POTILAS/LÄÄKÄRI -SUHTEEN ONGELMIA

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Lähettäjä: Soijuv Lähetetty: 22.11.2004 14:27

Seuraava artikkeli käsittelee potilas/lääkäri -suhteen ongelmia. Lopussa on muitakin vastaavia sivuja. Artikkelissa mainitut ongelmat sopivat yhtä hyvin Suomeen kuin todennäköisesti useimpiin maihin. Artikkelissa nainen etsii uutta sisätautilääkäriä 4 vuoden jälkeen, koska lääkäri ei välitä/ymmärrä ongelmia joita krooninen sairaus aiheuttaa hänelle, yhteistyön merkitystä jne. jne. Hippokrateen mukaan potilaan parantaminen on lääkäreiden/terveydenhuoltohenkilöstön ensisijainen tehtävä - mikään asia ei saa tulla sen edelle. Potilaan paras on etusijalla.


In Search of a Physician with Unobstructed Vision by Elizabeth Parrott, November 20, 2004

I'm looking for a new primary care physician. Why? My internist has forgotten who I am. He has forgotten the suffering that accompanies one of my chronic health problems. He has forgotten the importance of my relationship with the specialist treating that health problem. And he has forgotten how important it is for him to work on a team with that specialist.

So what? He?s still a fine technician. If he knows how to cure a sinus infection, why should it matter whether or not he knows who I am? Almost eighty years ago, Francis Peabody, M.D. wrote the following in an address to medical students at Harvard:

Now, the essence of the practice of medicine is that it is an intensely personal matter, and one of the chief differences between private practice and hospital practice is that the latter always tends to become impersonal. At first sight this may not appear to be a very vital point, but it is, as a matter of fact, the crux of the whole situation. The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for, in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients. [1]

If the physician ceases to see me, we cease to have a relationship, and, as Peabody points out, without a relationship there is no care of the patient.

What has happened to my internist, a physician who once excelled at patient care? Something, I suspect, has obscured his vision. Something has come between us. Some third entity has entered the relationship.

Hippocrates made it clear in his oath that nothing may interfere with the healing of the patient. ?Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.? [2] The benefit of the patient must be of primary importance. And the patient cannot benefit without patient care, and that, in turn, cannot happen without a strong patient physician relationship.

What has entered into the relationship between my internist and me? Is it a nurse who adds value as she delivers phone messages back and forth? Is it his new second career? Is it the size of his practice?

And what are the consequences of losing the patient physician relationship? The physician has four years of knowledge about me. I lose that. I lose the trust I had in that physician. I lose what has been a significant relationship, as any good patient physician relationship is. I have to find another internist, and once found, I have to establish a new patient physician relationship with that new internist.

My husband has been treated by the same internist. He is also now looking for a new internist. The physician exhibited what we hoped was a temporary visual disturbance a year ago in treating my husband. My husband, who has multiple chronic illnesses, was hospitalized with the flu over a weekend. Our internist was not on call. He saw my husband first early on Monday morning. Without listening to my husband, he said all objective indicators showed no reason for my husband to remain in the hospital. When I talked with the internist on the phone, he said he could not justify continued hospitalization to the hospital utilization review board, and so insurance wouldn't pay. He was really only trying to save us money, he said. My husband, however, felt very strongly that he needed to stay in hospital another night. I asked the internist to call my husband's hospital room and talk with him. I hoped he would hear my husband's concern and either keep him in the hospital or help him develop a plan for returning home. The physician refused to contact my husband. He wasn't seeing my husband, and he didn't want to see my husband.

Again the question arises, what was interfering in the relationship? Was it the hospital utilization review board? Was it the physician's patient load?

And what were the consequences? At the time we didn't know how severe the consequences would be. The doctor could not have known either. We know, in hindsight, that the chief consequence was a loss of trust that the physician could maintain unobstructed vision.

I saw a physician once who did not look at me. Instead, he spent most of the half-hour I was in his exam room asking me, sitting to the right of him, questions and typing the answers on a keyboard to the left of him. I could not imagine developing a patient physician relationship with that physician.

Sometimes the consequences of the lack of a strong patient physician relationship are deadly. On The Health Care Problems Archive web site [3], statement 10005 is from a man whose ex-wife has just died while being treated for lymphoma. He describes her last days in the become phone off hospital, where the physicians treating her were not her primary physicians and seemed interested only in obtaining a Do Not Resuscitate order from her. At one point the writer approached one of the physicians with an idea his friend mentioned:

Wednesday--Oncologist No. 2 (again, not primary--I never did see the primary) appears with same request [the DNR]. I mention that a friend, a biochemist who works on chemo, suggested I ought to inquire about a surgical possibility -- could we step over to the visiting room and talk?

Reply: "No. I have over a hundred patients, and I don't have an hour or two to spend on this case. This is private enough." I explain idea (surgery not to cure, but to restore condition enough to try last round of chemo). Without explanation, he says it won't work, and leaves. [4]

This physician apparently had so many patients that he was left with no time to establish a relationship with the writer's ex-wife, and so no hope of seeing her. This obstruction of his vision may have cost her her life.

Many things can be inserted between the patient and the physician, potentially interfering with the relationship. The writer of statement 10003 notes how an insurance company can interfere:

When I asked my doctor about this she was not happy but told me she had to go along with the change from what she had prescribed - that health insurance companies had the power to change doctor's prescriptions! I did the regular channels laid out by my insurance to request they uphold my physician's orders of the weekly meds and was rebuffed by their statement that that was their policy, take it or leave it, in so many words. I'm still amazed that they can get away with this! [5]

Another writer (statement 10017) describes the suffering when society's fear of narcotic pain relievers is interjected between patient and physician.

I have chronic rheumatoid arthritis. My doctor was turned in to the state medical board for writing too many prescriptions for pain medicine. I testified in front of the state medical board on behalf of my doctor. He was able to keep his license and his practice, but is unable to prescribe medication for pain relief, for three years. As a patient this is a tragedy. I don't think that these people understand what chronic pain really is?But I wouldn't wish this pain on anyone. I have felt so bad that I have thought of suicide before. I would never do that, but I have thought about it. Without pain medicine I just may have committed suicide. I would pray for death many nights. Sometimes the pain medicine I had was not good enough, so I would pray for death. [6]

The author of statement 10034 distinguishes between a relationship in which the physician does not see the patient and a relationship in which the physician sees the patient clearly:

Another thing, all he did concerning my episode of abdominal pain was order a bunch of expensive tests. Tests I will also have to pay the lion's share of. He did not question me about my symptoms or examine me. I guess in a 10 minute visit, all one can do is write orders. It seems to me that doctors are becoming less and less skilled. We are paying high prices for office visits without expertise. We pay to have them indiscriminately order a barrage of high priced tests. Needless to say, I left there that day not to return for a new prescription or to have high priced, unnecessary tests. Later, I saw a doctor from Mayo Clinic who correctly diagnosed my abdominal pain from severe constipation. He did this without any tests or procedures but by spending about 30 minutes interviewing me about the problem. [7]

The physician at the Mayo Clinic apparently knew what Francis Peabody, M.D. knew. ?The practice of medicine? Peabody wrote ?in its broadest sense includes the whole relationship of the physician with his patient.? [8]

How can medicine in the US continue when it is so easy for a physician?s view of the patient to become obscured? Is not the patient physician relationship the entire bedrock of medical care? Why don't we treat it as such? Why don't we remember that health care is not a commodity. Jerome Kassirer, M.D. wrote:

Many disagree vehemently with the proposition that health care is just another commodity. They argue that doctors have traditionally had a professional and moral responsibility to care for patients, the patients are vulnerable and dependent when they are ill and need to know that their physicians are not only at their side but on their side. [9]

Many of the examples from The Health Care Problems Archive reinforce what my husband and I have found with our internist: access to a physician is no guarantee of access to patient care. If the physician doesn't have an unobstructed relationship with the patient, there can be no patient care.



Notes

1. Francis W. Peabody, M.D., "The Care of the Patient." Journal of the American Medical Association 252, no. 6 (August 10, 1984): 813-820. Landmark Article, originally published 88 (March 19, 1927): 877-882.

2. Hippocrates, The Oath. Translated by Francis Thomas. Available at http://classics.mit.edu/Hippocrates/hippooath.html (last visited November 17, 2004).

3. The Health Care Problems Archive. http://www.healthcareproblems.org (last visited November 17, 2004).

4. The Health Care Problems Archive. Statement 10005. http://www.healthcareproblems.org/Patie ... t10005.htm (last visited November 17, 2004).

5. The Health Care Problems Archive. Statement 10003. http://www.healthcareproblems.org/Patie ... t10003.htm (last visited November 17, 2004).

6. The Health Care Problems Archive. Statement 10017. http://www.healthcareproblems.org/Patie ... t10017.htm (last visited November 17, 2004).

7. The Health Care Problems Archive. Statement 10034. http://www.healthcareproblems.org/Patie ... t10034.htm (last visited November 17, 2004).

8. Francis W. Peabody, M.D., "The Care of the Patient." Journal of the American Medical Association 252, no. 6 (August 10, 1984): 813-820. Landmark Article, originally published 88 (March 19, 1927): 877-882.

9. Jerome P. Kassirer, M.D., "Managed Care and the Morality of the Marketplace." The New England Journal of Medicine 333, no. 1 (July 6, 1995): 50-52.

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Lähettäjä: jukka61 Lähetetty: 22.11.2004 19:20

Voidaanko meillä (Suomessa) puhua edes potilas-lääkäri suhteesta (Borren osalta) "aikuisten oikeasti".

Jos joskus pääsee/on päässyt käymään infektiopolilla, yleensä sieltä potkaistaan ulos, kun on AB:t saanut, muiden lääkäreiden kiusaksi. Mitään jatkoseurantaa tai vast. ei ole, en tiedä, mutta yleensä he ilmeisesti kirjaavat hoidon saaneen potilaan parantuneeksi?

Sisätauti-/reumalääkäreiden ja neurologien tietämyksen kirjo taas Borren suhteen on melkoisen suuri ja yleensä melko suppea, valitettavasti. Aika normaalijuttu on se, että lääkärit vaihtuu, paperipino kasvaa ja mitään ei tapahdu. "Tapahtuminen" on yleensä kipulääkkeiden/vast. määrääminen, millä peitellään oireita ja siirretään Borre toisen erikoisalan lekurin kiusaksi.

Meillä on vielä se ongelma verrattuna vaikkapa Saksaan ja USA:aan, ettei Borreen löydy mitään "kilpailevaa" vaihtoehtoa edes yksityispuolelta. Itse asiassa olen eniten pettynyt yksityispuolen ammattitaitoon, palvelua ja empatiaa sieltä toki saa, muttei se korvaa ammattitaitoa.