How much choice does a patient have?

How much choice does a patient have?

Friedman, Joseph H

When I was a neurology resident a patient once kicked me out of her room, or rather, her husband did. I wasn’t insulted. It was a small plus for me actually. As a first year resident one spent most time on the ward service, seeing patients without private attendings referred primarily from the emergency room and occasionally the clinics. The months on the private service were quite different. On the ward service we’d admit three to five patients every fourth day usually, and took charge of the cases, formulating the differential, ordering and interpreting tests and generally caring for the patients. An attending level neurologist supervised but generally kept a low profile. On the private service, we’d admit ten patients, write a history, document a detailed neurological exam and conclude, “tests per Dr. X.” On non-admitting days, if interested, we’d stop by to see what was happening. But generally, if one wasn’t admitting, one didn’t have any in-patient work. The teaching advantage of the private service was extraordinary. Patients came from far and wide to see the famous experts. In those days patients would be admitted sight unseen. In this particular case, the patient came form Ohio to see the famous Dr. X., a true world expert. Rather then seeing him in the office she was admitted directly so that it would be easy to obtain any tests and also so that the fellows could see the patient on rounds. When I went to see the patient her husband informed me that his wife had seen a slew of neurologists in the Midwest, was here to see Dr. X., not me, and I should take a hike. I explained my need to examine all patients because I was responsible when I was the only doctor in the hospital overnight, but the man was adamant. I happily wrote up my admission note with a detailed history and, in large letters, “patient refused exam.” This saved a half-hour or more. As I was leaving to go to another floor I met Dr. X. and told him what happened, expecting him to shake his head and move on. He didn’t. “She can’t do that.” He marched me in to the room and told the patient and his spouse that I could examine her or she could leave. Although not pleased, I was impressed.

Recently a colleague was similarly thrown out of a patient’s room and it brought to mind the very complex issues surrounding medical care in hospitals, particularly teaching hospitals. In this case a patient, who was a university professor, asked a young Asian-born woman not to return. Dr. Asian woman was brought in as a consultant. She was an assistant professor and attending for one particular consulting service. Private doctors may also have been available but hers was the teaching service at the university hospital. The patient told her boss that he didn’t want a doctor who had trained at a foreign medical school. Her fellowship training at the Harvard hospital they were in didn’t seem to overcome his jingoist inclination and her status as a Harvard assistant professor didn’t either. Perhaps he didn’t feel comfortable with women. What was the “proper” response? What would the response have been if the doctor was black and the patient racist? Most likely the patient’s request would have been ignored. What if the patient was female, the doctor male and the problem gynecologic? Where do we draw a line between reasonable and unreasonable requests?

Should the service director have said, “Dr Asian woman has our complete confidence or we wouldn’t have hired her. If you don’t feel comfortable with her despite her unimpeachable conduct then she will be taken off your case and your primary doctor can find another consultant?” I think so. Medical treatment is a service that has several constraints. Patients cannot always exercise free choice. There is a TV commercial in which a plumber enters a house to find it submerged while water is gushing out of a pipe. The young owner instead of looking relieved that his disaster is about to be taken care of, instead asks for an estimate to make sure he’s getting a good price. An emergency is an emergency and generally if you’re in an American hospital in the 21^sup st^ century it’s an emergency and there’s usually not time to comparison shop. When the emergency resolves you can take time to find the best and most compatible doctor. In the case of a hospitalized patient, the rejection of a service without justifiable cause puts the onus on the patient or the patient’s primary doctor to provide alternate care. If the patients said, “I never heard of you but your boss is famous, I want her,” the request would have died immediately (unless the patient was a donor or a VIP).

Discrimination by doctors is unacceptable and punishable. Discrimination by patients, while not punishable, is no more tolerable and should not be supported.

Copyright Rhode Island Medical Society May 2003

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