Disagreements About Treatment

This covers a wide range of scenarios. Let’s begin with the mundane and work up …

I need an antibiotic

There are very few doctors who at some point in their career won’t have been faced with a patient with mild viral symptoms and a fever who says, ‘I need an antibiotic’. Many will accept symptomatic advice and be reassured by explanation that their sore throat and muscular aches will settle with time, along with safety-netting guidance - ‘come back / do X if things don’t settle’.

But some won’t, as they see it, be fobbed off in this way. Their history often changes: symptoms become more severe and new ones appear. They’re clearly very unhappy about the care being offered, which is never a good way to end a consultation.

Doctors have been inundated with messaging about antibiotic stewardship, notably to protect patients from Clostridioides difficile (C diff) infections and other drug-related side effects, also reduce the chances of bugs developing antibiotic resistance. But those offering such worthy advice aren’t the ones about whom complaints are made.

As a doctor, and in life in general, it’s sensible to pick your fights. Is this one to be picked? Show me a doctor who hasn’t prescribed antibiotics they didn’t think were necessary, perhaps with a suggestion that the prescription should only be collected from the pharmacy in a day or so if things don’t settle, and I’ll show you a doctor who’s done little medicine and/or been economical with the truth.

I need an X-ray

On a similar theme, ‘I’ve hurt my ankle … I need an X-ray’. Ambulances are queuing outside; all the chairs in the Emergency Department are occupied; there’s standing room only. It’s hot and tempers are fraying. The patient is an obese man whose Millwall football shirt strains unsuccessfully to cover his belly. After a few pints he turned his ankle when kicking a football around in a pub car park. He is unfamiliar with the Ottawa ankle rules that give evidence-based advice on who to X-ray, but it seems vanishingly unlikely he’s going to gracefully accept he doesn’t need one in front of so many witnesses.

My advice to the doctor? Do an X-ray, give him a couple of paracetamols and a tubigrip bandage (may help a bit and shows you care), and get him out of the building as soon as possible (with safety-netting advice of course).

Picking your fights

The purist would look down his or her long and pointed nose at these doctors. Both have exposed patients to danger, one from possible side effects of antibiotics and the other from ionizing radiation, when the evidence says they shouldn’t have done so. Both have wasted money that could have been put to better health care use. Were they not aware that the hospital’s Chief Finance Officer has been tasked with finding funds for another firm of management consultants to assist the organization’s drive to improve medical productivity?

The pragmatist will argue that what the doctors did was the best they could do in the circumstances. The risks of harm were low, the patients were satisfied, and the prospects of subsequent complaints were much reduced. They may even secretly entertain the thought that anything that impaired the chances of more management consultants arriving in the hospital was money well spent.

When it does matter

A common situation that can be very difficult to manage is the patient who is inevitably doomed. Their ‘illness trajectory’, to use the typical argot of professional discussions on the matter, is – using a vernacular phrase - heading into the turf. The destination is not reasonably in doubt but there are choices to be made about the route.

When planning a route from A to B using Google maps my phone allows me to specify options: ‘avoid tolls’, ‘avoid motorways’, ‘avoid ferries’ and ‘prefer fuel-efficient routes’. In the case of our patient, A is where they now are and B is when they are dead.

In years gone by, when people often lived in extended families, many were familiar with the fact that lives do not go on for ever. In the same way that they saw changes in the world as the seasons passed from summer into autumn and then into winter, they saw day-by-day the decay of their parents as they got older and frailer and they understood and accepted the order of things and their inevitable end.

We now live in a time where few have this day-by-day experience and we’re all generally much less likely to accept bad news. Show me a doctor who hasn’t had many conversations with many terribly distressed relatives who believe that the route from A could lead somewhere different if care options included ‘going to ICU’ and ‘having cardiopulmonary resuscitation’, and I’ll show you a doctor who’s done little medicine and/or been economical with the truth.

Doctors cannot be required to give treatment contrary to their clinical judgement. If pressed to do by patients or families they can as a last resort appeal to the courts, but no sensible doctor wants to go down this track unless circumstances are truly extreme. Our poor patient isn’t likely to last long whatever is done. If you want death to take longer and be more unpleasant than it need be, you can have this.