Biblical Reflections on Modern Medicine
Vol. 5, No. 3 (27)
I have pondered the theme and specifics of this article for the last 2-3 weeks. I have vacillated between naming people and events to limiting myself to a generic presentation of principles. I will end up somewhere in the middle.
Is there a minimum number of pillars by which to judge what is or is not an evangelical, medical ethic? "Where is the wise man? Where is the scribe? Where is the debater of this age? Has not God made foolish the wisdom of the world?" (I Corinthians 1:20, NASB)
What, then, is our goal as Bible-believers? Are we to seek common ground with unbelievers? Are we to argue on philosophical bases without reference to Scripture? Are we to seek to influence a godless society without requiring them to be born-again? Are we to argue on the basis of Western tradition?
The answer to all these questions is a qualified, "Yes!" We are called to be salt and light in the world. However, one is struck by the contrast in the Bible between the "world" and God's thoughts. For example, we are not to be "conformed to the world" (Romans 12:2). We are not to be "friends of the world" (James 4:4). We cannot love the world and love God (I John 2:15).
Other contrasts in the Bible between man's thinking and God's thoughts are "light" and "darkness," "sight" and "blindness," and "wise" and "foolish." Surely, if evangelical ethics does not sharply contrast with secular ethics, then something is amiss! I want to suggest some distinctions.
First, there must be no compromise on the Bible as the final arbiter of truth and ethics (right and wrong). More specifically, the Bible must be believed as being "infallible and inerrant" (IAI). More than any other descriptions of what the Bible is, this theological language separates Bible-believers from Bible-compromisers. If you are not aware of these terms, you are not aware of the ideological battle for truth in the 20th century.
Generally, IAI means that the Bible is conveyed to modern times under the guidance of the Holy Spirit so that modern translations (by men who believe in IAI) are the very Word of God. The Bible, then, is IAI when properly understood in everything to which it speaks.
Admittedly, many who believe in IAI differ over interpretation. However, there is a great gulf between those who argue within the beliefs of IAI and those who argue outside the beliefs of IAI. IAI is the two-edged sword that divides those who defend Biblical truth and those who don't. Those who believe in IAI may properly be called evangelicals. Those who don't believe in IAI are falsely using the label evangelical.
Two great conferences have been held in Chicago by the International Council on Biblical Inerrancy. The first in October 1978 defined the Biblical and historical position on the inerrancy of Scripture. The second in November 1982 focused on Biblical interpretation (hermeneutics). These two conferences defined the modern debate over the Bible as truth and its proper interpretation.
Second, there must be no compromise on abortion. Individual human life begins at conception (not implantation). That life must be protected and not medically aborted for any reason except possibly to save the life of the mother. Exceptions because of genetic defects, congenital malformations, or rape and incest are compromises that ought to exclude an evangelical, medical ethic.
Third, there must be no compromise on euthanasia. Euthanasia is any medical
act that intends the death of the patient. It is to be distinguished from
withdrawal or not initiating medical treatment because implementation
As this newsletter is being prepared for publication and distribution, a conference will be held at Trinity Evangelical Divinity School (May 19-21), sponsored by the school and the Christian Medical and Dental Society (CMDS). It has an impressive list of speakers, many of whom are solidly evangelical. However, some are not. I will not name them here, but point to this conference as an example where its description as "evangelical" cannot be trusted.
Some speakers would not subscribe to infallibility. Some are not strictly against abortion, as I have described above. Some might not even be against euthanasia.
First, Bible-believing Christians are being misled. By this conference being called "evangelical," speakers are being included who are not evangelical. They are wolves in sheep's clothing.
Second, such an approach is dishonest theologically and philosophically. While all appear to be in agreement on fundamentals, all are not. Consistency, congruency, and correspondence within a system is at best compromise and at worst an eclectic patchwork.
Third, such an approach dishonors Christ. Jesus said, "If you love me, keep my commandments." While none of us understands or keeps them perfectly, at least the three pillars that I have named are supports for a a truly evangelical approach.
I am only attacking one arena (medical ethics) where the Church of Jesus Christ is in serious trouble for her failure to be more discerning. Major evangelical publishers have published less-than-evangelical books and periodicals. Churches and Christians have virtually invited the Trojan Horse of psychology and psychiatry into the pulpit and pastoral counseling. Hebrews 5:12-6:8 calls Christians to get beyond the fundamentals, but most Christians today cannot even name the fundamentals, much less teach them or get beyond them. And, perhaps it is no wonder, with the deception that is perpetrated by their leaders.
However, I weary of those masquerading and prospering as evangelical Christians who demean the Word of God. I weary of those leaders who know better but don't call their brethren to account. Many leaders want respectability and the appearance of being "scholarly" from secular writers and institutions, rather than confronting them on their godless approach. They have chosen the praise of the world rather than faithfulness to God's Word.
True American Christianity is going to have to exercise far greaterdiscernment than it currently does in order to meet the challenges of modern times. A major arena of this challenge is medical ethics. The Church and our country are floundering from messages of false prophets. Perhaps, we need an old-fashioned Scottish revival: a large number of subtractions rather than additions (among leading teaching and writing evangelicals).
A New Stress for Stress Tests
A 71-year-old man was recently referred to our echocardiography laboratory for a stress test with dobutamine (a drug that stimulates the heart). Initially, he appeared to be a calm, soft-spoken man (a reflective thinker? - Ed). His resting heart rate was 81 beats per minute. During the first dose of dobutamine, his base-line heart rate was 92 beats per minute.
He then engaged one of the physicians in a discussion about Hillary Clinton (sic) and the Clinton administration's proposed health-care reform. It was clear from the conversation that the patient was strongly opposed to it. While he was talking about health-care reform, his heart rate increased from 91 to 117 beats per minute. When he stopped, his heart rate rapidly decreased to 94 beats per minute. With an incremental increase in the dose of dobutamine, the patient's base-line heart rate was 100 beats per minute.
When the discussion of health-care reform resumed, his heart rate increased to 124, and when the discussion stopped, his heart rate rapidly decreased to 105. With the next incremental dose of dobutamine, the patient's base-line heart rate was 117. It increased to 147 during the discussion of the proposed reform. When the discussion ended, his heart rate decreased to 124. The study was terminated at this point, since the target heart rate had been achieved.
In this patient, the additional stress induced by conversation about Hillary Clinton (sic) and the administration's proposal for health-care reform caused an average increase in the heart rate of 26 (+/- 3) beats per minute as each dose of dobutamine was administered. The discussion resulted in attainment of the target heart rate at a lower dose of dobutamine than might otherwise have been possible.
When a stress test with dobutamine is conducted, the addition of emotional stress induced by a discussion of health-care reform may lower the risk of untoward effects of high-dose dobutamine. With judicious application of the discussion, we were able to complete the stress test in a cost-efficient manner.
Further studies are needed to confirm these promising but preliminary findings.
Reprinted from The New England Journal of Medicine, March 24, 1994, pp. 869-870 (with minor changes for publication here).
As with any new procedure, major side effects may occur. In some patients who are even more strongly opposed to the Clinton's plan the "target heart rate" may be achieved without any medication. Such discussion might even precipitate a heart attack with even stronger anti-emotions! I recommend caution with this new approach to stress testing.
* I have named this column after a funny and punning subscriber, Robert W. Robinson ("Bob"). However, some selections for this column are my own (as this month). I leave his name attached so that he may achieve all the credit for good selections. The editor always receives the criticisms for bad copy anyway!
by Donald G. Smith
My son developed an interest in sports at an early age. As I recall, he was throwing a ball in the playpen while ignoring his stuffed animals. A born competitor, he grew up seeing me as a batting practice pitcher and punt return man as much as a father, and our blood bond was forged in the fires of competition.
A most important plank in our relationship evolved from the phantom curve, a rather clever bit of chicanery that I sold to him as the "unhittable pitch." I had used it in my playing days with the Dakota All-Stars, but only sparingly because I was acutely aware that this weapon could ruin the game of baseball. I jealously guarded my awesome secret and refused to teach the pitch to anyone else. As a player I had used it only in crucial situations and threw it no more than three or four times a game. As the story went, no batter ever came close to hitting the phantom curve.
As I said, my son was a competitor, and he was determined to hit the unhittable pitch, but of course he never did. When he hit the ball, he would look hopefully at me and ask if that was the phantom curve. The answer was always negative, but when he swung and missed, we had a different story. That, was the phantom curve.
He was about eight when he finally saw through the whole charade, realizing that he couldn't win because I was calling the shots. I alone decided what was, and what was not, this remarkable pitch. The whole thing was rigged, and he was the victim of a bit of deceit from a man with questionable pitching skills and an active imagination.
I recalled the phantom curve recently when I heard yet another speaker castigating the federal government for its "inadequate efforts" in dealing with AIDS and the homeless problem. The simple truth is that efforts to date have been far too ambitious because neither matter is the government's business, but that is another issue. The point to be addressed here is in the area of problem-solving. The speaker, and all people of like mind, see the federal government as a problem-solving institution, a place in which bureaus and departments are established to deal with social problems. Then, presumably, the problems go away and humanity takes a giant step forward.
It is another case of the phantom-curve deception because the whole thing is rigged from the outset and no batter will ever make contact. People who are awarded desirable government jobs, with all attendant perks, don't work their jobs out of existence. This is a universal law of human nature and shouldn't be all that difficult to comprehend. These people don't solve; they regulate. Solution is terminal, and regulation is forever.
This is not intended as a put-down of government workers, because they are human and they react. Not being entirely pure of heart, I would do the same thing if given a plush office with commensurate salary, medical coverage, a fat pension plan, a government car, and all kinds of business to conduct in Paris and the Bahamas. The problem is not the people, but the system--a system that makes problem-solving the kiss of death and problem-perpetuation a one-way ticket to the good life.
This is something that ourself-appointed humanitarians don't understand. Government doesn't cure diseases, and it doesn't make the indigent disappear. It doesn't make the deserts bloom, the blind see, or the lame walk. This is not why we have government.
It is interesting to note that since Lyndon Johnson offered to cure all our social ills with the Great Society, we have spent more than a trillion dollars trying to turn the federal government into the Magic Kingdom, and it hasn't even come close to working. We have added five cabinet-level departments, all devoted to some kind of social betterment, and this has resulted in nothing more than jobs for people who regulate this massive wheel-spinning operation.
All of this leads us back to the phantom curve, the unhittable pitch. Whenever I hear of a new Federal agency created to solve a social problem, I think of a seven-year-old boy, digging in at the plate and mustering all his skills and determination to do something that couldn't be done, simply because the man who controlled the game wouldn't let it be done. There is, however, one major difference. The little boy figured it out and went on to more constructive things. People who should know better are still up there swinging a bat.
Reprinted with permission of the original publisher. The article appeared in The Freeman, July, 1991, Foundation for Economic Education, Irvington-on- Hudson, NY 10533 and a recent pamphlet published by the Association of American Physicians and Surgeons.
by Stephen Lefrak, M.D.
Why should a hospital devote space and time to a display documenting events which took place more than 50 years ago? Why should health-care workers, patients, employees, or hospital visitors be interested in the crimes of National socialism? Although there are many ways to answer these questions affirmatively, I should like to emphasize the role medicine and physicians played at all levels in the Nazi regime, and particularly the view that "National Socialism is applied biology," as enunciated by Rudolf Hess, Hitler's Deputy Chancellor.
The doctors' trial at Nuremberg, in December 1946, at which 20 German physicians stood accused of heinous crimes and of whom 13 were found guilty, produced a convenient record to hide behind for the remainder of the profession. The vast majority of 95,000 German physicians were seemingly exonerated by the guilt of these 13 (plus some 250 others tried later). The world's medical profession could take solace in believing that "real" doctors were not involved in this evil.
However, the role physicians played in Germany between 1918 and 1945 in determining the form of society achieved there has just begun to be revealed. What is seen is nothing to make any physician proud. Instead of seeing a profession which resisted subversion of its ethical precepts, we find physicians in the foreground of racism and eugenics, as the initiators and designers of the apparatus of mass destruction and unethical experimentation. This, unfortunately, is not a history of a few madmen on the fringe, but rather a revelation of the depths to which the leading medical establishment of the time sank.
Medicine provided both the theoretical basis and the means by which National Socialism instituted their eugenic policies. Involuntary sterilization of over 450,000 German citizens was only the initial step in what was to become a vast eugenic enterprise. Obviously, (the means) to carry out a sterilization program of this magnitude required the support of the medical profession and other health-care workers. Physicians betrayed their patients by reporting those with "hereditary" diseases to the authorities, physicians and academics sat on the genetics courts, physicians and nurses carried out the procedures, and physicians examined the pathological specimens.
Soon, the mission to protect the germ plasm of the Volk and to preserve scarce financial resources moved from sterilization and castration to killing. It began with handicapped newborns, spread to adult German citizens, and eventually became mass annihilation. Throughout this entire process, physicians were the killers or directly abetted them. They reported their patients, falsified death records, designed the methods of death, regulated the flow of gas in the chambers first used to "euthanize" mentally ill German citizens, selected those to die in the concentration camps, and participated in direct killing. National Socialism could in fact claim that all the killing was medical; medically indicated and supervised and carried out by doctors. "Lives deemed unworthy of life" were destroyed, beginning with the handicapped and progressing to those judged genetically unfit by the physician eugenicists in German universities and research institutes.
Medicine has avoided confronting this issue by professing that this was the work of a handful of mad, immoral scientists. We must recognize that it was not a handful, but rather a plurality of a highly skilled and technically advanced medical profession who joined the Nazi party (approximately 50% of German physicians joined, twice the ratio of lawyers) and betrayed their patients and their oaths.
We stand on the doorstep of the 21st century, armed with a new genetics, confronted by arguments for cost control, encountering increasing participation of the state in the physician-patient relationship, and challenged by new debates over euthanasia and physician-assisted suicide. We must learn the lesson of German medicine during the 20th century!;
(Summary of a presentation at given at several locations. Reprinted with permission of the author.)
Dr. Lefrak is Professor of Medicine and Assistant Dean of the Program on Humanities in Medicine, Washington University School of Medicine, and Director of the Medical Intensive Care Unit and Chairman of the Ethics Committee, Jewish Hospital of St. Louis, Missouri.
There is some debate among Christians, and indeed I am not settled in my own mind about the need for vaccinations in children and adults. However, a pertinent thought came to mind as I discussed this issue with a caller recently.
While some childhood diseases for which vaccines are currently recommended are relatively mild in children, these same diseases in adults are far more severe. Examples are hepatitis A and B, chicken pox (varicella), measles, and mumps. Although German measles (rubella) is usually a mild disease in adults, the threat is to the unborn children of pregnant women who do not have antibodies to this virus. With more children and adults being vaccinated against these diseases, those who are not vaccinated are less likely to have the natural disease and subsequent immunity as children and be exposed as adults when the disease would be far worse.
All things considered, I favor most currently recommended vaccines (unless one is trying to hide his child from any form of state registration). The risks both to natural disease and to bureaucrats seem to outweigh the minimal risks of vaccination.
"Modesty: A 19th century idea that women's legs are joined together from the knees up, that breasts are not fit for public view unless they are on TV documentaries of native tribes, and that all children must be protected from seeing the human body." (Sheri S. Tepper. "This Is You." Rocky Mountain Planned Parenthood, Denver, Colorado, 1977.)
Commentary: This example is just another piece of evidence that liberals are revisionists and distortionists to the core of their being.
One executive of the Godfather's Pizza chain has calculated the impact of the Clintons' proposed health-care plan on his company. The present cost of Godfather's health insurance is $540,000, with the employer paying 80 percent of the cost.
Under the Clinton proposal, the same coverage would cost Godfather's $2.2 million, an almost four-fold increase. (Rush Limbaugh Program)
Commentary: While some claim that politicians must lie (I don't) to get into office and stay there, the lies of the Clintons on health care (and other issues) stagger the imagination of any moral person.
In January 1994, the American College of Obstetricians and Gynecologists recommended that "medical services (abortions) be provided by persons who are not physicians." "'I think the ideal would be that physicians would be performing them,' ACOG President-elect William C. Andrews, M.D., said. 'But as a pragmatic thing, if there are not enough physicians who are trained to willing to do the procedure, other options have to be considered. I think it's an access to care issue." (The Religion and Society Report, April 1994, p. 6)
Commentary: For decades, great wars have been fought at the state and national level by physicians to prevent optometrists, chiropractors, and other non-physicians from prescribing drugs and doing surgical procedures. It seems that physicians are only willing to release "turf" is when their own have insufficient numbers to handle the numbers of patients with a particular problem.
Obstetricians have had to allow nurse-midwives because fewer physicians were performing deliveries. Now, there are not enough physicians to kill unborn babies, so they are willing to go outside their own.
Two points are important. First, pro-life forces are being successful in getting more and more physicians out of the abortion business. Second, however, the few physicians who do perform abortions are deadly (pun intended) intent upon abortion being available, even if it means yielding their own territory.
Readers should recognize this intent as more than the provision of a contrived need. It is an intent that has been a 180 degree reversal of physicians as healers. Physicians have become mass murderers and they will do whatever it takes to preserve that reversal. With Big Brother taking over more of medicine, being treated by a physician is becoming an increasingly lethal hazard.
President Clinton is claiming the support of all 300,000 physicians who belong to organizations that have endorsed his Health Security Act, including the American Academy of Family Physicians (AAFP). Yet 71% of family physicians are opposed to the Plan, while 12% (+/- 3%) favor it, and 15% are undecided, according to a recent informal survey by the Association of American Physicians and Surgeons (AAPS).
AAPS sent surveys to 5000 randomly selected family physicians nation-wide; about 400 responded.
Given a list of adjectives to describe the plan, 9.5% checked "cost-saving," 4.7% "quality-enhancing," 29% "access-expanding," 11% "generous," 82% "bureaucratic," 63% "socialist," 54% "destructive," and 34% "unconstitutional." Fourteen respondents suggested an additional description that was positive or neutral in tone, and sixty contributed a negative description, e.g. "tyrannical," "deceitful," "unethical," and "self-aggrandizing for bureaucrats."
In response to the question, "If the Clinton Plan is enacted, what will you do?" only 43% checked the answer "sign up with the Plan, submit to the system, and try to make the best of it." Almost as many (38%) said they would "work to have the Plan repealed," and 21% said they would "retire or change my occupation." About 13% said they would "refuse to participate and attempt to practice privately." (More than one response was permitted.)
A large majority of respondents were opposed to specific provisions found in the Clinton Plan and various alternate proposals. An employer mandate is opposed by 65%. About 65% would object to diverting funds from sickness care to school-based clinics and other social projects. More than 75% oppose a lottery for selecting enrollees for over subscribed plans; 71% oppose requiring electronic data submission for all clinical encounters; and 61% oppose forcing everyone to pay for a standard benefits package.
The majority of respondents (55%) favor Medical Savings Accounts. Only 13% are opposed to this concept; 30% are undecided. Here is a sampling of comments.
"I feel betrayed by the AAFP."
"This issue is politically inspired to eliminate the middle class. If they really wanted to make health care available, all that would be necessary is to allow tax deductions for giving free care to those in need."
"AAFP never polled its grass-roots members. I am undecided about continuing my membership as a founding member." [About 8% said they had been polled by AAFP.]
"This plan would be the end of true democracy."
* Reprinted from the AAPS News, April 1994, p. 2
"Throw de bums out" (if I remember correctly) was the fans' demands of the former Brooklyn Dodgers when they were disgusted with their team's play. With the wimpy, politically correct, and out-of-sync leaders of the AAFP, AMA, and other organizations, the "rank and file" ought to "throw de bums out." Or, they (you) should not renew their (your) organization's professional dues.
I know that some readers either participate in survivalist activities (from food storage to military training) or know something of the movement. While I find some activities extreme, the modern growth of and encroachment by the state does warrant plans for a severe disruption of society as we know it.
Some activists paint survivalism as something that borders on, if not inclusive of, something romantic. For example, there is the image of the rugged pioneer in the woods, living off the land, and perhaps marauding against statist forces.
However, the current (or recently past) situation in Rwanda is more realistic and cautions against such romanticism. Totalitarian government is better than anarchy. Now, I believe in a free society as strongly as anyone, but let's not romanticize anarchy. Tens of thousands of Rwandans have murdered and maimed each other virtually at will. Any police or military actions are more a part of the anarchy than any control of the situation.
Further, being on the run from a totalitarian government is no picnic either, especially in light of today's surveillance technology. But, at least a totalitarian state will maintain some form of order, while underground presses and resistances are at work.
Yes, let's prepare for the worst, but no, let's not paint a romantic picture. I don't relish my sons dying in front of my eyes or my wife and daughters being raped or worse. It's not pretty. My family and I will be prepared as best we are able, but we don't look forward to it. One assault or one ambush, and everyone and everything is suddenly gone. May God have mercy on us and our nation.
I know that this subject is not specifically medical, but the picture of Rwanda has had a sobering effect on me. I hope that readers may profit from my reflection.
Under "Bob's Banter" in the March 1994 issue of Reflections, a University of Texas Professor, Margaret Maxey, was cited for her statement that the earth's population should be reduced to 2 billion people.
Professor Maxey was speaking against "eco-terrorists" and "eco-fascists," not for them. She was citing the opposition's statement calling for a reduction in the earth's population and then dismantling their argument.
We regret this error and wish to set the record straight on Professor Maxey who is on "our" side of this debate.
Vol. 8, No. 3 (52) May 1994
In the first 7 years of the AIDS "epidemic" (1981-1987), 93.2%* of all reported AIDS cases were either homosexual/bisexual, IV-drug abusers, or both. Another 3.8% were "heterosexual," that is, in men and women who had sex with a person known to have AIDS or at high risk for AIDS. Thus, these categories of "risk behavior" accounted for 97.0% of all reported cases of AIDS during this time.
In calendar year 1993, 87.0%* of reported cases were homosexual/bisexual, IV-drug abusers, or both. Another 9.0% were "heterosexual." Thus, 96.0% of all reported AIDS cases during this period were in these two categories.
You may be thinking, "So what, Ed? You have reported these numbers before as statistics for the AIDS epidemic." Yes, but I was reflecting on these numbers since the last newsletter. The most serious problem is not AIDS but immoral and illegal behaviors. I have reported earlier that the life expectancy of homosexuals who develop AIDS is 39 years and 42 years in those who don't. I don't know what the life expectancy of IV-drug abusers is, but it can't be very high with the violence and severe infections associated with that lifestyle.
Further, the life expectancy of those in the "heterosexual" category is certainly not that of the average American, because virtually every sub-cateory is also a high-risk for violence and infectious disease.
The point is that the primary problems of homosexuality, IV-drug abuse, and heterosexual immorality would not go away if we had an instant cure for AIDS! The people in these groups would die "before their time" of other dangers associated with their lifestyle without the presence of AIDS.
You see, the focus of a "cure" is all wrong. The real needed cure is a change in lifestyle, not the cure of AIDS. Eradication or prevention of the spread of HIV will change only slightly the general risk of these groups. You may see nothing new here from what I have said before, but for me this explanation is a new slant that minimizes the threat of AIDS. Thus, I have chosen the headline, "There Is No AIDS Epidemic." Now, technically speaking, there is an AIDS epidemic. In epidemiology, the appearance of any disease or deaths over a "normal" baseline is by definition an "epidemic."
However, to call AIDS an "epidemic" is to miss the more serious epidemic that has only a Biblical solution. Indeed, our culture has "sown the wind" and is "reaping the whirlwind." The "wages of sin is death," both physically and spiritually.
* These numbers include a percentage from the "Undetermined" category since most of these are "Incompletely reported." When fully investigated, they generally fall proportionally into the other risk categories.
Generally, the news media have been reporting that AIDS cases for 1993 have markedly increased over 1993. However, if you have been reading this page for the past year, you will know that most of those numbers come from the expanded definition of AIDS that was applied effective January 1, 1993.
Discarding the 1993 definition, AIDS cases are down 2% over 1992. There were a total of 103,500 newly reported cases of AIDS in 1993, with 54% of these under the new definition. In all honesty, some that were under this new definition would also have met the previous criteria, with the overall effect of a slight increase in AIDS cases.
We will see how the news media will treat 1994, when there will be a marked reduction in AIDS cases over 1993 because the new definition will have already been applied to the existing pool of HIV-infected people who were not previously reported as AIDS. (Morbidity and Mortality Weekly Report, March 11, 1994, pp. 160-161, 167-170)
Her more precise estimate was 550,000. Her survey "covered only people who live at home, not prisoners, the homeless, or hospitalized patients." (Chicago Tribune, December 14, 1993, Section 1, p. 12)
Commentary: In the mid- to late-1980s, the "official" estimate of HIV infections was 1.5 million. About 1990, this was reduced to 1 million. Now, this estimate is even lower.
The facts about the HIV/AIDS epidemic is that the numbers have never reached even conservative predictions by the CDC. Yet, neither they nor the news media ever "back off" these earlier estimates. Worse, regulations, laws, funding, and criminal and civil prosecutions have proceeded on the basis of worst-case figures. Such distortion of priority is one of the major travesties that our "officials" have foisted on us because of HIV/AIDS.
by Hilton Terrell, M.D.*
Yesterday a patient launched into a familiar critique of another physician who "did not listen to her." Her story was credible. The particular physician being excoriated varies from version to version, with some area names cropping up more frequently than others, but with all being named eventually. While I don't hear myself named, I'm sure I've been named in other offices. Why is it that physicians sometimes don't pay attention to patients, or at least give the impression that we haven't listened? A complete answer, could it be had, would fill volumes, and much of it would be various physician failures.
There are two sides to the doctor-patient equation, however, and one that gets less attention in print is patient failure. One of the reasons that doctors don't listen well to some patients is that the patients are so ill-prepared to talk. (I write here not of the senile, demented, retarded, juvenile or intoxicated.) In the prodigious transfer of responsibility that has occurred in medical care in the past 50 years or so, a large measure of responsibility for the medical interview has passed from the patient to the physician. We are presciently supposed to know to ask everything relevant, to pick up on non-verbal cues, and to use efficiently the medical records available to us. Any lapse in the giving and receiving of information is, ipso facto, our lapse, references to "poor historian" in our notes notwithstanding. The simple fact is that many patients are inexcusably poor historians, taking little responsibility for their end of the communication. Many outpatients cannot even state why they have come into the medical encounter. They sit like a lump of marble before Michelangelo, who can carve from it whatever he wishes. Even if a one-sentence chief complaint can be uttered, the patient has often not considered what else the doctor might need to know. Questions that involve timing -- when did it first began, how long does each attack last, how frequently do they occur -- are hardest to dig out, though critically important. A severe headache that began late night for the first time ever establishes different priorities than a severe headache occurring about once every two months over the past decade.
I struggle with timing questions largely because patients do not listen to me! A typical exchange might be as follows, after the patient has been given opportunity to state his complaint and a lull occurs when he has finished his recitation: Dr. "When did you first notice the lump?" Pt. "It's not painful, really, sort of, you know, I mean, maybe like a little bit sore, but it's not a pain or anything, you know. I didn't notice it because it hurt or anything, you know." Dr. "Thank you, ummm, I believe I've got that much. Now, I need to know when you first noticed it." Pt. "Oh. Well, ummm. Ummm. I don't know. Dr. "It would help me a lot to know when you first noticed it. Try to think." Pt. "Well, ummm. Ummm. I thought you could x-ray it or something. Well, anyhow, ahhh, ..... [triumphantly] it was right after we got back from the beach." The doctor waits for the obvious conclusion to this beginning, which is the information as to when the patient went to the beach, that trip not having been on his personal calendar. Since it is not forthcoming, he has to ask. "When did you go to the beach?" Pt. "You mean this last time? We go to the beach a lot. My brother has a house down there. He was the one who told me I ought to have it checked, that it might be a cancer or something, and that sort of got to me. I was like, you know, ummph [gestures with his hands]." Dr. "I mean when you went to the beach and noticed the lump." Pt. "Oh. We had to leave the dog with the vet since my sister wasn't here and had to drive out of our way for that. ..... ..... ..... ..... I think it was about two summers ago, maybe three."
And thus it goes, dragging the ore from the mine, then refining it for the precious metal. Patients don't bring their medicines, preferring to think that a doctor can identify a medicine prescribed on a visit out of state by the fact that it is pink, or maybe sort of reddish, and the size of a button. Patients don't know what organs were removed or rearranged beneath their surgical scars. I once thought that surgeons didn't explain well. Perhaps not, but for some people there is a decided lack of interest in retaining this kind of information. Patients don't listen to doctor's questions. They don't rehearse what they want to transmit. They don't prioritize their agendas, beginning with a skin hickey question and ten minutes later mentioning that their fingers turned blue yesterday and they almost passed out. Patients return to old agenda like salmon to their home stream. A physician who has told them that nothing further can be done for a matter is a physician whom patients will not believe. It's un-American. One must do something, even it has proven to be worse than useless. Patients are not even expected to tell the truth. Physicians have been sued over acting on information given to them by patients who were lying, because the physician did not discern the lie!
In the great lamentation that shrills and moans over the failures of American medicine, physicians need to consider judiciously apprising our patients that, if they really want to retain their God-given authority over their physical health, they need to get a firm grip on their God-given respon sibility to participate with their helper. A rule being gradually disseminated in my practice is that patients must bring all medicines with them, no matter whether over-the-counter or prescription, no matter who prescribed them or for what, to each visit. Being comatose on arrival is excuse for not having the medicines, but not much else. Repeated failure culminates in the visit being terminated if something critical is not likely. Someday, some way, as another means of returning patient authority to the patient I hope to tender the medical record into custody of the patient and retain only a brief computerized extract. The patient could then write his own symptoms and signs and the physician could refine from material already partly dragged from the mine.
Physicians who tacitly accept all of the responsibility for efficiently obtaining an accurate medical history do patients no favor. We should not routinely do for another what that person can and should do for himself.
* Dr. Terrell is Assistant Professor of Family Medicine at McCleod Medical Center, Florence, SC, and the editor of the Journal of Biblical Ethics in Medicine.
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