The Unworried Unwell
Dr. Abigail Zuger on the everyday ethical issues doctors face.
She is an organized, punctual patient who makes appointments and keeps them. He drops in whenever he feels like it. Her visits are short and organized; his seem to drag on forever. The two have nothing in common — except that they both leave the office empty-handed.
Most people leave a medical encounter with something to show for it, whether tangible (prescriptions, referrals) or ephemeral (good advice). These two patients accept nothing, especially not the advice.
They both feel fine, although neither could be called well. For her, the problem is blood pressure, with readings so far into the “malignant” zone that we compulsively recheck her with different cuffs, trying to blame the equipment.
No such luck: Her results are permanently stroke-making, kidney-ruining, eyesight-threatening. She declines any form of medication. At first, we figured she was just politely taking her business elsewhere, but no, she keeps coming back. “Just want to see how I’m doing,” she says. She is always doing the same.
His problem is a rapidly accelerating H.I.V. infection. His blood tests are as alarming as her blood pressure, and as suggestive of imminent catastrophe, but he has no interest in any of the ways we propose to avert it. “Just want to see how I’m doing,” he says every few months as he saunters away, lab report tucked into his pocket.
There aren’t many medical situations where doctors’ imaginations trump those of their patients. In fact, when it comes to chronic illness, doctors are notoriously shortsighted, seldom perceiving the seismic effects pain and disability can exert on all aspects of a patient’s personality and family life. The medical problems may be clear, but their context often remains obscure.
For people who feel fine, though, the situation can be just the reverse: It is the patient with feet of stone firmly planted in the here and now, while medical personnel spin wild tales of coming catastrophe, full of verbs conjugated in the future probable.
Some people see our visions even more clearly than we do, accepting all offered preventives and asking for more. Most of the rest take our word for it and resignedly go along with the program. A few say thanks but no thanks, and saunter away.
And it is that last little group — including him with his virus and her with her blood pressure — who hold the key to the way future generations of doctors will be practicing medicine.
Medical care is all about prevention these days: locating and disarming invisible swords of Damocles before they drop. In the process, of course, we are creating whole lists of “pre-illnesses,” situations likely to lead to actual illness over time — or, in the case of “prehypertension” (blood pressure that is almost too high), situations likely to lead to situations likely to lead to illness. People who opt to have their DNA analyzed by a commercial lab see their future spelled out in the vaguest possible terms: the risks of various diseases compared to the average.
Soon, it seems, we will do little but talk to our pre-patients about all their various pre-diseases. And we still have exactly no idea how best to conduct those conversations.
There is the reasoned numerical approach (“30 percent of people with your problem of X will develop Y”). Many studies (and all casinos and lotteries) illustrate how abysmal is the average person’s understanding of risk when couched in mathematical terms.
There is the in-your-face approach, like the one taken by a series of antismoking advertisements featuring harsh close-ups of painfully moribund smokers. No one likes those. “Couldn’t get the TV off fast enough,” said one smoker I know.
There is the blunt “it’s your funeral” approach: doctors who indicate by word or deed that they have no time for you till you are ready to knuckle under and behave the way a pre-patient should.
And there is the fallback “beat your head against the wall” approach, with the same dire predictions enunciated over and over again, a millstone ground by a plodding ox. This particular routine enervates doctor and patient alike: The future probable is a pretty dull tense, summoning none of the adrenaline that attends acute fix-it-up care.
Sometimes we forget, though, that medicine is fundamentally all about the thankless art of prognosis, a practice only a few little data-filled footnotes away from prophecy. In fact, our future of treating pre-illness will simply catapult us right back to a priestly past, as we offer up misty visions of the future and encourage the masses to see with us and act accordingly.
We have said many things over the centuries to those who, for whatever reason, cannot see what we see. Of them, I suspect that by far the best, most effective and most important has always been “See you next time.”