious microcalcifications on her mammogram is fairly simple. A biopsy is indicated, and there are basically two techniques to choose from. You can do an image-guided core needle biopsy, either a stereotactic biopsy (in which the image guidance is mammography) or an ultrasound-guided core biopsy (in which the image guidance is from, well, ultrasound). If neither of these are possible, then the patient will require an old-fashioned surgical biopsy, known as a wire localization or needle localization biopsy. This is a technique in which a wire is placed into the breast under local anesthesia such that the wire sits next to the abnormality that needs to be biopsied. In essence, the wire placed under either mammographic guidance or ultrasound guidance, leads the surgeon to the lesion. Given that even the surgical option is usually a same day surgery using local anaesthesia and sedation, even that isn’t so hard. The surgery can sometimes be a little trickier than one might think, but even then it’s usually not all that hard. Oh, sometimes you get patients with multiple abnormalities, and you have to decide if you want to go after them all or if you want to perform a triage and decide that some of them need to be biopsied and some of them don’t, all the while realizing that if you miss a cancer it can be a major disaster for the patient.

Of course, a 450+ lb. patient adds a new level of challenge. For one thing, she was way too heavy for the stereotactic table; so stereotactic biopsy wasn’t even an option. Not surprisingly, her health was horrible. She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians’ Desk Reference. I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it. So I made do and did my best to examine her while she was sitting in her wheelchair. It was a suboptimal examination, but, given the size of the room, it was all I could manage. Morbidly obese patients, because of their size, frequently make it very difficult to provide optimal care to them.

By the time I was done, I felt profoundly sorry for this woman. How on earth does such a person live, given her physical and medical problems? Despite my sympathy, I maintained the professional bedside manner that we’re all trained to keep up and explained what was abnormal about her mammogram, that she would need a biopsy, and how the biopsy would be done. I also explained the risks (which, for her, were much higher than the minuscule risks most patients undergoing this procedure face), and arranged for her to be seen by her pulmonologist and cardiologist in case something more than local anaesthesia were needed.

When finished, I asked if there were any more questions, gave her my card, and made my way past the family members to the door. Although it was near the end of the day, there were still a couple of more patients to see.

There was.

“Do you believe in God?” she said, looking at me expectantly.

I was still standing there, hesitating. To be honest, my first thought was: Why on earth should it matter whether I believe in God or not? Belief in God has nothing whatsoever to do with whether I’m a competent surgeon or not. Personally, if I needed surgery I’d prefer a surgeon who is a flame-throwing “militant” atheist like PZ or Richard Dawkins, as long as he or she is highly competent and has a bedside manner that doesn’t bother me (and, of course, doesn’t push his or her beliefs on me), over an incompetent believer. In the same vein, it wouldn’t matter to me if the surgeon is a Bible thumper, again as long as he or she is highly competent, easy for me to get along with, and doesn’t push fundamentalist beliefs on me. To me, the question of belief in God is utterly irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way. Thinking back on this incident, I can’t help but remember an interview I had heard with Eddie Tabash, an atheist attorney who mentioned during the interview that he sometimes defended prostitutes. During the interview, he went on to mention that it was not infrequent for prostitutes to become very uneasy about having him as their attorney when they found out about his atheism. I had never encountered this phenomenon among my patients, however.

My second thought was: Why on earth would this woman still believe that there was a benevolent God looking down on her? She was a mess. She couldn’t walk more than a few feet without assistance; she could hardly breathe; and she was on enough medications to stock a Walgreens or CVS. Her health was so bad that even a minor surgical procedure such as a breast biopsy could put her life at risk.

Worse, the question brought into sharp focus a question that I myself have been wrestling with myself for the last three years or so, a question whose answer seems to be yes one day and no on others. There’s nothing like being trapped in a small examination room with a 450 lb. woman and three members of her family, with nowhere to run and no way to dodge the question. I was trapped. A believer might have said that the woman’s question was God’s way of making me face my fluctuation between belief and disbelief; an atheist might say that such an assertion is wishful thinking. Whichever was the truth, that didn’t prevent the formation of a little bead of sweat that was slowly enlarging on my brow. I suspect the question would have still been uncomfortable for me to answer even if I were as religious as I was when I was younger, as even then I tended to view religion as a private matter, one I didn’t usually talk about much.

What if I were to tell her that I was an agnostic or an atheist, that I didn’t believe in God? Would she have sought out another surgeon? For a fleeting moment, I was sorely tempted to say just that. It might have been an out, a way of not having to do the case and all the attendant risks of major complications from what is normally a minor operation. On the other hand, this woman had no insurance and had to rely on charity care, which meant that she probably didn’t have the option of going to a different surgeon, at least not at a different institution, and her going to one of my partners would have been perceived as dumping on them. If that were the case and I said I was an agnostic/atheist/whatever, she would then be going into surgery with no confidence in her surgeon, clearly an undesirable situation. A patient needs to have confidence in her surgeon, and anything that undermines that confidence, regardless of the reason or what I think of the reason, is to be avoided if it is possible to do so within reason.

So what did I finally say?

“I’m Catholic,” I said. A pause. “But, to be honest, I don’t go to Mass much anymore.”

This answer was true, of course, but incomplete. I was raised Catholic but long ago drifted away from the Church and, more recently, away from belief itself. It seemed to answer her question, but in reality didn’t. Not really. The truth is much more complicated, but she didn’t need to know that. Fortunately, because the woman was Catholic herself, my answer seemed to satisfy her. “God will guide your hand,” she said.

“I hope so,” I replied. Bullet dodged successfully.

I walked out of the examination room not looking forward to the day when this patient and I would meet again in the operating room–or to contemplating the way I had handled the situation. To this day, I still can’t make up my mind whether my choice was a complete cop out or a clever and diplomatic strategy not to undermine a patient’s confidence in me. It was probably a little of both. Whatever the case, in that situation on that day it worked.

Comments

  1. #1 kcauqasiiksrogdivad
    February 10, 2012

    “At least I managed to keep enough self-control to restrain myself from voicing such thoughts to my nurse or any of the clinic staff at all, not just where the patient couldn’t hear. Not all clinicians exercise such self-restraint, and, I’m embarrassed to say, there have been times in the past when I didn’t either. I like to think that experience and maturity have provided me with the self-restraint to reign in my sarcastic tendencies.”

    And yet, you do it here. Yes, David…very mature and very professional.

  2. #2 palindrom
    February 10, 2012

    kcauqasiiksrogdivad @9 –

    “And yet, you do it here. Yes, David…very mature and very professional. ”

    There is a huge difference between dealing in person with a sick, frightened person who is entrusting you with their care, and dealing with public figures on a blog.

    One would think this would be obvious, but I guess not.

  3. #3 MI Dawn
    February 10, 2012

    @kcauqasiiksrogdivad: and you don’t know if the details are really accurate either. Perhaps this Catholic woman was morbidly obese. Perhaps she was rail skinny and another patient of another physician was morbidly obese.

    Perhaps Orac, as a physician, was trying to make the point that morbidly obese people pose surgical challenges due to their weight. Maybe THIS patient did not have all the health problems he listed, but many of them do, and it does make caring for them very difficult for a health care provider. This is simply a fact. He did not put down the patient for her weight, her diet, her smoking; he simply pointed out that for him, as a surgeon, this patient was a much bigger challenge and presented a lot more chances of complications than someone with better health (if she’d been obese but not had COPD, or sleep apnea, or diabetes).

    Point out ANYWHERE in his post that Orac commented negatively that she was obese except in relation to the challenges her care would provide.

  4. #4 palindrom
    February 10, 2012

    My vote: You did good. The poor woman wasn’t there for a metaphysical discussion, and your completely honest (if incomplete) answer gave her some reassurance.

  5. #5 Anj
    February 10, 2012

    Whoa.

    I understand that for people of faith, that aspect of their lives is very important to them. They sometimes don’t realize that asking about other’s faith is not only a personal question, but an invasion of privacy as well.

    “I don’t discuss my faith with patients.” would be a logical answer even if it wasn’t the answer the patient was looking for.

    The answer you gave was “good enough”, appeased the patient and didn’t cause any problems.

    I’ve never been confronted with such a situation in a professional context. I wonder who has, and how they handled it.

  6. #6 GAZZA
    February 10, 2012

    I’m not so sure. If she wasn’t there for a metaphysical discussion, why bring it up?

    Frankly the woman was rude, and while Orac is to be commended for his tactful response, I don’t think I could honestly condemn him for honestly answering the question negatively. People shouldn’t ask questions when they may not like the answer.

  7. #7 capnahags
    February 10, 2012

    First, do no harm. If you had lied about your confidence in your ability to perform the surgery, that would be one thing. But a slight distortion of the truth, which if not made could have a negative impact on the patient, and which has zero negative consequences, is the right decision.

    As to your own ethics- perhaps you felt you’d sold out on your beliefs or principles in a way. I think not- you were putting your patient’s well-being ahead of your own interests. Hopefully at some point we’ll live in a world where patients will have the same confidence in a physician whether or not he/she believes in a god/gods. However, there is a time and place for everything, and this didn’t seem like a good situation to become involved in a discussion/argument/whatever about the utility of religion in surgery. Long story short, sounds like you made the right choice.

  8. #8 Lawrence
    February 10, 2012

    I think it shows a side of humanity that the alt-woo people typically deny to the medical profession (that doctors are people too, with different sets of beliefs and opinions – and attempt to do the best that they can for their patients.)

    I don’t know how I’d answer that question – I think Orac did the right thing, especially not knowing the intimate details of this woman’s belief.

  9. #9 Birger Johansson
    February 10, 2012

    ” I think Orac did the right thing, especially not knowing the intimate details of this woman’s belief”

    I agree. A small white lie to provide reassurance is not the same as intellectual dishonesty.
    — — — — — — — — — —
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  10. #10 LAB
    February 10, 2012

    I am also a nonbeliever who was raised Catholic, and I think you made the right decision. You didn’t answer her question–your religious beliefs are really none of her business–but you stated a fact regarding religion in your life. I consider myself “culturally Catholic”–there is so much about the Catholic identity that is impossible to shake, especially if, like me, you attended Catholic school for years.

    I grew up in the midwest but now live in the South. If someone here asks me about religion, it’s no help at all to play the Catholic card. To many evangelical Christians, Catholics are Bad Eggs who are going straight to hell. This sort of rampant nonsense is what helped turn me into a militant atheist. For years I just ignored religion, gave it no thought whatsoever. Didn’t believe it, didn’t bother with it. But when I moved to the South and was confronted with it every day (it’s almost a given that church or Bible study will come up the minute you meet someone), I started to take a close look at this stuff and consider what it all meant.

    One wacko former coworker (Started speaking in tongues when he was ten years old! Explained how demons are all around us! Informed me that Jonah REALLY DID live inside a fish–it’s not just a story! and on and on) had a sticker at his desk that said something along the lines of, “I pray and I vote!” That scared the life out of me. I’d never want that guy operating on me. Every decision he made was based on magic and fantasy.

  11. #11 JGC
    February 10, 2012

    Bexarotene? I thought all they needed to do was convince the mice to fast for 28 days…/sarcasm

  12. #12 Calli Arcale
    February 10, 2012

    There is another possible reason she asked — not to gain insight into you, but to guide her subsequent reassurance. You couldn’t know that at the time, of course, but because she answered “God will guide your hand,” I think she knew that her health was bad and that it would be difficult for a surgeon to work on her and that she’d face far more risks of complications than other women, so she wanted to let *you* know it would be all right. She wanted to reassure you of what she believed, that God would guide you and all would be well, but didn’t want to say that without first checking whether it would be something that would offend. In that case, if you’d said you were an atheist, she might have either said nothing, said “that’s alright”, or given you a secular reassurance that you’d do fine with her and that she trusted you.

    Even so, it’s an awkward question, and a very personal one that can be a minefield to answer. I think you did good. Your answer worked for all possible situations, did not invite further personal questions (thus maintaining an appropriate doctor-patient separation), and had the additional virtue of being entirely true. You did good. ;-)

  13. #13 Sastra
    February 10, 2012

    Under the circumstances, you seem to have made the right choice. Her response to your response indicates that she thought God would be more likely to be on the side of a believer and those surgeons would be more successful. Which of course indicates one of the major hurtles atheists face when it comes to gaining acceptance in our culture: a literal belief in magic allows ridiculous prejudices to not only run rampant, but remain uncorrectable.

    One possible way of getting out of “the question” in professional or awkward situations is to tactfully turn the question back onto the person who asked it. Most people enjoy talking about themselves and in stress situations it can be a release. When asked “do you believe in God?” one can respond “Ah — is God then important to you?” If done with just the right tone of interest and sympathy it might even sound like a positive response. Which, in a sense, it is. Her superstitious concerns were probably outweighed by her need to be listened to.

    The more serious problem in these situations is when the medical professional asks this question of the patient. I’ve been appalled at recent articles and anecdotes which push the idea that faith is such an important aspect of “healing” that physicians will be more effective if they themselves introduce spirituality into their routine (after first being “sensitive” enough to ask if the patient wants this, of course.) Religion is so emotionally loaded that getting The God Question is not just “uncomfortable” for atheists, it’s downright painful. Oh gawd — now what?

  14. #14 Andreas Johansson
    February 10, 2012

    Just out of curiosity, how did you know she was Catholic?

    I’m not a doctor had have nothing resembling training in bedside manners, but I imagine about the third thing that would have gone through my mind would have been, what is the “right” answer? Is she a believer hoping for reassurance that I’m too, or, contrarily, is she not and hoping her doctor isn’t either?

    (The first and second things going through my head would have been, who the hell are you to ask me that?!? and should I just tell the truth and her fault if it makes her unhappy?. Where I’m from asking someone you don’t know well if they believe in God is very much not the done thing.)

  15. #15 Andreas Johansson
    February 10, 2012

    Hm. Just got a post stuck in moderation. It has no links – what else triggers moderation? There were a couple html tags in it, is that it?

  16. #16 Denice Walter
    February 10, 2012

    Well, I now fortunately counsel mostly non-westerners so there isn’t the Christian emphasis- most people assume I am a Christian altho’ I’m not and come from a family with a number of atheists and agnostics over the past century or so. If I am asked directly about my beliefs (in other contexts) I usually come right out and say I’m an atheist or if the situation is more delicate, I express my awe of the majesties of the universe, biology, the human mind-I figure dazzle them with poetry so as to evade the question entirely. It usually works.

    It is difficult if you provide a service and don’t wish to alienate patients who need you. I think that Orac handled it well. LAB presents a different situation- what do you say when you are confronted by extreme proseltyising in daily life ? My own solution is that I’ve only lived in places where I don’t stick out like a sore thumb and recently have started to restrict my discretionary travels ( and spending) to more tolerant climes. I really feel for you, LAB, it can’t be easy.

  17. #17 Beamup
    February 10, 2012

    A particularly relevant part of the difference is that we don’t know or interact with the lady in question. That’s not true of Orac’s colleagues.

    Telling the story here preserves her anonymity. Talking to others in the same office would not.

  18. #18 Viking WarriorPrincess
    February 10, 2012

    If I’d been asked the same question I’d been bloody furious and would have told the person to mind their own business and that it had no bearing what so ever on the way I perform my job.
    But I’m not a medical doctor so I don’t have to have good bedside manners the way Orac does. And as Andreas pointed out (judging by his name we come from the same place), here ones religious views are considered very private and it is extremely rude to ask someone else what they believe in.

  19. #19 lilady
    February 10, 2012

    It certainly was a challenging moment for Orac and I suppose the correct thing to do…to put the patient at ease…no matter that the physician is put in an awkward position.

    “And yet, you do it here. Yes, David…very mature and very professional.”

    And yet, you feel compelled to post here…on a blog that annoys you…”

    -FTFY

  20. #20 Pot Troll Patrol
    February 10, 2012

    I think Birger is the pot troll. Leading to the pot plant offering for alzheimers..

  21. #21 Orac
    February 10, 2012

    As far as I can tell, Birger is not the cannabis troll.

  22. #22 Lou Jost
    February 10, 2012

    I live in a very Christian part of rural Ecuador. I run a conservation foundation there, where most of my employees are very religious. I value transparency and honesty, so I have spent a lot of time trying to get them to open up and be honest if they see some problem with the foundation’s projects. The culture here frowns on employees saying anything they think might upset their bosses, so in most companies the bosses would be the last to know if there was a problem.

    The only way to show workers that they can be open and transparent is to be that way myself. Early on, I was always asked about my religious beliefs. I had to tell them the exact truth, with no ambiguities, because that is how I want them to communicate with me. I told them I am an atheist because there is no real evidence that gods exist. They have accepted my answer, and perhaps they appreciated my directness, though I am glad they had time to get to know me before they asked.

    I think there is something condescending or disrespectful in assuming that somebody can’t handle the truth that there really is no god. I prefer to treat other people as I wish someone had treated me back when I was a clueless Catholic.

    I don’t want to criticize Orac’s choice. Medical situations are more delicate than most conversations. If I had been in Orac’s shoes, maybe I would have done as he did. But it would have been very hard for me. I probably would not make a good doctor.

  23. #23 madder
    February 10, 2012

    I once handled that question in a way very similar to Denice Walter’s: something to the effect of “you only need to look at the beauty of the universe and the intricacies of life.” That particular believer views these things as proofs of God’s existence, and probably still hasn’t realized that not everyone does.

    Was it a white lie? Sure it was. Do I take other opportunities to label myself an atheist? Sure I do. But not that time, because that particular confrontation wasn’t appropriate that day.

  24. #24 rork
    February 10, 2012

    I guess it’s OK, but it’s mighty close to giving a homeopathic pill (without making many claims for it, just saying “take these and see if you feel better”) and telling yourself it’s a beneficial white lie.
    Someone teach me to see where the line is, cause it’s hard to spot.

  25. #25 Melissa G
    February 10, 2012

    I think Orac handled it beautifully. Everything he said about how a doctor needs to handle a patient interaction, especially when that patient has limited choices, speaks of great understanding and compassion.

    I myself have been known to jump like a startled rabbit when asked of my religious beliefs, since I grew up in the rural South, was raised pagan, and am now an atheist. (There are times, in such a context, when an honest answer puts one in physical danger.) Jumping like a startled rabbit would not be a very confidence-inspiring thing for a surgeon to do.

  26. #26 lilady
    February 10, 2012

    The circumstances of the case presented years ago were detailed by Orac:

    “The patient list for the day had simply the words “abnormal mammogram” next to her name. That used to be the most common reason that of breast patients came to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal.”

    and…

    “These days, because at my current institution so many more practitioners order breast biopsies, most of the patients I see are already pre-diagnosed with breast cancer. Be that as it may, nothing on the list prepared me for the woman I greeted when I walked in the examination room.”

    Here Orac sees a patient with the sole diagnosis of “abnormal mammogram” and a patient who is morbidly obese with severe and multiply comorbidities:

    “She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians’ Desk Reference.”

    and…

    Orac is concentrating on the logistics of getting the patient on the examining table.

    “I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it.”

    As he is concentrating on how to best approach the problems of limited medical history, a non-definitive diagnosis and the heightened risk for this particular patient associated with a minimal risk biopsy, she questions him about his belief in God.

    Physicians are well-aware that issues of “faith” may be an important part of a patient’s life and I don’t think that it is “professional” to debate these issues with a patient.

  27. #27 ConspicuousCarl
    February 10, 2012

    LAB said:
    > a sticker at his desk that said something
    > along the lines of, “I pray and I vote!”

    So they have experienced the failure of both a 2-party system and a 3-party system?

  28. #28 rw23
    February 10, 2012

    @rork #24:

    I guess it’s OK, but it’s mighty close to giving a homeopathic pill (without making many claims for it, just saying “take these and see if you feel better”) and telling yourself it’s a beneficial white lie.
    Someone teach me to see where the line is, cause it’s hard to spot.

    Except that giving a homeopathic pill would have been the beginning and the end of the medical intervention.

  29. #29 Roadstergal
    February 10, 2012

    “God will guide your hand,” she said.

    Oy. That just strikes me as so condescending and dismissive. The doctor’s own skill and training and care don’t matter; if all goes well, goddidit.

    It just seems part and parcel of the woo-crowd, where you ‘integrate’ your ‘alternative’ medicine, and if you do well, it’s because of your mental healing vibes and the supplements and the homeopathic remedy, not all of the work that went into the science and the health care that provided the rationally-based treatments that you ‘intregrated’ the woo into.

  30. #30 Nicole
    February 10, 2012

    I’ve always felt, that when someone is dying (or on their way to dying), comfort comes first. My grandmother spent most of my childhood dying- she was a mess (diabetes, heart disease, severe obesity, strokes, kidney failure, blind, needing a foot amputated, etc). I was only 12 when she died, and at the time I was just becoming agnostic. So the conversation did not come up.

    I can promise you, though, if she were alive today and in the condition she was the last ten years of her life, I’d pretend to be a bible believing Christian if it made her happy. Because, ultimately, I don’t want to hurt people at the end of their lives. I’ll debate a healthy christian until I’m blue in the face. But honestly, if one of my family members was dying, and on their death bed asked me to accept Jesus, I’d fake it.

    As an atheist, I really see this life as the only life we have. Therefore I don’t believe in a heaven, or a hell, or anything pleasent or unpleasent after death. Therefore whatever comfort you can have at the end is extremely important to me.

  31. #31 starskeptic
    February 10, 2012

    Calli @10
    excellent point- I hadn’t thought of that…

  32. #32 Melissa G
    February 10, 2012

    @ #30, Nicole– Nicely articulated. That really made me think.

  33. #33 mikeb
    February 10, 2012

    Funny world we live in, where the ignorant can so easily put the thoughtful into a defensive mode.

  34. #34 jrkrideau
    February 10, 2012

    @ 7 LAB

    ” I consider myself “culturally Catholic”–there is so much about the Catholic identity that is impossible to shake, especially if, like me, you attended Catholic school for years.”

    Amazingly hard to shake isn’t it? :)

  35. #35 pm
    February 10, 2012

    As an atheist, ex-Catholic and a physician (though only a pathologist who sees occasional patients in a FNA clinic) I would say that you did the right thing. I’m sometimes jealous of Jews I know who are basically atheists. Since they are Jews it seems that no cares about their beliefs or asks them, “so what church are you sending your kids to?”

    Man, I don’t miss patient care. I still have bad Med school memories of doing rectal exams on morbidly obese people.

  36. #36 DLC
    February 10, 2012

    That’s one of those situations where most of the honest answers will cause friction. I’m usually not one for diplomacy, but here I think you made the right move. You gave a more-or-less truthful answer without making yourself look like a weasel and without kicking anybody’s sore spots.

  37. #37 Gary
    February 10, 2012

    There is nothing wrong with finessing the matter. My standard answer when confronted by a stranger with that question is: “What I believe is not your business,” but that doesn’t work in a professional context.

  38. #38 Anthropologist Underground
    February 10, 2012

    I was in the ER a few years ago with bleeding during a much-longed-for pregnancy. When the ultrasound showed no immediate threat to the pregnancy, the doctor said, “Praise God! God will let you keep this baby!” or something along those lines. Completely inappropriate, and completely undermined my faith in his medical opinion.

  39. #39 JakeS
    February 11, 2012

    This sort of situation illustrates how an institutional policy of referring all such discussions to the chaplainry not only protects users from proselytising employees, it also provides the employees an out. “Our institution has a policy against employees answering that sort of question. I have to refer you to [other office].”

    But then, the doctor-patient relationship is more serious than most, and for some reason people tend to be more concerned about authority figures taking a personal interest in them over a professional one. Which I suppose could be taken either as a sign of trust (“I believe that you’re a competent professional – I want you to care about me as a person on top of that“) or as a sign of the most supreme mistrust (“I don’t believe that you can maintain a professional relationship, so I need you to care about me“). I must confess to assuming the latter.

    I guess if I thought that what I regard as the professional response would not be accepted, I’d fall back on the observation that Jesus said not to display your faith ostentatiously for the benefit of men, but rather privately for the benefit of God. Which is perfectly good advice for believer and non-believer alike.

    But Orac’s “I haven’t been to church in a while/a long time” works too.

    – Jake

  40. #40 BillyJoe
    February 11, 2012

    To be honest, I’ve never been asked that question. I’m so nice they just assume I’m a believer. God’s honest truth.

  41. #41 Marcello Jun
    February 11, 2012

    I don’t think there’s a right way or a wrong way to deal with this sort of situation!

    I never tell my patients I’m an Atheist precisely in order to avoid hurting the patient-doctor trust issue.

    However, I also believe full honesty can only nurture trust. Whenever the subject comes up — and it usually comes in the form of a direct question from the patient — I am always forthcoming, though packaged with a reassuring posture that I will never be judgmental of others’ faith.

    In my anecdotal experience, this has never been a problem for them. I always show respect for their faith, and usually they respect my lack-of-faith!

    I have dumped patients who insist on voicing religiously-based prejudiced opinions or CAM enthusiasts, but that’s another story! ;-)

  42. #42 Daniel J. Andrews
    February 11, 2012

    How did the procedure go, Orac? Did she have cancer? Do you know if she lived much longer?

    I know that’s not the point of your anecdote, but my sister-in-law is moving into morbidly obese territory, just been diagnosed with diabetes, is suffering from mood swings, hypertension, fibromyalgia,j and is applying for disability due to the aforementioned problems plus some stress-disorder issues (and I think she’s just turned 40). So I felt some empathy for your patient and was curious to know what happened.

  43. #43 Melissa G
    February 11, 2012

    The one time I have been *not* disturbed by my physician voicing a religious opinion was this ex-Army-doctor who was the OBGYN at a university health center I went to for routine checkup. After our medical interaction, and I was dressed and all, he came in and talked about how he believed it was God’s will that young women be allowed to follow their dreams and that women can do anything and any job that men can do. It was weird, but… I dunno, coming from an Army guy, I found that really uplifting and encouraging. :)

    I would call that experience a definite statistical outlier rather than the rule, though.

  44. #44 Big Blue
    February 11, 2012

    Wow. I think you managed this situation quite nicely, actually. That said, I really wish more physicians would be up front about their religious/societal beliefs and how that affects their treatment choices.

    Yes, one would hope that everyone would follow standard of care guidelines and evidence based medicine. The sad fact is that there are all sorts of people out there who think all kinds of things, and follow their biases rather than the standard of care–whether it’s devoutly Catholic OB/GYNs who won’t prescribe birth control or doctors who simply aren’t good at managing care for gay patients (PMID: 16510743) or doctors who are afraid to prescribe adequate pain management under the new DEA regulations.

    The usual exhortation to interview doctors to find a good fit is simply infeasible for the vast majority of people, lots of whom don’t have access to any primary care doctors at all, much less the ability to pick and choose. I have pretty good insurance myself, and even I shudder at the time and cost of going through my PPO network to find a non-religious, abortion- and birth control-friendly, minimally-antibiotic-using, pain management-friendly, health care proxy-honoring, evidence-based primary care physician who won’t be too judgmental about my personal life. I somehow lucked out with my current doc, but I’ve had plenty of previous GPs who seemed awfully sure that tetracycline cured everything from plantar’s warts to PMS and that anyone who would occasionally choose a graceful exit over months in the ICU was an effin’ idiot/mentally ill.

    I don’t know that there are any mechanisms to address this issue though. There are a lot of disincentives even within the medical profession, too–“interview” too many doctors and you’re thought to be hypochondriac, drug-seeking, noncompliant, etc. If you live in an area where you’re the black sheep, as LAB mentions, it can be downright impossible to find a doctor you feel able to trust with full disclosure. Hence the proliferation, I think, of online reviews.

  45. #45 Scared and Confused
    February 11, 2012

    PMID: 22226313

    Homeopathic medicines substantially reduce the need for clotting factor concentrates in haemophilia patients: results of a blinded placebo controlled cross over trial.

    Melp!

  46. #46 Politicalguineapig
    February 13, 2012

    I think Orac made the right decision here. He had a very frightened patient, and she needed reassurance. That said, if any of my doctors, including my primary care physician (who I hate, but am scared to drop) voiced a religious opinion, that would be the end of the doctor patient relationship. I simply couldn’t trust them to care for me.

  47. #47 Lucie
    February 13, 2012

    Good for you, ORAC. You did the right thing. In the midst of your (understandable) dismay over this woman’s train wreck medical condition, you saw her question for what it was (at least so it seems to me): a request for reassurance. I’ve faced the same situation in clinical practice in a predominantly Mormon community. Albeit, being a Catholic doesn’t win me any “points,” but it usually closes down the line of query in a kind but firm manner. With colleagues–well that is different. It has been my experience that the only colleagues who ask me this question aren’t interested in my faiths, but rather are seeking an opportunity to preach. I start out nicely–talking about being a “little ‘c'” Catholic and talking about the meaning of catholic as a reflection of universality of faith. Yes, even atheists believe in something–i.e. the lack of a deity or power or God or goddess overseeing this whole show. If that doesn’t work to end the preaching I get progressively snarkier and try to walk away from the discussion. If pressed, I remind co-workers of my company’s policy against discussing such topics at work and offer to discuss it with a manager. That usually works!

  48. #48 hoary puccoon
    February 13, 2012

    Is anyone else struck by the irony of a woman who supposedly believes in a god so omnipresent that he micromanages minor operations– but who treats her own, supposedly god-given, body like an open cess pool, and then relies on medical science to keep herself alive?

    Personally, I’m quite sure the human body is simply one result of the blind laws of physics operating over a few billion years. But I still think it’s an amazing thing that deserves respect, care, and maintenance– reverence, if you will.

  49. #49 Anonymous
    February 13, 2012

    I was having a phone conversation with a friend while I was waiting for my breast biopsy results and he said to me, “I know you don’t believe in this stuff, but I’m praying for you.”.

    I said, “Well stop it!”.

    Ok, it actually doesn’t matter if he prays or not But, he’s a doctor for God’s sakes!!! WTH?! I was mad. Why couldn’t he say something useful?

    So basically — my friend is a very intelligent man who has studied science and he just happens to have an imaginary friend who may or may not grant wishes.

    [rant over]

  50. #50 Rokujo lady
    February 16, 2012

    Hoary, I find that your language in describing this lady’s treatment of her body as an open cesspool to be a bit disturbing. Do you think she would not change if she could? Do you think she likes being stared-at and compared to Jabba the Hutt? Does she enjoy feeling like a burden on her relatives? It takes a lot of willpower to loose weight and a lot of insight into your own psychology. If you don’t struggle with weight, good for you but don’t assume your strengths apply to everyone else.

  51. #51 Rokujo lady
    February 16, 2012

    Hoary, I find that your language in describing this lady’s treatment of her body as an open cesspool to be a bit disturbing. Do you think she would not change if she could? Do you think she likes being stared-at and compared to Jabba the Hutt? Does she enjoy feeling like a burden on her relatives? It takes a lot of willpower to lose weight and a lot of insight into your own psychology. If you don’t struggle with weight, good for you. Don’t assume your strengths apply to everyone else.

  52. #52 usethebrainsgodgiveyou
    February 19, 2012

    When there is no right answer, the truth works pretty well. Why overthink it?

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