The Line

There has been much written about the doctor-patient relationship, and specifically how to best maintain a clinical distance while at the same time being empathic and compassionate. This is something individual doctors work on throughout their careers, but something else interests me here.

Most physicians derive enjoyment from helping people. Altruism (a topic way too complex for me to pretend to understand in depth) feels good both from the act itself and from the response one gets from the object of the altruism. This last bit has comes with potential pitfalls.

My job is to help people. If they express appreciation for this, well, that's a nice perq, but I cannot and should not rely on this. When we count on our patients to validate our good feelings about ourselves, we are engaging in psychologically complicated behavior that is not entirely consistent with some basic principles of medical ethics.

As with all ethical problems, an example is much better than an abstract discussion.

Let's say that, as part of my board recertification process, I am asked to gather data from patients and colleagues on my performance as a physician. I may feel awkward asking my patients to "grade" me, but should I anyway?

That all depends on how I ask. If I tell them truthfully that their feedback is confidential and the data, if returned to me at all, is sufficiently vague as to make responses difficult to trace, and if I ask them to be honest and direct with their grading, then it seems fairly neutral ethically, in that there is little downside for the patient. Additionally, helping the board certification helps the patient directly and indirectly by winnowing out docs who don't make the cut, including their own.

If, however, I ask my patients either implicitly or explicitly to support me, I have put my own needs above theirs. The act of evaluating or supporting me should be entirely voluntary and should not involve coercion. Cui bono? If the purpose of my asking is to benefit myself first, then there is no reason to ask my patients to do this. There is no advancement of the ethical goal of beneficence, and the patient may in fact feel coerced.

If a patient wants to say nice things about me, that's great, but there are some very messy ethical issues involved here and some very narrow lines to toe.


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Physicians need to care for their patients, but they also need to keep their own needs in mind. There is a line one crosses from altruism to martyrdom.
I have had patients (OK, their parents) criticize me because I was out of town and did not personally call them about something. The idea that I would not make patient calls when away from the office baffled them; if they get surveyed during my MOC, I'm screwed, even though I think they are completely unreasonable.
It's kind of like having students evaluate instructors. You want to know how the teacher does, but you need to weed out unreasonable bullshit responses (an African American instructor was once criticized for wearing brown).
Of course, my biggest complaint about MOC is that I am in the first cohort required to do it. Something magically changed and those before me are certified FOR.EV.ER. while I am only competent for a decade at a time. I understand the legal reasons they won't make time-limited certification retroactive, but it still sucks on this side of the divide.

Something magically changed and those before me are certified FOR.EV.ER. while I am only competent for a decade at a time.

What changed is that people noticed that they're...not. Competent forever that is to say. I just finished all my recert requirements except for the @#^%@* PIM that Pal seems to be dealing with now and I actually am glad that I had to do it. As a specialist, it is all too easy for me to ignore advances in general medicine and being forced to pay attention has its advantages. Like continuing to really be competent. (Whether it's as helpful for generalists I don't know.)

Just one thought: A survey of your own patient base would seem to suffer from selection bias. These are people who have already selected you as their primary care physician, possibly after having tried and rejected several others. Now, I am not a doctor, nor do I know if this is accounted for by statistical correction or not.

Besides, who wouldn't like having a doctor who has such a friendly pseudonym?

The specific PIM/MOC process I used as an example was perhaps unfortunate, since I didn't base it on a real one (forgetting that doctors read this shit...).

I'm fortunate in that one of my choices for a PIM is to evaluate my residents, which I will probably do rather than some of the others.

I was hoping to make a broader point about asking our patients to do us favors and speak out on our behalf...

"...but you need to weed out unreasonable bullshit responses"

The marvel of statistics! Recert boards are looking at aggregate data, not seeking a perfect score. I don't claim to know their scoring system, but it's fairly likely that extreme outliers are discarded entirely (below a certain threshold). Either way, as long as you have a reasonably large body of more-or-less representative patients, it's safe to assume that your irrationally aggravated responders will roughly conform to the baseline for your field and general practice circumstances. It's only a problem if you have *more* unreasonable bullshit responses than this baseline. Further, a total absence of unreasonable bullshit responses would be a big red flag that something was fishy, or at least a probabilistic anomaly.

Statistics don't lie. They just don't say what most folk think they do. Any statistical analysis is like an individual adjective: wonderful for describing, but absolutely incapable of defining or explaining.

One problem is that I don't know what sort of sample they are using for the patient feedback portion of my MOC since my specialty hasn't defined that component yet. The educational and testing components are expensive and dreary and there really isn't any evidence that they improve competency. I have recertified once already, and it was a pain but obviously not impossible. This process could be a major problem for docs in practice who do not have the time for CME etc that I do in academics.
I was also required to recertify once in general pediatrics; however, I will no longer do this because I do not practice general peds and do not have a patient base for any of the practice-based MOC.
My major gripe is that most of this process has been designed by docs who do not have to do it. I feel it would be quite reasonable to say that as of some date in the future, everyone who wants to continue saying they are boarded in a specialty will have to enroll in MOC, regardless of the status of their original certification.
Finally, I spent much of yesterday editing an article on Frequentist vs. Bayesian statistics. If anyone needs further proof that statistics can say anything you want, we have it. Data will be tortured until it confesses...

Statistical analyses to rule out "unreasonable BS" as long as the sample sizes are sufficient and the expectations are reasonable. I am now working for a company which evaluates me based on student surveys. I have has issues on occasion because the only passing score is "excellent" (very good doesn't cut it) and no student ever may not like you for any reason and because the sampling occurs so frequently that the sample sizes are ridiculously small.

Ex: You had a 100% excellent review! Keep up the great work! We expect you to maintain this level of excellence. (Sample size: 2 respondents.)

You had a 66% excellent review. As you know, we expect your reviews to remain at 70% excellent or better at all times. Please review the following materials and improve your score for next time. (Sample size: 3 respondents.)


Unreasonable Bullshit Response:
"Dr Pal sux roxxors at canoeing ! "
or would a worse one be
"Dr Pal is a Lizard hybrid from Gamma Cygnax 3, and I can prove it! "

My mother is a Lizard hybrid from Gamma Cygnax 3.

I demand an apology.

By Prometheus (not verified) on 21 Jan 2010 #permalink

My mother is a Lizard hybrid from Gamma Cygnax 3.

Cool. Can I get a tissue sample from you? Just a little one?

Originally I'd meant to write a comment apologizing for diverting the conversation, but it seems to have gone even further afield.

Back to the original subject: Asking patients for favors is probably a bad idea for much the same reason that asking students, employees, and interns for favors is a bad idea: they may not feel free to say no. But how to avoid it? For example, I work at a university hospital. As part of the second year physical diagnosis course, students interview and examine patients. But is this ethical? It is of no direct benefit to the patients and asking them to allow the students to examine them is really asking for a favor. But how else can they learn physical diagnosis? (My very imperfect solution so far has been to find patients that have complained of feeling bored in the hospital and ask them first on the grounds that maybe the interview and exam will end up amusing them and therefore give them some benefit.)

Everyone knows lizard hybrids from Gamma Cygnax 3 make the best doctors.