Tough Love: When Should Physicians Use This Strategy?
Have you ever stopped bothering to care about a patient? A doctor sent me his own personal account of the smoking Mr Jones:
Dear Happy. I read your article on bounce backs with great interest, and was astonished by some of the vitriol it elicited. I remember having one COPDer bounce back to me three times within a month at the VA when I was a medicine resident. He would leave, smoke and drink, and then come back and be readmitted to my service with exactly the same course each time. It was like Groundhog Day.
Finally I had a little talk with him and said: “Mr. Jones, each time you come in, you’re on death’s door. So I come down to the ER, stay up with you all night and save your life. But you know, I’m really getting tired of having you come in after drinking and smoking and then working like a dog to save your life. So let me tell you, if you don’t quit smoking, the next time you do this there’s a good chance that I’m not going to bother. Why should I? It doesn’t seem to be doing either of us any good.”
To my complete astonishment, he actually quit smoking and stayed quit for about a year. Then he fell off the wagon, deteriorated too far before getting to the hospital and died. I was frankly proud of him for the effort, but somehow suspect that I’d be shot in a drive-by if I ever told that story in public.
What do you think? What is the patient responsibility for their own health when they are armed with the knowledge necessary to make the right decisions and choose to ignore their own responsibility?
It appears in this situation that tough love is exactly what gave this man an extra year of life. Should we as a nation sit by and accept the bankrupting of our nation at the hands of an unmotivated populace given guaranteed access to the fruits of other’s labors without any personal sacrifice? Should we allow the destruction of our country’s solvency to be destined by COPDers who bounce back every month because they choose to smoke and ignore their personal responsibility to society? Should we not expect the population that benefits most from a system of FREE=MORE to pay exponentially higher prices for their right to to express their freedom on the sweat and sacrifice of others?
It’s clear to me if as a nation we choose to excuse our citizens from the financial responsibility of their actions, we will get a nation of Mr Jones’ who have no personal interest to help themselves or society. Only if we stop excusing Mr Jones from raping our nation’s Treasury will we have the opportunity to make significant strides toward financial solvency.
Either patients will have to start paying for the freedom to spend other people’s money, or they will have to be excluded from the fixed pool of resources available to help those who wish to help themselves. As long as we pretend that we can provide unlimited resources to everyone and ignore the responsibility our citizens have to reduce their own consumption of their own health care resources, we are destined to meet a financial collapse of unimaginable pain.
In the hospital setting, I would find it difficult to ignore the death knocking on Mr Jones’ door. I would stabilize and treat him like I do all COPDers who come in, smoking or not. I would do everything I could, within reason, to stabilize his disease process, even if he smoked four packs a day. That’s the way the current health care system operates. That’s the system we practice in.
However, at some point or another, when all the money is gone and hospitals and emergency rooms start shutting down for good, Mr Jones will move to the bottom of The List to make way for patients who offer self sacrifice in their disease process. His care will be triaged. His access will be denied. In fact, if you think this is crazy, just such a suggestion made headline news in Britain a year or two ago as their country’s national health system continues to get buried under uncontrollable costs.
When our nation finally wakes up and realizes that difficult economic health care decisions will have to be made based on self sacrifice and choice, you can be assured that those who choose to do nothing for themselves will be sent to the bottom of The List. If you want to be in that Line, I suggest you continue your ungraceful march toward mortality by pretending that your actions today have no effect on your place in the Line to come.
*This blog post was originally published at The Happy Hospitalist Blog*
I certainly agree with you on your main point. There is much more to the picture of how we spend our healthcare dollars, though. I work in a hospital trying to develop the Lean philosophy and I facilitate the improvement teams. The waste we see daily in our processes can be extensive: asking a patient the same question 5 times and 5 different stations; doctors and nurses not practicing proper hand hygiene; 3 weeks of inventory on hand when only 1 day’s worth is necessary.
Yes, I agree that irresponsible patients who take their health for granted should be held accountable in some way – probably in the form of paying much greater proportionately for healthcare than those who take care of themselves. But, our healthcare delivery systems also need a LOT of work, and unfortunately, the biggest obstacle to this that I see is complacency, which is a great obstacle to positive change.