This is sort of a re-write.
Or, perhaps, a re-write of a re-write.
Last week (or was it this?) I re-blogged one of my old posts.
Re-blogging is when you post a post that has been posted. Fairly obvious. You can either just send it out again or you can post with a comment.
The original blog was about the concept of medical paternalism through to nicey nurse overlykindness. Killing with kindness, IDLES might say. When we do to patients rather than with them, when we forcibly or potentially unnecessarily move them from being people to being patients.
The comment related to an interaction with one of my patients. I offered him a Covid booster. He said no. that’s it.
It was more than that as I had drawn-up the vaccine and visited his house which in 2022 in the UK (and, I suspect most of the developed world) is quite unusual (a doctor visiting you at home, rather than a vaccine being offered).
And, my point had been his refusal, which after some discussion, was accepted. I moved-on. (The next patient said ‘yes’ so the vaccine didn’t go to waste).
All of this relates to the powerplay between people – that is mostly patients, but also their charges, in the situation of carers of children or older people who are less able or who have lost capacity and the world of healthcare, that is doctors, nurses, pharmacists, therapists and so on, although, you would probably want to include social workers in this for although a central tenet of social work philosophy is ‘strength-based’ i.e. looking at what people can do rather than can’t (the latter being the medical, pathology based, where is the disease? Analysis).
So, basically health and social care walk a tightrope between doing with people and doing to.
Doing with is for the most, considered the ideal. It is aligned with teaching me to fish rather than providing me with a haddock.
And yet, for the most, there is what is considered, the health and social care, ‘my way or the high-way,’ approach.
You have a pain. The doctor says, ‘You have a pain, it could be nothing, it could be something serious, I would like to investigate.’ (Doctor is actually saying, it is very possibly something serious and I want to find-out but I don’t want to freak you out.’
The patient answers, ‘Sure, let’s do this.’
The doctor prescribes pain relief, the scan is normal, the pain settles and all is well.
Or, in another scenario, the scan shows cancer, and whatever happens, happens, depending on the type, grade, size, location of the malignancy.
In both situations things have played-out and we are where we are.
In a third scenario, the doctor eventually explains, ‘I am worried about your pain, it could be cancer, I would like to investigate,’ and, you, the 40, 50 or whatever year old says, ‘No, I’d rather not, please give me pain relief.’
Is it here that things unravel.
The patient doesn’t want the test, the doctor wants to do the test, they potentially make a ‘clinical’ i.e. best guess diagnosis and a tension develops. The patient might ask for more pain relief, the doctor again suggests tests, again the patient says no.
It all feels very uncomfortable and somehow wrong.
The doctor might say, ‘I won’t give you any more pain relief until you have a test,’ a kind of pharmacological blackmail.
A tension develops.
Perhaps pain and cancer isn’t a good example.
That was why my patient saying no was one.
‘Just say no.’
Remember that from the 80’s?
There was an advert with Nancy Reagan.
You can’t have ‘my way or the highway’ in medicine, although plenty of doctors and nurses operate thus.
Clinical interaction should be a give and take, a negotiation, a relationship, an exposure of vulnerabilities.
If one of the partners is unprepared to engage it can be tricky.
Standing-up to medicine can be amazingly difficult.
Remember the case of the parents of Ashya King who wanted their kid to have proton beam treatment – they had to kidnap their child and take him out of the country. (I literally Googled ‘parents kidnap child proton’ to get the Wikipedia page.
We often discuss patient empowerment but we know it is a falsehood as too much patient power is difficult to manage. We can’t offer too much choice in the NHS because the waiting lists are too long and the pressures too great.
We are caught.
We become trapped.
And that is what made my patient saying ‘no’ all the more prescient.
I can’t imagine a day working with every one of my patients arguing or disagreeing with what I suggest. It would be exhausting.
For the most, people comply, go along with what is offered and are grateful.
Those who don’t, well, they are in the minority and for the moment we should celebrate them.
Photo courtesy of ‘The Daily Scandinavian’