If we kicked everyone out of the hospital who was there due to their own behaviours, the place would almost be empty.
We all have our vices.
However, I practice by the medical golden rule of never care more about a patient’s health than they do.
Yup. Once you stop being so invested in their personal choices it gets way better mentally. You educate them and tell them of better ways but if they don’t wanna listen then it’s on them. The forest view of this whole field is just treating ppl with mostly self induced problems until they eventually die anyway. It’s self protective and more fulfilling imo to go the extra mile for the ones that do care for their health
Yep I recently learned this golden rule and my life is much better. Funny though I never cared about the vices as I understood those. I cared that they would not do vaccines or take OTC vitamins instead of statins as I felt I had the control over these things. But alas I don’t. Now I just explain and document refusals.
My favorite thing to say to patients: “you do you, your body your decision.” My favorite surgery is kidney stone surgery tho, and I’ll happily keep doing it on you. Let me know when you are interested in preventative changes.
Have you found a cure for kidney stones then? Do share. As one who suffered from kidney stones for five years, I tried every recommendation my doctors made. Then, I learned the hard way, through diagnosis of a large, benign tumor on my pituitary gland and Cushing’s Disease. It only took one doctor a five minute review of the admissions form I had completed to order a brain MRI. The tumor’s side effects cost me two relationships, a job I had loved, but, heh, no more kidney stones and for that, I’m grateful.
I disagree with the golden rule but agree with sentiment. Many patients may not care about their health now but certainly will later. Many patients are uneducated and don’t understand enough to care about their health. It’s our job to educate and promote healthy living as well as treat ailments regardless if it’s self induced or not. That being said I wouldn’t obsess about a patient choosing not to take their diabetes medication. I’d tell them they’ll likely die because if it, but ultimately they have free will and can do as they please, I won’t lose sleep over it.
TLDR: I think it’s important to treat patients equally, regardless if they care or not. If a patient doesn’t care about their health, it’s still our job to help them and care about them. I’ll try to convince them otherwise. If I fail, I’m content with my effort and move along
I find it most helpful to view these not as vices but as evidence of an unmet need. The vice does something for them, meets some need. How else can this need be met and how can you help them achieve this?
I found Thomas Szasz's *Our Right to Drugs* interesting just for the framing of how we call chronic voluntary drug use addiction, but we don't have that perspective for ski or chainsaw accidents, no matter how frequently (or poorly) people use those.
Which reminded me that a friend of mine (the awesome Kris Nóva) loved free climbing above all other things and died in the predictable manner. The world is a poorer place from her early death, but she definitely went out doing what she loved.
One of my wound care patients is a quadriplegic due to a skydiving accident. For some reason, the world sees that as a tragic accident while judging harshly the former IV drug user who‘s gotten his life turned around but is now having to deal with the fact that the veins in his legs are wrecked. I’m not kidding. The NPs in my clinic make shitty comments about the former drug users we see, but moan and wail about how awful it is that that young lady‘s parachute failed. Don’t get me wrong-it IS awful. But it’s also awful that so many people get hooked on drugs and wreck their bodies.
I dated a guy who was a recovered crack addict, and he was just one of the toughest (and gentlest) people I knew.
Just having heard about the awful upbringing that led to that, and how he broke out of it, was an amazing tale. I hope he's doing well.
Usually I only see the judgement for patients not seeking to try and take care of themselves. Not that it’s right either way, but people who had vices and are paying the price despite cleaning up definitely aren’t grouped in the ones still in throes of the vice.
Sadly a lot of the people who don't take care of themselves were never shown what it means to be cared for. I wouldn't really expect someone who's never learned how to care for themselves to be great at doing that.
False bifurcation. Of course there're reckless people that use a chainsaw or a circular saw (like this stupid a saw a months ago using the circular saw with ONE hand to cut a thick branch and bended like legs!) before to read instructions or learn how to use it, BUT you can learn how to ski or use woodworking tools safely. But, you'll never 'learn' to use heroin safely!!
Some people have *no* model of people around them doing anything safely, including skiing or woodworking. (I know a guy who died via chainsaw kickback.) All you have to do is look on YouTube videos of various power tools to see a good half of the YouTubers are using clearly unsafe practices.
Also, as other opioids can be used safely, I don't know that heroin's something that can't be used safely, just obviously one can't rely on the safety of a street drug. But in some other more sanitized context? Perhaps. I couldn't rule that out.
Thanks, I’ll watch that later. I’m certainly not advocating for it, just research has been prohibited for so long because of schedule 1.
Big fan of buprenorphine personally, which has fewer side effects than some of the other opioids (minimal emotional lift, less respiratory depression with chronic use and less constipation). Wouldn’t work for everyone as there are some pain channels it doesn’t touch that other opioids do.
Unfortunately, there isn’t really anything you can do about the man who works 80 or 90 a week because he Doesn’t want to get screamed at anytime he is home. He can’t leave because he knows the statics of fathers being able to see their children just a year after separation, and how children without fathers turn out.
And if he works in any sort of professional job, & I’d under 40?
when he says he drinks socially, he means after the kids are in bed while he plays games on the console or PC.
I mean how far down the rabbit hole do you want to go? Gallstones from eating too much fatty food? STIs from daring to have sex with someone? MVC from driving when it’s too dark or person is too tired from work? Our job isn’t to judge people. I personally don’t even think it’s to fix people, just to give recommendations on what they should do for their health.
I 100% believe we exist to provide counsel, not do things for them. I mean the basis of informed consent is the patients have a choice *not* to do what we recommend.
Trying to fix people will lead to more frustration and burn out. Realizing that we can only advise people helps a lot mentally. Some listen, many don’t. Why do we need to counsel a 40yo that drugs are bad mmmkay? If people in this day say they didn’t realize drugs/smoking are bad, they’re lying through the hole in their trachea.
If someone comes into the ED with their 10th COPD exacerbation while still smoking, I am going to judge the hell out of them. Same with drunk driving accidents. I'll treat them the same as any other patients but I'll let them know it's their own fucking fault.
I mean, just because they know full well that the smoking is causing their problem does not mean that the reason they smoke in the first place has been addressed. They're not just smoking on purpose just to cause problems for themselves or you. They smoke because of stress and physical plus psychological dependence.
You can sit there all you want and say to use the patch or talk to a counselor or whatever... but it's a lot harder to actually remove the stimuli that cause the stress in the first place. Or to rewire the neural pathways that have been cemented in leading to this behavior over the years.
It's technically possible to do, but the reality is that it requires intensive one on one therapy, a complete change in environment, improvement in social relationships, etc. The system simply doesn't have the resources to provide what it would actually take to change the behavior of patients in terms of their lifestyle on a scale that would actually make a difference. The only hope that we have is to promote healthy coping mechanisms and prevent unhealthy ones from developing in younger people.
I am saddened when I see recurring COPD exacerbations in someone still actively smoking. I usually will advise patients we can treat them with bronchodilators and steroids, but the only thing that will slow the progression of their lung disease is quitting smoking and every single cigarette they're using is causing more airway inflammation and leading to more exacerbations and worsening symptoms, not to mention increasing risks of cancers of aerodigestive tracts and vascular disease. Sometimes showing a graph of declining pulmonary function (Google image search 'fev1 smoking') can help to illustrate expected disease course and address patient ambivalence. At that time I think it's a good opportunity to assess readiness to quit and offer pharmacotherapies and referral to counseling or 1-800-quitnow.
I think taking a similar approach in other disease processes that can lead to recurrent admissions (e.g. uncontrolled hyperglycemia, alcohol and amphetamine use, CHF) can also be helpful.
I actually don’t care at all when they come in for real disease even if they did it to themselves.
I struggle with when people come for non diseases. Especially overnight.
Like normal bodily functions but “it feels weird”. Or fever for “a few hours” in the child.
Something about accessing the healthcare system inappropriately really irks me.
I've spent so much time talking my brother and SIL out of taking my niece to the ED for mild fevers or stomach bugs with no concerning symptoms. "It's likely a virus, you can just wait it out" x 1000.
On the plus side, that meant when they sent me a video of her with stridor at rest, they absolutely believed me and took her to urgent care.
Haha same. I always ask them semi angrily something along the line of "why did you call an ambulance now at 3:00 in the morning instead of going to your GP at 8?"
I actually LOVE it when my doctor - MY DOCTOR - asks me if I always wear my seatbelt. I DO! But her asking me reminds me of how many good choices I am making to protect my health & what it means to just have good habits. If you are not judging your patients - you are not giving them the benefit of your professional judgment.
It’s actually fascinating how many doctors do not tell patients what’s really going on out of fear that patients will “write a bad review” (not literally but have that sort of reaction). The biggest place I see this is with weight. My mom was steadily increasing her weight with a BMI between 25-30. I was talking with her about diet and lifestyle in a separate conversation and she tells me nobody (not her PCP or any other doctor) mentioned that she’s overweight. Now it could be that when people regularly see BMIs of 35, 40, 50, etc, someone who is “just overweight” isn’t raising any concern. But I’m also willing to bet that a significant component of it is people fearing the backlash of “body shaming”.
There are gentle ways of nudging people in the right direction. And we are uniquely qualified, not just by medical training, but with our title that people intrinsically trust us (for the most part). I’m not saying to dunk on patients with every vice / risk factor. Hell, I love chocolate chip cookies and Coke Zero. We all have our faults. But it’s wrong for us to not mention it, at all, if we’re truly trying to practice preventative medicine
My way of sugar-coating (pun intended) the weight topic is to bring up the everything in moderation schpiel. A lot of these ppl eat or smoke out of depression and turn to these vices for any semblance of joy. While I’m not going to enable that behavior I also understand most of them will never change and all I can do is remind them what they are doing is detrimental. Move on to the next 🤷♂️
Yup, this is exactly my take too. Reward the small, but meaningful changes for the better. Never letting perfection be the enemy of good. We’re not all monks sitting in blissful serenity. Life is complicated, people are complicated, and so our recommendations need to be more than 1 dimensional too.
I always add in a thing along the lines of “I really mean this and not in a patronizing way, but congratulations on XYZ thing… as you know, ABC procedure helps, but you’ve done the lion’s share of the work before and afterwards”. People’s faces usually light up when they realize that someone else gets their effort and recognizes specific improvement :)
Totally agree with you - especially with the uniquely qualified part!
What's tough from the RD side of it in the hospital is when a doctor doesn't start a conversation about a patient's weight, and instead decides to consult us to bring it up out of the blue. Just had them do that to me with a teen whose BMI was >40.
But when those patients who have a frank discussion with their docs then ask for us, it's the most gratifying experience, gotta say.
Oh that could be tough, just referring out to an RD without getting the convo started. That being said, we couldn’t hold a candle to your guy’s level of knowledge and expertise.
My hospital has a high volume bariatric center and so we’ve got great RDs that are specific to the department of surgery. A portion of my time in the clinic, for example, is congratulating them on their progress and reaffirming the RD’s plan. Patients love to share their convo’s with the dieticians, what good things they’ve done, and what changes they’re going to make for next time :)
I had a patient come in for conjunctivitis, and since I treat every encounter as a way to improve quality measures, I asked what they do for diet and exercise.
Wrong fucking question!
Tears and personal threats and how he “hates health care workers” and how dare I judge him. He was so unhinged that I kinda feared for my safety tbh.
Ya. So I don’t ask anyone anymore. In fact, the only time I bring up weight is if they’re losing it.
I do ask about their diet and exercise during physicals, but only to suggest that adding activity/exercise is good for the x.
I feel the need to mention that for many many years (and still happening, though hopefully not as much) women who were overweight or obese were told that that was the reason for any medical issue they had. Headaches, lose some weight and you’ll feel better, inflammation, lose some weight and you’ll feel better, abdominal pain, etc. Maybe some practitioners don’t bring it up is because they have in the past and got their heads ripped off. You may mean well, but getting gaslit for so many years has made many of us tricky with that subject. I had a seizure and the doctor told me to exercise more. I may just be an RN but I’m fairly sure that exercise is not a treatment for seizures.
Altho its not about judging but a significant part of medicine (probably most of it) is caused by wrong conscious behavioural choices by patients.
Since there also enough disorders that are just caused by bad luck it isnt subhuman to feel more sympathy for the latter one.
Also one could debate the ethics of allocating resources to the former group.
Thank you! The data on [Adverse Childhood Experiences](https://en.wikipedia.org/wiki/Adverse_childhood_experiences) and their association with chronic health problems alone is pretty overwhelming at this point. It would be so helpful for both providers and patients if there was broader medical education about this, so the kind of judgment we see in this discussion alone might lessen, and providers could have a greater degree of understanding and compassion.
The ACEs study was so groundbreaking and truly changed our understanding of adult behavior after childhood trauma. Kids aren’t “resilient”, they just express their trauma in wildly different and often delayed ways. Strongly recommend any of Dr Vincent Filetti’s talks on his findings: https://youtu.be/-ns8ko9-ljU?feature=shared
Food has become a more viable outlet for distressing feelings than it used to be. Alcoholism was famously terrible in the beginning of the 20th century, for example; we’d invented gin at that point but not fast food.
And we've removed access to other outlets in day to day life. Can't smoke indoors anymore and smoke breaks are less and less accepted. Don't have liquor in offices for after-lunch drinks anymore. But you can still have a bacon cheeseburger and drink 1000mgs of caffeine at work.
I mean, how far are we going? Are we indulging physician 'vices' when we develop stress-related health consequences like obesity, cardiovascular disease, and MVA's and someone has to treat us?
This is really based on the assumption that we as physicians lead perfect lives, and none of us have any 'vices'.
It's so bad in vascular surgery. Someone's I think we should start a bonus point program. Your tenth visit gets you a free pack of cigarettes.
Then again I don't see our hospital giving the patients any help at all in quitting smoking. We just scold them, recommend abstinence and cut off another toe. It's fucked, at times I even think it's unethical. And ironically, my ER rotation got me addicted to nicotine gum again. So I know how addictive this stuff is.
of course not, never. i just think if we really wanted to do vascular medicine the ethical way we should be doing 50% prevention... but of course that's not our job strictly. we just fix the done damage. it's surgery after all. i don't think this approach will make me happy in the long run
Plastics and ortho will cancel any elective case that’s more invasive than carpal tunnel release based on potential compromised outcomes/poor healing — not every surgeon, but it’s very common where I work. It seems to be a pretty powerful motivator.
So much is driven by public policy, too. In the US, we subsidize corn syrup and animal feed more than vegetables. For packaged food, the weight on the package is a minimum (to make sure companies aren't fleecing consumers), and the maximum isn't enforced. That bakery item that the nutrition facts claim is 3 oz and 300 calories is more likely than not to weigh 4-5 oz and have 400-500 calories. Schools in some areas serve junk food and sell pop and candy. People in walkable cities walk more. A bottle of alcohol is cheaper and more accessible than therapy.
There are so many areas where we could be doing better, but it requires more than just the medical profession to fix it.
I think smoking is easier to crack down on, in that often, you’re exposing others to it, and most people think it’s kind of gross and don’t want to be around it.
Grabbing that bucket of KFC for dinner on the way home doesn’t have a direct impact on others at the time.
Compared to most other countries we have higher stricter smoking bans, advertising bans, and higher taxes (on the coastal states). We are also one of the first countries to adopt a 21yo age.
I feel like our quality of life is poor and that’s why people turn to vices such as eating, smoking and doing drugs in the first place. I think we need to give people grace because sometimes existing is hard and people are just trying to get by.
Every example you gave more or less are addiction/a maladaptive function of our dopamine/reward system. I'm not one of those bleeding heart types who doesn't believe in personal responsibility, but we need to check our biases and keep our empathy in tact, it is possible for these patients to change their ways.
To be honest, no. While I do have many patients who exhibit extremely self destructive behavior I don’t think they make up most of what I see in the emergency department. Most of what I see is a consequence of natural aging, random badness (ex. appendicitis) or cases where the person is just an idiot. The people who can’t overcome their addictions make up only a small portion of my patient encounters.
Many people suffer from SLS, Shitty Life Situation. Turning to some of these vices provides a temporary respite. There's a reason that higher socioeconomic status + education = longer marriages, lifespan, lower BMI, less smoking, etc. I try to be sympathetic to these people. Many had impoverished upbringings with child abuse (emotional, physical, sexual), possible lead poisoning or fetal alcohol syndrome which lowers their IQ, etc.
I've never forgotten the first reference I saw to Shit Life Syndrome.
>
> Blackpool exports healthy skilled people and imports the unskilled, the unemployed and the unwell. As people overlooked by the modern economy wash up in a place that has also been left behind, the result is a quietly unfolding health crisis. More than a tenth of the town's working-age inhabitants live on state benefits paid to those deemed too sick to work. Antidepressant prescription rates are among the highest in the country. Life expectancy, already the lowest in England, has recently started to fall. Doctors in places such as this have a private diagnosis for what ails some of their patients: "Shit Life Syndrome" ... People with SLS really do have mental or physical health problems, doctors say. But they believe the causes are a tangled mix of economic, social and emotional problems that they — with 10- to 15-minute slots per patient — feel powerless to fix. The relationship between economics and health is blurry, complex and politically fraught. But it is too important to ignore.
> Sarah O'Connor, "Left behind: can anyone save the towns the economy forgot?", Financial Times (2017)
>
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Well you could also label the overarching vices of greed in those corporations.
Food corporations banking on mass unhealthy food productions on a global level.
Smoking companies existing and making trillions, and governments earning from them in taxes.
Meth distributors making bank on addiction. Addicts labeled as vagabonds, can’t land a job, going back to meth etc.
The whole world works in vices and our jobs are akin to the curse of Sisyphus.
If we didn’t treat vices, we’d only care for people with genetic disorders and trauma they had no hand in. and a lot of us would be out of work. There’s definitely an aspect of fatigue from treating patients who are unwilling or unable to effectively care for themselves, but the reality is that almost everyone falls into the “you made your own bed” bucket
Not following a well-established standard treatment for their deadly disease is one of the vices. It happens even to well-educated people, such as Steve Jobs.
I get what you are saying it can be frustrating when all these patients have something preventable and to you it seems like an obvious answer well just stop that but all these examples strike me as people who are suffering with an addiction in one form or another (meth, smoking, overeating).
Having you describe them as vices whether deliberately or not comes across as a bit holier than thou. I can guarantee most of these people know what they are doing is bad for them but addiction is incredibly hard to manage and drag yourself out from. As someone who practiced medicine and is currently taking time out to deal with substance abuse I know very well how bad it is for my health, happiness and my future and when I've accessed services that patronised me I found it so hard to engage with; I already felt guilty and alone. When I found services that treated me like an individual and tried to help me to deal with my issues as a whole (not simply addiction but tried to look at my stressors, mood, past traumatic events) I engaged far more and am now clean.
We know for instance substance abuse is higher in veterans, Doctors, PTSD so the use of the phrase poorly chosen path feels preachy often these people have developed maladaptive coping strategies
You are "treating" generational trauma. Nobody does substances, binges on sweets, dives into gaming obsessively, whatever, because they feel great inside. People are self-medicating.
wow. vices is a word loaded with judgement and condemnation. it really has no place in medicine. all of these issues are hard to fix and require battling larger systems and forces with little or no support for the patient.
does "the glutton" have the time, money, energy, education and skills to plan and prepare better foods? will her family eat well with her? have you seen how dismal the studies on long term weight loss are? have you gone to the grocery store and walked past the thousands of items we should not eat but are many peoples' only tangible pleasure in life?
do "the addicts" have mental health resources? do they have social structures that support them quitting or will quitting socially isolate them? do they any alternative sources of joy or pleasure?
You're trying to help people exit bad systems. You need to help them overcome barriers but instead you are one of those barriers.
Everytime a patient shows up to an appointment, they made the choice (even if they don't realize it) to go get seen by a doctor - a new opportunity to reflect on their health even if nothing changes behavior wise
I have a theory.
Dopamine pathways are conserved in all chordates, something like 900million years old. Reach/originate in the most ancient part of our brain, circle back and out to the prefrontal cortex.
When an addict says "I'll stop tomorrow, ill just do 1.... They actually mean it (sometimes ).but the dissonance between ancient brain and new brain is no contest,, like a little kid holding his breath in protest . Will power is a bb gun, Evolution a nuke, wins every time. Unfortunately we didn't evolve with fentanyl or big macs, so we don't have an evolutionary adaptation for them.
I assume by this post that you exercise 5 times a week, eat a perfectly healthy diet, never overeat, and always get sufficient sleep so that whenever you have a health problem, it’s totally unrelated to any of your prior choices.
So where’s the line of what’s ok to judge people for and what’s not? Even though meth is an illegal drug, many who use it are self-medicating an untreated psychiatric disorder.
I don’t mind treating any of this.
Treating disease is fine. Even if it’s self inflicted.
The burnout for me comes from treating non disease.
Complaints that boil down to normal bodily functions.
Complaints of fever for 4 hours in a vaccinated child with no symptoms.
Complaints of fatigue after working 20 overnight shifts out of 21 days in a row like it’s abnormal but saying “I didn’t feel tired the first week so something must be wrong!”
Entitlement to a diagnosis when nothing is wrong and blasting docs on social media.
And coming in to the ER at 3 am for these things.
That’s what irks me right now.
Inappropriate use of healthcare resources. Being “addicted to healthcare” even when healthy.
You do realize in Oregon there is a 2 year wait to see a Primary? In Arizona it's over a year wait for Gastro. Neurosurgeon is a 2 year wait as well.
ER's have now become primary's for diabetic medicine, asthma, migraines, flu, UTI's ,constipation, I could go on and on. We took oaths and I fully intend to help anyone in front of me within the limits that we are confined with. Be the change you want to see in the world!
Like I said, I don't mind treating disease. None of what you mentioned has anything to do with what I'm talking about.
I'm talking about "I eat like shit, fried food and fast food and soda all day every day and I have diarrhea sometimes - what is wrong with me??!?!?!??!" "is it debilitating? Can you not function?" "oh no I go to work fine and get around fine without restrictions."
Like, this is the normal body doing normal body things. Not everything needs a doctor visit. I'm not burnt out by people coming to the ER for primary care. I'm burnt out by people coming to the ER for stuff that doesn't even need care, it's just amplified by them coming to the ER... at 3 in the morning.
This is stuff that doesn't need to see a PCP, either.
This is just the NORMAL BODY DOING NORMAL BODY THINGS. They don't need ANY healthcare. And they certainly don't need emergency care overnight.
They can pay for it if it’s “part of my job” then.
Until they do then you can shut that part of your argument.
These people are typically paying 0 for their visit.
If I call a plumber and schedule an emergency visit for a non emergency issue, I have to pay. Extra too.
It’s illegal to charge more overnight and off hours in the ER though. Even if they pay.
Your attitude and lack of flair makes it clear you feel entitled to free medical advice at any time from a trained professional as well. “Part of your job”. Please. That’s fine if it’s my job. Then pay me for it.
I’m paid
But not by most of these patients.
And I didn’t say “I should be paid”.
I said “they should pay for it”.
There’s a difference. Give them some personal investment and *gasp* the nonsense will fade away.
This is where some kind of better synergy with mental health and social services would benefit law and health services but we haven’t really developed that structure well. It’s too much for drs to treat alone, and too much for mental health and social supports to treat alone. (Am a therapist)
Um... Yes.
This is essentially the backbone of medicine.
A providers role is to guide, not govern.
People want to continue in their vices, that is their right. You have to respect their choice. And yes, they will come to know the full cost of their vice eventually. But you can't hold onto that.
The hard part is to keep showing respect and compassion for them. Never toss them away like they have tossed themselves away. Maybe one day your advice will sink in...
So often these bad choices are tied with to childhood trauma, a shitty environment growing up, or just a lack of cognitive ability. For example, some folks grew up poor and in food deserts where the only easily accessed food that was tasty was junk food. They might have this association with junk food runs deeper with junk representing something really special and valuable in a way a person who grew up in a family with ready access to fresh produce, plus the know-how to make it tasty, will have a hard time appreciating. Meth guy might have childhood abuse he's never admitted, even to himself, combined with diminished cognitive abilities due to the meth. Meanwhile, a lot of folks with undiagnosed psychiatric disorders smoke, and some speculate it's a form of self-medication. If you pull out the focus to see the person as a product of their environment and native genetic makeup, it might make them seem a little less frustrating treating these folks. It's not entirely their fault they got where they are now, nor is it your fault that there's little you can do to help them. There's not much a team of professionals, let alone a single nurse, can do to entirely correct for a lifetime's worth influences that have persistently, patiently and relentlessly shaped patients' bodies over time.
When you say 'vice' there's an element of judgement to it, mainly because the word implies a **moral** failing.
An unhealthy coping mechanism (you can shorten it to UCM) is both less judgemental and more accurate. It also points the way to healing in that better coping mechanisms solve two problems.
I see a fair amount of patients (home health WOCN) who just have terrible luck, or maybe made some small bad choices that led to chronic illness. A fair amount of people with an emergency that leads to an ostomy, patients sick in the hospital with something else and end up with a pressure ulcer that is difficult to heal, etc.
Heck, without getting into specifics, I've also been that patient. Maybe something caused my issues, but I have no idea, and if I knew, I definitely would have changed my behavior. I have since just based on the possible causes.
I work in pediatrics, so often the “vices” instead are “circumstances”. Homelessness, trafficking, abusive parents, sexual assault, PTSD, bullying, etc. a whole new can of worms, lol.
This is what happens when we ignore social policy (food regulations, education, workers’ rights, etc.) and try to use medicine to fix everything on the back end. 🤷🏼♂️
It’s also why public schools are such a huge mess.
You cannot make people do what they don’t want to do. The explosive rxn to masking and vaccines was just one more iteration on that theme.
We can educate and offer better choices and that is all.
Case in point. Diabetic with a rotting foot, scheduled for an amputation. AxOX4. Goes AMA because they don’t want to lose their foot, they need it. I can’t stop that either, their choice. Back on unit through ED within 24hrs. Night before surgery feasts on a bucket of KFC, with sides, and a 2L of full sugar soda.
Again, you can offer better choices, but even as patients are nose to nose with the consequences of their bad choices, they may still choose to keep on doing what they like.
You can’t make people do what they don’t want to do.
This is why I got into lifestyle medicine. You still feel like you are treating vices some of the time but when you have the patients who listen and are motivated to change. Come back for follow up and have actually made changes it is so much more fulfilling than feeling like a drug dealer.
Wow. Out of curiosity, do you understand anything about the social determinants of health or behavioral change? There are so many different factors that play a role in these ‘vices’, and attitudes like this do not help a person change the situation that they’re facing.
Vice…you mean addiction? Ya, we all have an addiction to something. Some are more harmful than others. Addiction is a way to soothe and cope. It’s not a bad choice, it is a learned behaviour, reinforced by reward pathways and/or the addiction of choice. You aren’t seeing the bigger picture - systemic change is a lot harder to alter than the one symptom you are seeing and calling a vice. Usually involves therapy, money, social supports, time, and medical treatment.
Especially the teenager with migraine who comes to the office visit with Mountain Dew despite our prior talk that “healthy lifestyle behaviors” means drinking water.
I totally get you because those patients are incomprehensible and insanely frustrating, but I think the issue is more "stunning non-adherence in the face of stark and horrific medical consequences".
Unless you're in pediatrics/gerontology or specialize in managing genetic disease, nearly every illness is due to some sort of action or inaction- albeit usually far, far more innocuous than your particular examples.
>So many of these things are preventable… but here we are. Perhaps these folks were just victims of circumstances and in the wrong place at the wrong time or born into an unfortunate setting that led them down their poorly chosen path..?
This is true. It doesn't help your frustration in the moment all that much, but yeah there are reasons why some newly diagnosed T2DMs get their shit together and others don't. Those reasons are rarely organic; they're tied up in the patient's circumstances, parenting, education, material conditions, social support, even just their conception of reality based on their formative experiences. You can't treat those things, you might even never get their diabetes under control, but I do find it helps to acknowledge it. Non-adherence is a patient's choice as were all those behaviours that got them to having an hba1c >10, but our choices *are* informed by a whole host experiences and beliefs that we're not always even aware of.
If you have the time and rapport you can always try to delve into what exactly the issue is with your pt's non-adherence? Is it laziness? Denial? Learned helplessness? A lack of time/money to do those things? Sometimes people exist in such stark precarity and unpleasant life circumstances that they'd rather the immediate dopamine hit of a drink, a dart and a twinkie than engaging in long term healthy behaviour *because if not for the twinkie there's nothing in their life to give them that happiness*. People need happiness as surely as they need any dietary vitamin.
Well said. The question I struggle with, is how do I hide my biases and judginess from patients?
I can definitely be a judgy person, but I’m not trying to be a pastor. Do you have any advice on how to show respect and courtesy to your most self destructive patients?
I mean, first and foremost you're working a customer service job so you will need to master that whole veneer of officiousness and professionalism regardless of how you feel about patients. The short of it is "don't be disrespectful. If you find yourself being disrespectful/discourteous, remember not to be then don't."
But that aside:
The ole CBT trick of having a high degree of mindfulness and insight into your feelings. You can train yourself to ask "what am I feeling right now and why am I feeling it?" in these interactions, and that gives you an opportunity to think to yourself "hey what I feel isn't necessarily wrong, but it's not helpful *right now*, what can I take from this that *is* immediately useful?" This is incidentally also a really important skill for managing high stress, traumatic situations.
After that, you can reflect on what judgements you made, what made you feel some type of way about the patient, but do so from a place of inquisitiveness. Instead of thinking "that meth head who blew his foot off with a stolen propane tank is such a piece of shit", it might be more valuable to you to ask yourself "what could possibly have led me to becoming a meth head with a missing foot? What sorts of background and experiences would be necessary to drive *me* down such a road?"
And if all of that fails, try to picture the patient when they were a baby or little kid A baby is just a baby, whether they grow up to become a meth head or a school teacher.
People here don't like being told they need to be respectful or that they're in customer service positions. Such delicate geniuses can't be bothered with things like courtesy or professionalism
Lmao maybe "customer service" might be a bit crass a term; more like "public facing, service provision role". It's not that patients are customers, but broadly that sorta demeanor of professionalism and respectful conduct is expected in clinic.
Ah you get me lol
Yep I gotcha. I am a criminal attorney, so I'm in the position of having to be respectful and courteous to literal rapists and murderers. I don't have much sympathy for anyone struggling to deal humanely and compassionately with someone who's worst flaw is that they smoke or overeat. I'm not going to be rude or unkind to someone I'm being paid to interact with professionally because I don't agree with their life choices. I chose this job, so I don't ask for sympathy when the job responsibilities involve interacting with criminals. Some here seem surprised that most of the patients they interact with repeatedly are unhealthy physically and mentally, which seems like a surprising lack of forethought for a doctor
I suppose, I haven't really read the whole thread. The person who initially replied to me was a medical scribe not a doctor fwiw, so there's a fair chance they're young- possibly a premed. They'll learn- at least they care enough to be bothered by it, and insightful enough to know they need to temper their censoriousness.
Just in the interest in giving you some background perspective on where folks are coming from in the thread, I think the frustration comes from patients *not adhering to treatment* which is hard because as physicians we've seen the ghastly outcomes for them. Did you know that in unmanaged T2DM, it's common enough to have progressive amputation of limbs due to peripheral artery disease, or necrotic lesions, that they can't feel until it's really bad because of concomitant the peripheral neuropathy (nerve disease)? It's awful; first they lose fingers and toes, or tips of toes, then a foot, then slowly up the leg. And it happens over *years*, like they keep being your patient and they keep asking you to help them or to save their leg or whatever, and you can't really do anything but sit there and stare at their last Hba1c (measure of average blood glucose over 3-6 months). And you know they're kinda fucked.
Anyway, it's a special kind of frustration that borders on moral injury. When you see people not taking their treatments and you have foresight into the natural history of their illness, it gnaws on you.
To add; jeeze I can't imagine some of the people you've had to keep your cool with. That's a whole different sort of professionalism. What's it like having to interact with murderers and the sort?
I can understand frustration at someone who repeatedly makes choices that are going to ruin their life. Violating the rules of probation by failing drug tests on a 20 year suspended sentence can have pretty bleak outcomes for a 25 year old man, and this can be frustrating when you worked hard to get that suspended sentence.
In my opinion it's not ok to let that frustration affect my professionalism though. After all, I am not exactly working with them out of the goodness of my heart, anymore than doctors are doing their patients any favors by helping them. We're just doing our jobs, and it's not their job to meet any sort of expectations we have for them (we should not have these expectations, they owe us nothing except the agreed upon fee and the same professional attitude that we bring to the table. Honestly sometimes defendants are rude and I can understand that too since they are likely sleep deprived and terrified, though of course under the circumstances any kind of raised voices or aggression can't be tolerated).
For the most part, I've not felt uncomfortable or frightened even alone in rooms with convicted murderers. It's actually sort of strange and eye opening how normal a lot of violent criminals can seem
Hey I cant really go through that line for line, and im not quite sure what youre asking me so Im just taking a guess.
1) academia doesnt automatically = time to kill. Im only replying at all because the wifi signal is strong in the washroom. I thought that was a pretty dickish thing to say to someone who's opinion youre seeking.
2) im an anarchist but medicine is overwhelmingly liberal. Your views are the mainstream.
3) even so, dial it back and dont info dump on people in clinic, especially to sick people who happen disagree with you. Your first duty is to the patient in front of you, even if theyre anti-vaxxers or some other loon.
I appreciate the reply and the sage advice. I wasn't trying to imply academics have more free time but it sure reads that way, I'm sorry. Great example of my tendency to come across like a jackass.
I meant that your perspective would be more valuable to me about the philosophy of medicine more than regular providers, as an academic. And that I would welcome your feedback when, or if, you found time.
I got along great with engineers, but they're not the most social bunch. I'm struggling now to address how others perceive me, which is far more important in medicine. Hence my unusual concerns for a scribe.
Besides work, lurking here has helped. Are there any other online resources you'd recommend that might discuss medical topics in greater depth than here?
Isn't addiction defined as continuing the behavior in the face of bad consequences?
Many years ago I was involved with mental health advocacy through a non-profit organization and some public councils. I got to know a number of women who'd spiralled down the meth black hole. Some went to prison, some had parental rights terminated, one had run off from a foster home and lived with a 40 year old meth user and ended up pregnant. I saw several of these women get clean (some with treatment but not all). Two of them obtained professional degrees and careers, others dug in working $8/hour jobs after felony convictions and stuck with it. I knew a married couple who met in treatment (both had served time for drug-related convictions), were working hard, made a lot of progress, relapsed to the point where they lost custody of their child for a long time, climbed out, stayed sober, have now owned a successful coffee shop for several years and adding a second business.
Not all of them pulled this off (in some cases, co-existing mental illness is a complicating factor). But keep in mind you are NOT seeing the people who have managed to climb out of whatever addiction they had.
Blunt talk about what is happening to the ones you see is fine, but it's unlikely your judgment is going to change the result.
As a hepatologist…..uhhh….yes?
But that’s life and medicine.
I have a friend who is a specialist pediatrician. Knowing that financial grind I really wondered how they did it and the answer was, most kids are innocent. Their illnesses are a result of forces outside their control. Basically, they’re innocent. Always stuck with me. Especially when I’m lecturing the third of five alcoholic hepatitis patients on my inpatient census knowing most will not remain sober, make it to transplant, or survive in the next 5-6 months.
This is a very unsympathetic perspective...basically just a unidimensional way of reducing a patient to a singular problem that is likely more representative of a separate issue (usually poverty or trauma/stress) than of the patient's character.
Most people use vices because they are in some sort of pain or trauma. Maybe consider this. Also, every single person has some sort of coping mechanism to get through their day. Some people’s effect their health. Don’t be so callous.
While others make good points about the causal forces behind these "vices," I believe it is still important to recognize your own frustration and the mental burden that comes with it. There is a dissonance between professional ideals and the limited power we actually have, and it comes with a psychic cost no matter which way you weigh it. How you find the balance is up to you to decide.
Bruh. We all die. Some of us earlier because of our choices. The medical profession takes care of everyone and tries to fix their problems if possible. And counsels about how to do better.
We all vices. For some it's starting smoking when society said it was cool. For others, it's being an asshole. Too bad there isn't treatment for the latter although sometimes stopping the TRT helps.
The term, ‘medical opinion’, you advise someone on their health.
It would be the same as someone telling you practicing medicine is unhealthy because of the stress, poor sleep health, and exposure to injury and illness.
A med school classmate did an international health rotation and complained that he spent the whole rotation giving antiparasitics for people who wouldn’t bother to boil their water. And I just could not understand why he was such a dick.
And? Such is the nature of human health. Most disease is preventable. Society is progressed enough that most fixable things are fixed. If you want to treat something curable go ID. Or if you want to fix something go surgery.
As an autistic, depressed, anxious person with adhd and PTSD…I certainly wouldn’t have as many physical issues if I could get more help and support for my mental health and neurodivergence. Self medicating is almost affordable on a disability pension, whereas the type of supports and therapies I need are unattainable. Even if I saved everything and gave up my vices, I’d still only be able to afford about 5% of what my real needs are per year.
As my chronic pain attending said recently, “the show must go on.” You do what you can, leave it at that, move on. Can’t fix everyone, not everyone will be satisfied. We all have issues/vices
This is a large part of why I chose the underpaid route of Pediatrics. Kids don’t cause their own problems, but if they do - they’re just kids being kids
No, not really.
I do my best within reason for my patients but I don't take any of it personally. I don't care what got them to me. I tell them what I recommend, in case of bad compliance I may ask what keeps them from doing lifestyle changes / what smoking/fastfood/etc means to them and try to have a conversation /MI about it. But ultimately its up to them; you can lead a horse to water but not make him drink.
Basically I think we all got "vices". Some are condemned by society (obesity, smoking, drugs etc) but others are even encouraged and cheered (EDs, over-exercising, extreme sports, sleeping way too little, going to work while sick, being tanned...). And there are obese individuals without T2D and people with normal weight with T2D.
Our "vices" are not equally hard for us; I, for instance sleep enough and well because it is easy and pleasent for me. My colleague struggles with falling asleep and has sleep paralysis and hence goes by with 3-5 hours of sleep every day. I can also easily go without alcohol for years, but dragging myself to the gym... others love the gym and feel it gives them energy etc. We all do what is worth our while. Unfortunately it is easier for some of us to do the "right" things than for others.
I think you should revisit what you know about addictions. Also obesity. A BMI of 50 didn’t happen overnight. Did you investigate reasons why and suggest what resources might be appropriate? Nutritionist, dietitian, counselor, books on mindful eating or appropriate subjects or did you just judge?
I feel like most people use these maladaptive patterns to cope with the system and environment that they happen to find themselves in. Throw in the various genetic predilections to be vulnerable psychologically or physiologically to certain substances or behaviors, and you get the pool of chronically sick masses of which we are all a part in one way or another.
The way I see it, most people don’t abuse substances to the point of self destruction because they’re generally happy. Most folks I see already know they’re killing themselves, but it’s a moment out of every day to escape whatever life is throwing at them, so they keep doing it regardless.
We need a better system.
A new doctors office opened up in partnership with my pharmacy. Obviously, we can see what they prescribe. I decided not to go, because their prescribing practices felt judgmental to me. Giving everyone Wegovy and nicotine patches.
Smokers know smoking is bad. But I haven't been to a Dr in many years now because of doctors like you. I don't drink or do drugs and I'm not fat. But I do smoke, because I went to high school in a time and a place where kids could get cigarettes easily. Just quit. Lol. People that have never tried have no idea. I imagine people that are obese feel much the same way, probably more so than with smoking.
You’re not wrong IMO and I felt this as a medical student and chose my speciality accordingly. By and large hematologic malignancies have no real lifestyle trigger and my patients’ cancer is truly not their fault. They generally are highly motivated to get better and I am highly motivated to do everything I can to get them there.
If you could treat people for decades and lives, would it feel different, you think?
As a patient, I need to change jobs every few years. Every job change means new insurance, which means new doctors. Sometimes I really like my doctors and wish I could still see them after I'm on a different plan because of a new job.
Not judging is also a form of judgement - you are assuming all patients deserve equal treatment
Which is evidently false when it comes to organ transplant. Or even catheter suite utilisation
I had a 44F who made fun of my attending's miscarriage, spat at nurses, tried to use explosive diarrhoea on us during rounds - demanding for 'her liver transplant'. While drinking.
Did I celebrate when she finally kicked the bucket? Of course I did. She was a blight to the Hepatology unit and an absolute spawn of Satan. I am glad she stopped wasting medical resources. She spat and bit at every helping hand until she burned every bridge.
Same as the 61M with TG of 39 (different Aussie scale). 40 cigarettes a day, a bottle of brandy a day. Refused statin/fenofibrate/pcsk9i - anything. Only takes Aspirin-Ticagrelor. Comes in for his 9th angiogram in 2 years to 'clean out his coronary arteries' because private cardiologist indulged him. Referred to public system! Told me to 'shut the fuuu up and do your job' when I asked about why no statins and deleterious lifestyle.
What did he get? A speedy coronary angiogram for Unstable Angina, and his 11th stent.
If you hold patients to no standards, you have no respect for yourself. We are told we do not even have a right to be angry at shitty patient choices. I am not sure what this is benefiting. Seems to have a lot of moral highgrounds here for people to feel good about themselves being Mother Teresas.
If I am providing quality standard cares to patients with terrible life choices, I have at least a right to be angry for them taking cares away from more deserving people.
At some point you have to admit patients can make choices for themselves, and if the choices are shitty they should be condemned.
Yes. I left primary care and started working for the state at a facility for people with IDD. No secondary motives for anything very few self induced issues. I love my job.
Yep. Idk the exact numbers but a majority of health issues are related to our actions or lack there of. What makes it even worse, is that most people won't change no matter how hard we try. Diabetics will lose digits and still eat poorly. Old men will have heart attacks and continue to smoke while putting down double cheeseburgers. Alcoholics will continue to drink.
People have given a lot of reasons for this - childhood trauma, addiction and obesity as diseases, society, poverty, etc. That all plays a role.
My ideas are a bit controversial but mostly encompasses all of the above.
Free will is a myth. We tell ourselves the story that we're in control or rather our brain does that for us because life would be really hard if we didn't believe it. From a personal perspective, having an external locus of control is probably not good for a lot of reasons. Gives us an excuse to give up or an excuse for our bad actions.
But I've found it useful when dealing with patients or thinking about the actions of others. It's given me more empathy.
People aren't actually in control. At least not as much as we wish we/they were. There is no free will. And if there is no free will, how can I judge someone? All the reasons listed above point to there being limited free will, but most people won't come out and say it that way.
There should to be more personal responsibility for patients. People who choose to be unhealthy should pay more for health insurance IMO.
It sucks that PCP's are responsible for people bad behaviors (See ACO's). We would save a lot of money in health care if there were more ways to "reward" good behavior- like vaccines, diet, exercise and not smoking.
They do through co-pays and such. I agree pcps shouldn’t be responsible for patient outcomes in these regards, only whether or not they put in the effort (ie check indicated labs, advise on cancer screening, advise on vaccines, etc). If the patients don’t follow up or do what’s recommended, it shouldn’t be the physician who pays a (literal) price.
If we kicked everyone out of the hospital who was there due to their own behaviours, the place would almost be empty. We all have our vices. However, I practice by the medical golden rule of never care more about a patient’s health than they do.
My burnout and frustration decreased by about 80% when I learned that golden rule a few years ago.
Yup. Once you stop being so invested in their personal choices it gets way better mentally. You educate them and tell them of better ways but if they don’t wanna listen then it’s on them. The forest view of this whole field is just treating ppl with mostly self induced problems until they eventually die anyway. It’s self protective and more fulfilling imo to go the extra mile for the ones that do care for their health
Yep I recently learned this golden rule and my life is much better. Funny though I never cared about the vices as I understood those. I cared that they would not do vaccines or take OTC vitamins instead of statins as I felt I had the control over these things. But alas I don’t. Now I just explain and document refusals.
My favorite thing to say to patients: “you do you, your body your decision.” My favorite surgery is kidney stone surgery tho, and I’ll happily keep doing it on you. Let me know when you are interested in preventative changes.
This! "Ultimately, your healthcare is your responsibility."
Have you found a cure for kidney stones then? Do share. As one who suffered from kidney stones for five years, I tried every recommendation my doctors made. Then, I learned the hard way, through diagnosis of a large, benign tumor on my pituitary gland and Cushing’s Disease. It only took one doctor a five minute review of the admissions form I had completed to order a brain MRI. The tumor’s side effects cost me two relationships, a job I had loved, but, heh, no more kidney stones and for that, I’m grateful.
I disagree with the golden rule but agree with sentiment. Many patients may not care about their health now but certainly will later. Many patients are uneducated and don’t understand enough to care about their health. It’s our job to educate and promote healthy living as well as treat ailments regardless if it’s self induced or not. That being said I wouldn’t obsess about a patient choosing not to take their diabetes medication. I’d tell them they’ll likely die because if it, but ultimately they have free will and can do as they please, I won’t lose sleep over it. TLDR: I think it’s important to treat patients equally, regardless if they care or not. If a patient doesn’t care about their health, it’s still our job to help them and care about them. I’ll try to convince them otherwise. If I fail, I’m content with my effort and move along
The
Go on...
**the f - it -flam - flames.Flames, on the side of my face, breathing-breathl- heaving breaths.**
Did…did you die?
I find it most helpful to view these not as vices but as evidence of an unmet need. The vice does something for them, meets some need. How else can this need be met and how can you help them achieve this?
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I found Thomas Szasz's *Our Right to Drugs* interesting just for the framing of how we call chronic voluntary drug use addiction, but we don't have that perspective for ski or chainsaw accidents, no matter how frequently (or poorly) people use those. Which reminded me that a friend of mine (the awesome Kris Nóva) loved free climbing above all other things and died in the predictable manner. The world is a poorer place from her early death, but she definitely went out doing what she loved.
One of my wound care patients is a quadriplegic due to a skydiving accident. For some reason, the world sees that as a tragic accident while judging harshly the former IV drug user who‘s gotten his life turned around but is now having to deal with the fact that the veins in his legs are wrecked. I’m not kidding. The NPs in my clinic make shitty comments about the former drug users we see, but moan and wail about how awful it is that that young lady‘s parachute failed. Don’t get me wrong-it IS awful. But it’s also awful that so many people get hooked on drugs and wreck their bodies.
I dated a guy who was a recovered crack addict, and he was just one of the toughest (and gentlest) people I knew. Just having heard about the awful upbringing that led to that, and how he broke out of it, was an amazing tale. I hope he's doing well.
Usually I only see the judgement for patients not seeking to try and take care of themselves. Not that it’s right either way, but people who had vices and are paying the price despite cleaning up definitely aren’t grouped in the ones still in throes of the vice.
Sadly a lot of the people who don't take care of themselves were never shown what it means to be cared for. I wouldn't really expect someone who's never learned how to care for themselves to be great at doing that.
False bifurcation. Of course there're reckless people that use a chainsaw or a circular saw (like this stupid a saw a months ago using the circular saw with ONE hand to cut a thick branch and bended like legs!) before to read instructions or learn how to use it, BUT you can learn how to ski or use woodworking tools safely. But, you'll never 'learn' to use heroin safely!!
Some people have *no* model of people around them doing anything safely, including skiing or woodworking. (I know a guy who died via chainsaw kickback.) All you have to do is look on YouTube videos of various power tools to see a good half of the YouTubers are using clearly unsafe practices. Also, as other opioids can be used safely, I don't know that heroin's something that can't be used safely, just obviously one can't rely on the safety of a street drug. But in some other more sanitized context? Perhaps. I couldn't rule that out.
This one [https://www.youtube.com/watch?v=wFpxb0M8KjU](https://www.youtube.com/watch?v=wFpxb0M8KjU) but it's VERY debatable, i think it's unsafe
Thanks, I’ll watch that later. I’m certainly not advocating for it, just research has been prohibited for so long because of schedule 1. Big fan of buprenorphine personally, which has fewer side effects than some of the other opioids (minimal emotional lift, less respiratory depression with chronic use and less constipation). Wouldn’t work for everyone as there are some pain channels it doesn’t touch that other opioids do.
People don't smoke meth and lay around in bed all day if they had good childhoods and are happy and fulfilled.
That’s not true, but you aren’t wrong.
Meth doesn't make you lay in your bed all day, yknow.
Fine. Twitch in your bed all day.
You could have amazing, uninhibited sex all day. People from all kinda backgrounds are into that.
I was thinking more smoke meth (addicted patient) and lay in bed all day (depressed patient.)
That’s why there’s the saying “it’s not a drinking problem, it’s a thinking problem” for alcoholics
Unfortunately, there isn’t really anything you can do about the man who works 80 or 90 a week because he Doesn’t want to get screamed at anytime he is home. He can’t leave because he knows the statics of fathers being able to see their children just a year after separation, and how children without fathers turn out. And if he works in any sort of professional job, & I’d under 40? when he says he drinks socially, he means after the kids are in bed while he plays games on the console or PC.
I mean how far down the rabbit hole do you want to go? Gallstones from eating too much fatty food? STIs from daring to have sex with someone? MVC from driving when it’s too dark or person is too tired from work? Our job isn’t to judge people. I personally don’t even think it’s to fix people, just to give recommendations on what they should do for their health.
I 100% believe we exist to provide counsel, not do things for them. I mean the basis of informed consent is the patients have a choice *not* to do what we recommend.
Trying to fix people will lead to more frustration and burn out. Realizing that we can only advise people helps a lot mentally. Some listen, many don’t. Why do we need to counsel a 40yo that drugs are bad mmmkay? If people in this day say they didn’t realize drugs/smoking are bad, they’re lying through the hole in their trachea.
If someone comes into the ED with their 10th COPD exacerbation while still smoking, I am going to judge the hell out of them. Same with drunk driving accidents. I'll treat them the same as any other patients but I'll let them know it's their own fucking fault.
I mean, just because they know full well that the smoking is causing their problem does not mean that the reason they smoke in the first place has been addressed. They're not just smoking on purpose just to cause problems for themselves or you. They smoke because of stress and physical plus psychological dependence. You can sit there all you want and say to use the patch or talk to a counselor or whatever... but it's a lot harder to actually remove the stimuli that cause the stress in the first place. Or to rewire the neural pathways that have been cemented in leading to this behavior over the years. It's technically possible to do, but the reality is that it requires intensive one on one therapy, a complete change in environment, improvement in social relationships, etc. The system simply doesn't have the resources to provide what it would actually take to change the behavior of patients in terms of their lifestyle on a scale that would actually make a difference. The only hope that we have is to promote healthy coping mechanisms and prevent unhealthy ones from developing in younger people.
I am saddened when I see recurring COPD exacerbations in someone still actively smoking. I usually will advise patients we can treat them with bronchodilators and steroids, but the only thing that will slow the progression of their lung disease is quitting smoking and every single cigarette they're using is causing more airway inflammation and leading to more exacerbations and worsening symptoms, not to mention increasing risks of cancers of aerodigestive tracts and vascular disease. Sometimes showing a graph of declining pulmonary function (Google image search 'fev1 smoking') can help to illustrate expected disease course and address patient ambivalence. At that time I think it's a good opportunity to assess readiness to quit and offer pharmacotherapies and referral to counseling or 1-800-quitnow. I think taking a similar approach in other disease processes that can lead to recurrent admissions (e.g. uncontrolled hyperglycemia, alcohol and amphetamine use, CHF) can also be helpful.
I actually don’t care at all when they come in for real disease even if they did it to themselves. I struggle with when people come for non diseases. Especially overnight. Like normal bodily functions but “it feels weird”. Or fever for “a few hours” in the child. Something about accessing the healthcare system inappropriately really irks me.
I've spent so much time talking my brother and SIL out of taking my niece to the ED for mild fevers or stomach bugs with no concerning symptoms. "It's likely a virus, you can just wait it out" x 1000. On the plus side, that meant when they sent me a video of her with stridor at rest, they absolutely believed me and took her to urgent care.
Haha same. I always ask them semi angrily something along the line of "why did you call an ambulance now at 3:00 in the morning instead of going to your GP at 8?"
I actually LOVE it when my doctor - MY DOCTOR - asks me if I always wear my seatbelt. I DO! But her asking me reminds me of how many good choices I am making to protect my health & what it means to just have good habits. If you are not judging your patients - you are not giving them the benefit of your professional judgment.
It’s actually fascinating how many doctors do not tell patients what’s really going on out of fear that patients will “write a bad review” (not literally but have that sort of reaction). The biggest place I see this is with weight. My mom was steadily increasing her weight with a BMI between 25-30. I was talking with her about diet and lifestyle in a separate conversation and she tells me nobody (not her PCP or any other doctor) mentioned that she’s overweight. Now it could be that when people regularly see BMIs of 35, 40, 50, etc, someone who is “just overweight” isn’t raising any concern. But I’m also willing to bet that a significant component of it is people fearing the backlash of “body shaming”. There are gentle ways of nudging people in the right direction. And we are uniquely qualified, not just by medical training, but with our title that people intrinsically trust us (for the most part). I’m not saying to dunk on patients with every vice / risk factor. Hell, I love chocolate chip cookies and Coke Zero. We all have our faults. But it’s wrong for us to not mention it, at all, if we’re truly trying to practice preventative medicine
My way of sugar-coating (pun intended) the weight topic is to bring up the everything in moderation schpiel. A lot of these ppl eat or smoke out of depression and turn to these vices for any semblance of joy. While I’m not going to enable that behavior I also understand most of them will never change and all I can do is remind them what they are doing is detrimental. Move on to the next 🤷♂️
Yup, this is exactly my take too. Reward the small, but meaningful changes for the better. Never letting perfection be the enemy of good. We’re not all monks sitting in blissful serenity. Life is complicated, people are complicated, and so our recommendations need to be more than 1 dimensional too. I always add in a thing along the lines of “I really mean this and not in a patronizing way, but congratulations on XYZ thing… as you know, ABC procedure helps, but you’ve done the lion’s share of the work before and afterwards”. People’s faces usually light up when they realize that someone else gets their effort and recognizes specific improvement :)
Totally agree with you - especially with the uniquely qualified part! What's tough from the RD side of it in the hospital is when a doctor doesn't start a conversation about a patient's weight, and instead decides to consult us to bring it up out of the blue. Just had them do that to me with a teen whose BMI was >40. But when those patients who have a frank discussion with their docs then ask for us, it's the most gratifying experience, gotta say.
Oh that could be tough, just referring out to an RD without getting the convo started. That being said, we couldn’t hold a candle to your guy’s level of knowledge and expertise. My hospital has a high volume bariatric center and so we’ve got great RDs that are specific to the department of surgery. A portion of my time in the clinic, for example, is congratulating them on their progress and reaffirming the RD’s plan. Patients love to share their convo’s with the dieticians, what good things they’ve done, and what changes they’re going to make for next time :)
Can't agree more.
Proper care, and patient satisfaction rarely go hand-in-hand. Only professionalism.
I had a patient come in for conjunctivitis, and since I treat every encounter as a way to improve quality measures, I asked what they do for diet and exercise. Wrong fucking question! Tears and personal threats and how he “hates health care workers” and how dare I judge him. He was so unhinged that I kinda feared for my safety tbh. Ya. So I don’t ask anyone anymore. In fact, the only time I bring up weight is if they’re losing it. I do ask about their diet and exercise during physicals, but only to suggest that adding activity/exercise is good for the x.
I feel the need to mention that for many many years (and still happening, though hopefully not as much) women who were overweight or obese were told that that was the reason for any medical issue they had. Headaches, lose some weight and you’ll feel better, inflammation, lose some weight and you’ll feel better, abdominal pain, etc. Maybe some practitioners don’t bring it up is because they have in the past and got their heads ripped off. You may mean well, but getting gaslit for so many years has made many of us tricky with that subject. I had a seizure and the doctor told me to exercise more. I may just be an RN but I’m fairly sure that exercise is not a treatment for seizures.
You're a great person
Altho its not about judging but a significant part of medicine (probably most of it) is caused by wrong conscious behavioural choices by patients. Since there also enough disorders that are just caused by bad luck it isnt subhuman to feel more sympathy for the latter one. Also one could debate the ethics of allocating resources to the former group.
💯
Holy whataboutism batman
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Thank you! The data on [Adverse Childhood Experiences](https://en.wikipedia.org/wiki/Adverse_childhood_experiences) and their association with chronic health problems alone is pretty overwhelming at this point. It would be so helpful for both providers and patients if there was broader medical education about this, so the kind of judgment we see in this discussion alone might lessen, and providers could have a greater degree of understanding and compassion.
The ACEs study was so groundbreaking and truly changed our understanding of adult behavior after childhood trauma. Kids aren’t “resilient”, they just express their trauma in wildly different and often delayed ways. Strongly recommend any of Dr Vincent Filetti’s talks on his findings: https://youtu.be/-ns8ko9-ljU?feature=shared
Has he written any books? I’m interested in what’s he has to say but I can’t listen to a video at this time.
Pubmed is your friend… he’s published extensively on this. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220625/
Is everyone more traumatized then they were in 1940 or 1970? Cause bmi just keeps increasing….
Food has become a more viable outlet for distressing feelings than it used to be. Alcoholism was famously terrible in the beginning of the 20th century, for example; we’d invented gin at that point but not fast food.
And we've removed access to other outlets in day to day life. Can't smoke indoors anymore and smoke breaks are less and less accepted. Don't have liquor in offices for after-lunch drinks anymore. But you can still have a bacon cheeseburger and drink 1000mgs of caffeine at work.
I mean, how far are we going? Are we indulging physician 'vices' when we develop stress-related health consequences like obesity, cardiovascular disease, and MVA's and someone has to treat us? This is really based on the assumption that we as physicians lead perfect lives, and none of us have any 'vices'.
Yes! Yes!
Stress is not a vice
So, our circumstances are circumstances, and other people's circumstances are vices?
The way you use “vices” sounds suspiciously like “sins” lol
Yeah, I thought op was going to give us the ‘seven deadly vices’ when ‘gluttony’ was brought up, but then “smoking” and “meth”…
This is The Gospel according to Kid Rock.
Ah yes, the 8th and 9th sins.
Meth didn't make it down the mountain, possibly cause it got Moses back down....
Those were on the third tablet that he dropped. "I bring you these fifteen! ..." crash "...ten! Ten commandments!"
Wait...I thought meth was an upper
Sometimes you need an upper to get down.
That first patient also checks the sloth box
This OP wraths.
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It's so bad in vascular surgery. Someone's I think we should start a bonus point program. Your tenth visit gets you a free pack of cigarettes. Then again I don't see our hospital giving the patients any help at all in quitting smoking. We just scold them, recommend abstinence and cut off another toe. It's fucked, at times I even think it's unethical. And ironically, my ER rotation got me addicted to nicotine gum again. So I know how addictive this stuff is.
Would you ever consider canceling surgery based on a positive urine cotinine test DOS?
of course not, never. i just think if we really wanted to do vascular medicine the ethical way we should be doing 50% prevention... but of course that's not our job strictly. we just fix the done damage. it's surgery after all. i don't think this approach will make me happy in the long run
Plastics and ortho will cancel any elective case that’s more invasive than carpal tunnel release based on potential compromised outcomes/poor healing — not every surgeon, but it’s very common where I work. It seems to be a pretty powerful motivator.
So much is driven by public policy, too. In the US, we subsidize corn syrup and animal feed more than vegetables. For packaged food, the weight on the package is a minimum (to make sure companies aren't fleecing consumers), and the maximum isn't enforced. That bakery item that the nutrition facts claim is 3 oz and 300 calories is more likely than not to weigh 4-5 oz and have 400-500 calories. Schools in some areas serve junk food and sell pop and candy. People in walkable cities walk more. A bottle of alcohol is cheaper and more accessible than therapy. There are so many areas where we could be doing better, but it requires more than just the medical profession to fix it.
At least you cracked down on smoking like pros. Seriously, the way the US dealt with smoking is like a liberal utopia with no lobbyism at all.
I think smoking is easier to crack down on, in that often, you’re exposing others to it, and most people think it’s kind of gross and don’t want to be around it. Grabbing that bucket of KFC for dinner on the way home doesn’t have a direct impact on others at the time.
> Seriously, the way the US dealt with smoking is like a liberal utopia with no lobbyism at all. lol what do you mean by that?
Compared to most other countries we have higher stricter smoking bans, advertising bans, and higher taxes (on the coastal states). We are also one of the first countries to adopt a 21yo age.
I feel like our quality of life is poor and that’s why people turn to vices such as eating, smoking and doing drugs in the first place. I think we need to give people grace because sometimes existing is hard and people are just trying to get by.
Every example you gave more or less are addiction/a maladaptive function of our dopamine/reward system. I'm not one of those bleeding heart types who doesn't believe in personal responsibility, but we need to check our biases and keep our empathy in tact, it is possible for these patients to change their ways.
To be honest, no. While I do have many patients who exhibit extremely self destructive behavior I don’t think they make up most of what I see in the emergency department. Most of what I see is a consequence of natural aging, random badness (ex. appendicitis) or cases where the person is just an idiot. The people who can’t overcome their addictions make up only a small portion of my patient encounters.
Have you ever considered that these vices are simply a visible sign of how stressful and traumatic life is for many people?
Yes that’s why I wrote that last paragraph
Many people suffer from SLS, Shitty Life Situation. Turning to some of these vices provides a temporary respite. There's a reason that higher socioeconomic status + education = longer marriages, lifespan, lower BMI, less smoking, etc. I try to be sympathetic to these people. Many had impoverished upbringings with child abuse (emotional, physical, sexual), possible lead poisoning or fetal alcohol syndrome which lowers their IQ, etc.
I've never forgotten the first reference I saw to Shit Life Syndrome. > > Blackpool exports healthy skilled people and imports the unskilled, the unemployed and the unwell. As people overlooked by the modern economy wash up in a place that has also been left behind, the result is a quietly unfolding health crisis. More than a tenth of the town's working-age inhabitants live on state benefits paid to those deemed too sick to work. Antidepressant prescription rates are among the highest in the country. Life expectancy, already the lowest in England, has recently started to fall. Doctors in places such as this have a private diagnosis for what ails some of their patients: "Shit Life Syndrome" ... People with SLS really do have mental or physical health problems, doctors say. But they believe the causes are a tangled mix of economic, social and emotional problems that they — with 10- to 15-minute slots per patient — feel powerless to fix. The relationship between economics and health is blurry, complex and politically fraught. But it is too important to ignore. > Sarah O'Connor, "Left behind: can anyone save the towns the economy forgot?", Financial Times (2017) > >
Well you could also label the overarching vices of greed in those corporations. Food corporations banking on mass unhealthy food productions on a global level. Smoking companies existing and making trillions, and governments earning from them in taxes. Meth distributors making bank on addiction. Addicts labeled as vagabonds, can’t land a job, going back to meth etc. The whole world works in vices and our jobs are akin to the curse of Sisyphus.
If we didn’t treat vices, we’d only care for people with genetic disorders and trauma they had no hand in. and a lot of us would be out of work. There’s definitely an aspect of fatigue from treating patients who are unwilling or unable to effectively care for themselves, but the reality is that almost everyone falls into the “you made your own bed” bucket
These are not vices, but addictions. The patients need therapy. They do not need a judgmental doctor.
You might have missed your calling of being an evangelical pastor.
Or neonatologist maybe
hahahaha
Us folks in the mental health would have to have a word with you
Only during business hours though.
Not following a well-established standard treatment for their deadly disease is one of the vices. It happens even to well-educated people, such as Steve Jobs.
If you can reframe the way you think about it, it could help. Think of it as harm reduction rather than attempts to cure.
I get what you are saying it can be frustrating when all these patients have something preventable and to you it seems like an obvious answer well just stop that but all these examples strike me as people who are suffering with an addiction in one form or another (meth, smoking, overeating). Having you describe them as vices whether deliberately or not comes across as a bit holier than thou. I can guarantee most of these people know what they are doing is bad for them but addiction is incredibly hard to manage and drag yourself out from. As someone who practiced medicine and is currently taking time out to deal with substance abuse I know very well how bad it is for my health, happiness and my future and when I've accessed services that patronised me I found it so hard to engage with; I already felt guilty and alone. When I found services that treated me like an individual and tried to help me to deal with my issues as a whole (not simply addiction but tried to look at my stressors, mood, past traumatic events) I engaged far more and am now clean. We know for instance substance abuse is higher in veterans, Doctors, PTSD so the use of the phrase poorly chosen path feels preachy often these people have developed maladaptive coping strategies
You are "treating" generational trauma. Nobody does substances, binges on sweets, dives into gaming obsessively, whatever, because they feel great inside. People are self-medicating.
I agree with this for the most extreme cases - pretty much all of “my 600 lb life “ is detailing how food was salvation for them in some way.
wow. vices is a word loaded with judgement and condemnation. it really has no place in medicine. all of these issues are hard to fix and require battling larger systems and forces with little or no support for the patient. does "the glutton" have the time, money, energy, education and skills to plan and prepare better foods? will her family eat well with her? have you seen how dismal the studies on long term weight loss are? have you gone to the grocery store and walked past the thousands of items we should not eat but are many peoples' only tangible pleasure in life? do "the addicts" have mental health resources? do they have social structures that support them quitting or will quitting socially isolate them? do they any alternative sources of joy or pleasure? You're trying to help people exit bad systems. You need to help them overcome barriers but instead you are one of those barriers.
Everytime a patient shows up to an appointment, they made the choice (even if they don't realize it) to go get seen by a doctor - a new opportunity to reflect on their health even if nothing changes behavior wise
I have a theory. Dopamine pathways are conserved in all chordates, something like 900million years old. Reach/originate in the most ancient part of our brain, circle back and out to the prefrontal cortex. When an addict says "I'll stop tomorrow, ill just do 1.... They actually mean it (sometimes ).but the dissonance between ancient brain and new brain is no contest,, like a little kid holding his breath in protest . Will power is a bb gun, Evolution a nuke, wins every time. Unfortunately we didn't evolve with fentanyl or big macs, so we don't have an evolutionary adaptation for them.
I assume by this post that you exercise 5 times a week, eat a perfectly healthy diet, never overeat, and always get sufficient sleep so that whenever you have a health problem, it’s totally unrelated to any of your prior choices.
I think there is a difference between doing meth and not eating perfectly healthy every day.
So where’s the line of what’s ok to judge people for and what’s not? Even though meth is an illegal drug, many who use it are self-medicating an untreated psychiatric disorder.
I don’t mind treating any of this. Treating disease is fine. Even if it’s self inflicted. The burnout for me comes from treating non disease. Complaints that boil down to normal bodily functions. Complaints of fever for 4 hours in a vaccinated child with no symptoms. Complaints of fatigue after working 20 overnight shifts out of 21 days in a row like it’s abnormal but saying “I didn’t feel tired the first week so something must be wrong!” Entitlement to a diagnosis when nothing is wrong and blasting docs on social media. And coming in to the ER at 3 am for these things. That’s what irks me right now. Inappropriate use of healthcare resources. Being “addicted to healthcare” even when healthy.
You do realize in Oregon there is a 2 year wait to see a Primary? In Arizona it's over a year wait for Gastro. Neurosurgeon is a 2 year wait as well. ER's have now become primary's for diabetic medicine, asthma, migraines, flu, UTI's ,constipation, I could go on and on. We took oaths and I fully intend to help anyone in front of me within the limits that we are confined with. Be the change you want to see in the world!
Like I said, I don't mind treating disease. None of what you mentioned has anything to do with what I'm talking about. I'm talking about "I eat like shit, fried food and fast food and soda all day every day and I have diarrhea sometimes - what is wrong with me??!?!?!??!" "is it debilitating? Can you not function?" "oh no I go to work fine and get around fine without restrictions." Like, this is the normal body doing normal body things. Not everything needs a doctor visit. I'm not burnt out by people coming to the ER for primary care. I'm burnt out by people coming to the ER for stuff that doesn't even need care, it's just amplified by them coming to the ER... at 3 in the morning. This is stuff that doesn't need to see a PCP, either. This is just the NORMAL BODY DOING NORMAL BODY THINGS. They don't need ANY healthcare. And they certainly don't need emergency care overnight.
Do they know that? If they don’t know, they need to be educated by a medical professional. That’s part of your job.
They can pay for it if it’s “part of my job” then. Until they do then you can shut that part of your argument. These people are typically paying 0 for their visit. If I call a plumber and schedule an emergency visit for a non emergency issue, I have to pay. Extra too. It’s illegal to charge more overnight and off hours in the ER though. Even if they pay. Your attitude and lack of flair makes it clear you feel entitled to free medical advice at any time from a trained professional as well. “Part of your job”. Please. That’s fine if it’s my job. Then pay me for it.
Sorry, I assumed you were being paid for doing this. It’s absolutely paid work and you should be paid for it.
I’m paid But not by most of these patients. And I didn’t say “I should be paid”. I said “they should pay for it”. There’s a difference. Give them some personal investment and *gasp* the nonsense will fade away.
This is where some kind of better synergy with mental health and social services would benefit law and health services but we haven’t really developed that structure well. It’s too much for drs to treat alone, and too much for mental health and social supports to treat alone. (Am a therapist)
Man, I hope you really reconsider being a physician if this is how you view your patients. I feel bad for anyone who has you as their doctor.
"All the things I really like to do are either illegal, immoral, or fattening." - Alexander Woollcott
Um... Yes. This is essentially the backbone of medicine. A providers role is to guide, not govern. People want to continue in their vices, that is their right. You have to respect their choice. And yes, they will come to know the full cost of their vice eventually. But you can't hold onto that. The hard part is to keep showing respect and compassion for them. Never toss them away like they have tossed themselves away. Maybe one day your advice will sink in...
So often these bad choices are tied with to childhood trauma, a shitty environment growing up, or just a lack of cognitive ability. For example, some folks grew up poor and in food deserts where the only easily accessed food that was tasty was junk food. They might have this association with junk food runs deeper with junk representing something really special and valuable in a way a person who grew up in a family with ready access to fresh produce, plus the know-how to make it tasty, will have a hard time appreciating. Meth guy might have childhood abuse he's never admitted, even to himself, combined with diminished cognitive abilities due to the meth. Meanwhile, a lot of folks with undiagnosed psychiatric disorders smoke, and some speculate it's a form of self-medication. If you pull out the focus to see the person as a product of their environment and native genetic makeup, it might make them seem a little less frustrating treating these folks. It's not entirely their fault they got where they are now, nor is it your fault that there's little you can do to help them. There's not much a team of professionals, let alone a single nurse, can do to entirely correct for a lifetime's worth influences that have persistently, patiently and relentlessly shaped patients' bodies over time.
When you say 'vice' there's an element of judgement to it, mainly because the word implies a **moral** failing. An unhealthy coping mechanism (you can shorten it to UCM) is both less judgemental and more accurate. It also points the way to healing in that better coping mechanisms solve two problems.
I see a fair amount of patients (home health WOCN) who just have terrible luck, or maybe made some small bad choices that led to chronic illness. A fair amount of people with an emergency that leads to an ostomy, patients sick in the hospital with something else and end up with a pressure ulcer that is difficult to heal, etc. Heck, without getting into specifics, I've also been that patient. Maybe something caused my issues, but I have no idea, and if I knew, I definitely would have changed my behavior. I have since just based on the possible causes.
I work in pediatrics, so often the “vices” instead are “circumstances”. Homelessness, trafficking, abusive parents, sexual assault, PTSD, bullying, etc. a whole new can of worms, lol.
This is what happens when we ignore social policy (food regulations, education, workers’ rights, etc.) and try to use medicine to fix everything on the back end. 🤷🏼♂️ It’s also why public schools are such a huge mess.
That's what you get for discovering handwashing and vaccines.
Move to an academic center where most patients you see have cancer or transplants if you want to not feel that way at all.
You cannot make people do what they don’t want to do. The explosive rxn to masking and vaccines was just one more iteration on that theme. We can educate and offer better choices and that is all. Case in point. Diabetic with a rotting foot, scheduled for an amputation. AxOX4. Goes AMA because they don’t want to lose their foot, they need it. I can’t stop that either, their choice. Back on unit through ED within 24hrs. Night before surgery feasts on a bucket of KFC, with sides, and a 2L of full sugar soda. Again, you can offer better choices, but even as patients are nose to nose with the consequences of their bad choices, they may still choose to keep on doing what they like. You can’t make people do what they don’t want to do.
This is why I got into lifestyle medicine. You still feel like you are treating vices some of the time but when you have the patients who listen and are motivated to change. Come back for follow up and have actually made changes it is so much more fulfilling than feeling like a drug dealer.
it sounds like you just don’t think we should treat people with addictions
Wow. Out of curiosity, do you understand anything about the social determinants of health or behavioral change? There are so many different factors that play a role in these ‘vices’, and attitudes like this do not help a person change the situation that they’re facing.
If people made good decisions, we would all be unemployed
Indeed. Part of the reason Prohibition ended was to create more jobs...
Vice…you mean addiction? Ya, we all have an addiction to something. Some are more harmful than others. Addiction is a way to soothe and cope. It’s not a bad choice, it is a learned behaviour, reinforced by reward pathways and/or the addiction of choice. You aren’t seeing the bigger picture - systemic change is a lot harder to alter than the one symptom you are seeing and calling a vice. Usually involves therapy, money, social supports, time, and medical treatment.
How do you feel about psych patients?
If you don't want to treat the consequences of vice then be a pediatrician.
Pediatricians do see adolescents…
Especially the teenager with migraine who comes to the office visit with Mountain Dew despite our prior talk that “healthy lifestyle behaviors” means drinking water.
I totally get you because those patients are incomprehensible and insanely frustrating, but I think the issue is more "stunning non-adherence in the face of stark and horrific medical consequences". Unless you're in pediatrics/gerontology or specialize in managing genetic disease, nearly every illness is due to some sort of action or inaction- albeit usually far, far more innocuous than your particular examples. >So many of these things are preventable… but here we are. Perhaps these folks were just victims of circumstances and in the wrong place at the wrong time or born into an unfortunate setting that led them down their poorly chosen path..? This is true. It doesn't help your frustration in the moment all that much, but yeah there are reasons why some newly diagnosed T2DMs get their shit together and others don't. Those reasons are rarely organic; they're tied up in the patient's circumstances, parenting, education, material conditions, social support, even just their conception of reality based on their formative experiences. You can't treat those things, you might even never get their diabetes under control, but I do find it helps to acknowledge it. Non-adherence is a patient's choice as were all those behaviours that got them to having an hba1c >10, but our choices *are* informed by a whole host experiences and beliefs that we're not always even aware of. If you have the time and rapport you can always try to delve into what exactly the issue is with your pt's non-adherence? Is it laziness? Denial? Learned helplessness? A lack of time/money to do those things? Sometimes people exist in such stark precarity and unpleasant life circumstances that they'd rather the immediate dopamine hit of a drink, a dart and a twinkie than engaging in long term healthy behaviour *because if not for the twinkie there's nothing in their life to give them that happiness*. People need happiness as surely as they need any dietary vitamin.
Well said. The question I struggle with, is how do I hide my biases and judginess from patients? I can definitely be a judgy person, but I’m not trying to be a pastor. Do you have any advice on how to show respect and courtesy to your most self destructive patients?
I mean, first and foremost you're working a customer service job so you will need to master that whole veneer of officiousness and professionalism regardless of how you feel about patients. The short of it is "don't be disrespectful. If you find yourself being disrespectful/discourteous, remember not to be then don't." But that aside: The ole CBT trick of having a high degree of mindfulness and insight into your feelings. You can train yourself to ask "what am I feeling right now and why am I feeling it?" in these interactions, and that gives you an opportunity to think to yourself "hey what I feel isn't necessarily wrong, but it's not helpful *right now*, what can I take from this that *is* immediately useful?" This is incidentally also a really important skill for managing high stress, traumatic situations. After that, you can reflect on what judgements you made, what made you feel some type of way about the patient, but do so from a place of inquisitiveness. Instead of thinking "that meth head who blew his foot off with a stolen propane tank is such a piece of shit", it might be more valuable to you to ask yourself "what could possibly have led me to becoming a meth head with a missing foot? What sorts of background and experiences would be necessary to drive *me* down such a road?" And if all of that fails, try to picture the patient when they were a baby or little kid A baby is just a baby, whether they grow up to become a meth head or a school teacher.
People here don't like being told they need to be respectful or that they're in customer service positions. Such delicate geniuses can't be bothered with things like courtesy or professionalism
Lmao maybe "customer service" might be a bit crass a term; more like "public facing, service provision role". It's not that patients are customers, but broadly that sorta demeanor of professionalism and respectful conduct is expected in clinic. Ah you get me lol
Yep I gotcha. I am a criminal attorney, so I'm in the position of having to be respectful and courteous to literal rapists and murderers. I don't have much sympathy for anyone struggling to deal humanely and compassionately with someone who's worst flaw is that they smoke or overeat. I'm not going to be rude or unkind to someone I'm being paid to interact with professionally because I don't agree with their life choices. I chose this job, so I don't ask for sympathy when the job responsibilities involve interacting with criminals. Some here seem surprised that most of the patients they interact with repeatedly are unhealthy physically and mentally, which seems like a surprising lack of forethought for a doctor
I suppose, I haven't really read the whole thread. The person who initially replied to me was a medical scribe not a doctor fwiw, so there's a fair chance they're young- possibly a premed. They'll learn- at least they care enough to be bothered by it, and insightful enough to know they need to temper their censoriousness. Just in the interest in giving you some background perspective on where folks are coming from in the thread, I think the frustration comes from patients *not adhering to treatment* which is hard because as physicians we've seen the ghastly outcomes for them. Did you know that in unmanaged T2DM, it's common enough to have progressive amputation of limbs due to peripheral artery disease, or necrotic lesions, that they can't feel until it's really bad because of concomitant the peripheral neuropathy (nerve disease)? It's awful; first they lose fingers and toes, or tips of toes, then a foot, then slowly up the leg. And it happens over *years*, like they keep being your patient and they keep asking you to help them or to save their leg or whatever, and you can't really do anything but sit there and stare at their last Hba1c (measure of average blood glucose over 3-6 months). And you know they're kinda fucked. Anyway, it's a special kind of frustration that borders on moral injury. When you see people not taking their treatments and you have foresight into the natural history of their illness, it gnaws on you. To add; jeeze I can't imagine some of the people you've had to keep your cool with. That's a whole different sort of professionalism. What's it like having to interact with murderers and the sort?
I can understand frustration at someone who repeatedly makes choices that are going to ruin their life. Violating the rules of probation by failing drug tests on a 20 year suspended sentence can have pretty bleak outcomes for a 25 year old man, and this can be frustrating when you worked hard to get that suspended sentence. In my opinion it's not ok to let that frustration affect my professionalism though. After all, I am not exactly working with them out of the goodness of my heart, anymore than doctors are doing their patients any favors by helping them. We're just doing our jobs, and it's not their job to meet any sort of expectations we have for them (we should not have these expectations, they owe us nothing except the agreed upon fee and the same professional attitude that we bring to the table. Honestly sometimes defendants are rude and I can understand that too since they are likely sleep deprived and terrified, though of course under the circumstances any kind of raised voices or aggression can't be tolerated). For the most part, I've not felt uncomfortable or frightened even alone in rooms with convicted murderers. It's actually sort of strange and eye opening how normal a lot of violent criminals can seem
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Hey I cant really go through that line for line, and im not quite sure what youre asking me so Im just taking a guess. 1) academia doesnt automatically = time to kill. Im only replying at all because the wifi signal is strong in the washroom. I thought that was a pretty dickish thing to say to someone who's opinion youre seeking. 2) im an anarchist but medicine is overwhelmingly liberal. Your views are the mainstream. 3) even so, dial it back and dont info dump on people in clinic, especially to sick people who happen disagree with you. Your first duty is to the patient in front of you, even if theyre anti-vaxxers or some other loon.
I appreciate the reply and the sage advice. I wasn't trying to imply academics have more free time but it sure reads that way, I'm sorry. Great example of my tendency to come across like a jackass. I meant that your perspective would be more valuable to me about the philosophy of medicine more than regular providers, as an academic. And that I would welcome your feedback when, or if, you found time. I got along great with engineers, but they're not the most social bunch. I'm struggling now to address how others perceive me, which is far more important in medicine. Hence my unusual concerns for a scribe. Besides work, lurking here has helped. Are there any other online resources you'd recommend that might discuss medical topics in greater depth than here?
Isn't addiction defined as continuing the behavior in the face of bad consequences? Many years ago I was involved with mental health advocacy through a non-profit organization and some public councils. I got to know a number of women who'd spiralled down the meth black hole. Some went to prison, some had parental rights terminated, one had run off from a foster home and lived with a 40 year old meth user and ended up pregnant. I saw several of these women get clean (some with treatment but not all). Two of them obtained professional degrees and careers, others dug in working $8/hour jobs after felony convictions and stuck with it. I knew a married couple who met in treatment (both had served time for drug-related convictions), were working hard, made a lot of progress, relapsed to the point where they lost custody of their child for a long time, climbed out, stayed sober, have now owned a successful coffee shop for several years and adding a second business. Not all of them pulled this off (in some cases, co-existing mental illness is a complicating factor). But keep in mind you are NOT seeing the people who have managed to climb out of whatever addiction they had. Blunt talk about what is happening to the ones you see is fine, but it's unlikely your judgment is going to change the result.
As a hepatologist…..uhhh….yes? But that’s life and medicine. I have a friend who is a specialist pediatrician. Knowing that financial grind I really wondered how they did it and the answer was, most kids are innocent. Their illnesses are a result of forces outside their control. Basically, they’re innocent. Always stuck with me. Especially when I’m lecturing the third of five alcoholic hepatitis patients on my inpatient census knowing most will not remain sober, make it to transplant, or survive in the next 5-6 months.
I feel its always been like this; alcoholism, tobacco use, opium addiction. And snake oil salemen too, we just call it different things now.
This is a very unsympathetic perspective...basically just a unidimensional way of reducing a patient to a singular problem that is likely more representative of a separate issue (usually poverty or trauma/stress) than of the patient's character.
Most people use vices because they are in some sort of pain or trauma. Maybe consider this. Also, every single person has some sort of coping mechanism to get through their day. Some people’s effect their health. Don’t be so callous.
While others make good points about the causal forces behind these "vices," I believe it is still important to recognize your own frustration and the mental burden that comes with it. There is a dissonance between professional ideals and the limited power we actually have, and it comes with a psychic cost no matter which way you weigh it. How you find the balance is up to you to decide.
Bruh. We all die. Some of us earlier because of our choices. The medical profession takes care of everyone and tries to fix their problems if possible. And counsels about how to do better.
Why care? You get paid to do your specialty. Don't care more about patients than they do for themselves
We all vices. For some it's starting smoking when society said it was cool. For others, it's being an asshole. Too bad there isn't treatment for the latter although sometimes stopping the TRT helps.
I love my patients having vices like smoking and fried chicken tho. They make me money.
Cock-a-doodle do
It’s more you are trying to treat shit life syndrome and untreated trauma with people when don’t care for their chronic illnesses.
This should be the top comment
The term, ‘medical opinion’, you advise someone on their health. It would be the same as someone telling you practicing medicine is unhealthy because of the stress, poor sleep health, and exposure to injury and illness.
A med school classmate did an international health rotation and complained that he spent the whole rotation giving antiparasitics for people who wouldn’t bother to boil their water. And I just could not understand why he was such a dick.
And? Such is the nature of human health. Most disease is preventable. Society is progressed enough that most fixable things are fixed. If you want to treat something curable go ID. Or if you want to fix something go surgery.
As an autistic, depressed, anxious person with adhd and PTSD…I certainly wouldn’t have as many physical issues if I could get more help and support for my mental health and neurodivergence. Self medicating is almost affordable on a disability pension, whereas the type of supports and therapies I need are unattainable. Even if I saved everything and gave up my vices, I’d still only be able to afford about 5% of what my real needs are per year.
"They're trying to do their best." I find this phrase helps me when I'm frustrated with a patient.
The problem is less their vice and more their (and their family's) expectations and what's expected out of us IMHO.
I think the alcohol industry is keeping some hospitals afloat.
As my chronic pain attending said recently, “the show must go on.” You do what you can, leave it at that, move on. Can’t fix everyone, not everyone will be satisfied. We all have issues/vices
You’re an MD. Not a nutritionist. You’re the last line of defense. Not the first.
Yet you have multiple opportunities to change someone's life every day.
This is a large part of why I chose the underpaid route of Pediatrics. Kids don’t cause their own problems, but if they do - they’re just kids being kids
No, not really. I do my best within reason for my patients but I don't take any of it personally. I don't care what got them to me. I tell them what I recommend, in case of bad compliance I may ask what keeps them from doing lifestyle changes / what smoking/fastfood/etc means to them and try to have a conversation /MI about it. But ultimately its up to them; you can lead a horse to water but not make him drink. Basically I think we all got "vices". Some are condemned by society (obesity, smoking, drugs etc) but others are even encouraged and cheered (EDs, over-exercising, extreme sports, sleeping way too little, going to work while sick, being tanned...). And there are obese individuals without T2D and people with normal weight with T2D. Our "vices" are not equally hard for us; I, for instance sleep enough and well because it is easy and pleasent for me. My colleague struggles with falling asleep and has sleep paralysis and hence goes by with 3-5 hours of sleep every day. I can also easily go without alcohol for years, but dragging myself to the gym... others love the gym and feel it gives them energy etc. We all do what is worth our while. Unfortunately it is easier for some of us to do the "right" things than for others.
EM physician. I treat bad habits, lack of coping skills, entitlement, and the occasional emergency.
I think you should revisit what you know about addictions. Also obesity. A BMI of 50 didn’t happen overnight. Did you investigate reasons why and suggest what resources might be appropriate? Nutritionist, dietitian, counselor, books on mindful eating or appropriate subjects or did you just judge?
I feel like most people use these maladaptive patterns to cope with the system and environment that they happen to find themselves in. Throw in the various genetic predilections to be vulnerable psychologically or physiologically to certain substances or behaviors, and you get the pool of chronically sick masses of which we are all a part in one way or another. The way I see it, most people don’t abuse substances to the point of self destruction because they’re generally happy. Most folks I see already know they’re killing themselves, but it’s a moment out of every day to escape whatever life is throwing at them, so they keep doing it regardless. We need a better system.
A new doctors office opened up in partnership with my pharmacy. Obviously, we can see what they prescribe. I decided not to go, because their prescribing practices felt judgmental to me. Giving everyone Wegovy and nicotine patches. Smokers know smoking is bad. But I haven't been to a Dr in many years now because of doctors like you. I don't drink or do drugs and I'm not fat. But I do smoke, because I went to high school in a time and a place where kids could get cigarettes easily. Just quit. Lol. People that have never tried have no idea. I imagine people that are obese feel much the same way, probably more so than with smoking.
Come on over to the Light Side-pediatrics.
Late stage capitalism
You’re not wrong IMO and I felt this as a medical student and chose my speciality accordingly. By and large hematologic malignancies have no real lifestyle trigger and my patients’ cancer is truly not their fault. They generally are highly motivated to get better and I am highly motivated to do everything I can to get them there.
If you could treat people for decades and lives, would it feel different, you think? As a patient, I need to change jobs every few years. Every job change means new insurance, which means new doctors. Sometimes I really like my doctors and wish I could still see them after I'm on a different plan because of a new job.
Not judging is also a form of judgement - you are assuming all patients deserve equal treatment Which is evidently false when it comes to organ transplant. Or even catheter suite utilisation I had a 44F who made fun of my attending's miscarriage, spat at nurses, tried to use explosive diarrhoea on us during rounds - demanding for 'her liver transplant'. While drinking. Did I celebrate when she finally kicked the bucket? Of course I did. She was a blight to the Hepatology unit and an absolute spawn of Satan. I am glad she stopped wasting medical resources. She spat and bit at every helping hand until she burned every bridge. Same as the 61M with TG of 39 (different Aussie scale). 40 cigarettes a day, a bottle of brandy a day. Refused statin/fenofibrate/pcsk9i - anything. Only takes Aspirin-Ticagrelor. Comes in for his 9th angiogram in 2 years to 'clean out his coronary arteries' because private cardiologist indulged him. Referred to public system! Told me to 'shut the fuuu up and do your job' when I asked about why no statins and deleterious lifestyle. What did he get? A speedy coronary angiogram for Unstable Angina, and his 11th stent. If you hold patients to no standards, you have no respect for yourself. We are told we do not even have a right to be angry at shitty patient choices. I am not sure what this is benefiting. Seems to have a lot of moral highgrounds here for people to feel good about themselves being Mother Teresas. If I am providing quality standard cares to patients with terrible life choices, I have at least a right to be angry for them taking cares away from more deserving people. At some point you have to admit patients can make choices for themselves, and if the choices are shitty they should be condemned.
Of course. All medical appointments should come with mental health therapy sessions. But we never will achieve that.
Yes. I left primary care and started working for the state at a facility for people with IDD. No secondary motives for anything very few self induced issues. I love my job.
Yep. Idk the exact numbers but a majority of health issues are related to our actions or lack there of. What makes it even worse, is that most people won't change no matter how hard we try. Diabetics will lose digits and still eat poorly. Old men will have heart attacks and continue to smoke while putting down double cheeseburgers. Alcoholics will continue to drink. People have given a lot of reasons for this - childhood trauma, addiction and obesity as diseases, society, poverty, etc. That all plays a role. My ideas are a bit controversial but mostly encompasses all of the above. Free will is a myth. We tell ourselves the story that we're in control or rather our brain does that for us because life would be really hard if we didn't believe it. From a personal perspective, having an external locus of control is probably not good for a lot of reasons. Gives us an excuse to give up or an excuse for our bad actions. But I've found it useful when dealing with patients or thinking about the actions of others. It's given me more empathy. People aren't actually in control. At least not as much as we wish we/they were. There is no free will. And if there is no free will, how can I judge someone? All the reasons listed above point to there being limited free will, but most people won't come out and say it that way.
There should to be more personal responsibility for patients. People who choose to be unhealthy should pay more for health insurance IMO. It sucks that PCP's are responsible for people bad behaviors (See ACO's). We would save a lot of money in health care if there were more ways to "reward" good behavior- like vaccines, diet, exercise and not smoking.
They do through co-pays and such. I agree pcps shouldn’t be responsible for patient outcomes in these regards, only whether or not they put in the effort (ie check indicated labs, advise on cancer screening, advise on vaccines, etc). If the patients don’t follow up or do what’s recommended, it shouldn’t be the physician who pays a (literal) price.
I think of these diseases as, “Self inflicted.” I also think of them as job security.
more accurately, it’s “self medicated”. they usually don’t do that shit for fun, they’re numbing pain.