No, you can’t autopsy my father. When I was 19, saying no to a physician was like cursing at a priest.
I mustered the answer because it carried certainty – funeral then burial then true mourning. Years later, I grasped deeper consequences – Dad becoming body, then cancer specimen, then data blocks and, overriding all, an autopsy delaying everyone getting on with their lives.
In medicine, saying no has muscle. Patients told there are no beds, no chances of survival and no water after midnight. Physicians are told no end to paperwork (verifying, testifying, glazing over), no end to pushy hospital administration (earn your privileges) and no relief from second-guessing.
It takes courage for a patient to say “no” or “not yet” to a physician’s recommendations. It arises from conflict – frustration, mistrust, fear.
For some, it launches dialogue – persuade me how your therapy will benefit me now and 10 years from now. For the newly insured, it’s a blunt challenge to the white-smocked expert that he explain my care in simple doughnut-shop speak.
Why is such transliteration not built in? The jagged-glass payment system doesn’t reward education and lifestyle management.
No requires homework. The doc says you need a total knee replacement. After a lengthy wait for a second opinion, you opt for a simpler, outpatient meniscus repair. In between, you’d scoured the web, talked to physical therapists and patients. Maybe you’ll need a new knee, but you weren’t sold now.
No – to hand reconstruction. That was a hand surgeon’s high-cost, long-recovery remedy for a recurring cyst. You chose less radical but highly cringe-worthy draining by a primary care doc. Author-surgeon Dr. Atul Gawande said incremental care, providing a grocery store of services, never gets the credit it deserves.
Skilled specialty surgeons draw research grants and myriad resources, while primary care docs are lucky to afford nurses.
Biopsies, mammograms, colonoscopies – gray areas to patients. Physician-as-mentor won’t pillory you for wariness. There is time in a bottle – watchful waiting – for lots of ailments and diagnostic tools. Even so, the patient should feel compelled to remind a physician about worsening aches or discolorations.
Physicians are rarely praised for their relentlessness, selflessness and frenzy. Neither are abusive physicians pursued for their self-lubricating criminalities with the zeal we accord terrorists.
Some patients need to be told no. Some milk the system to feed addictions (so much so that California enacted CURES, an electronic database that tracks prescriptions for painkillers and other controlled substances). Some saturate emergency departments as though they were taking free carnival rides. (Fresno County has taken steps to deter such “frequent fliers.”)
Some patients – and doctors – need to experience a hard stop when it comes to pumping kids with cough medicine and useless antibiotics for the convenience of pawning them off as healthy enough for day care.
Patients should weigh their words carefully. Unlike politics, good manners and civility count for something. A recent study in Pediatrics found that nurses and doctors didn’t provide the same quality of care when they encountered rude behavior.
Navigating no is getting more complex. For one thing, the hands-on part of caregiving is diminishing. Your doctor visit doesn’t routinely include checking ears, throat and eyes unless they’re attached to your complaint. Medical intermediaries abound – tasked with gauging your blood pressure and pulse, taking an X-ray. You’re supposed to know – instinctively? – what not to ask them.
So, digging in your heels may get you the higher-up attention you want. Any doctor who doesn’t appreciate a patient’s commitment to his own well-being deserves a turnstile, not a waiting room.
John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at firstname.lastname@example.org.