Tuesday, March 03, 2009

You Didn't Even Ask?


Okay, I'm going to ramble (I know it, even before I've started) and I don't quite know where I'm going with this. Please notify me if I get there.

There's an assumption in medicine that the responsibility for pulling out the truth rests with the doctor. Really? I don't know, and I've never seen it stated as such. It feels like it's there, though, in insidious ways that leave us with the sense that if we don't ask the right questions, don't elicit the right information, that the fault (and, yes, I think I mean fault), and the liability, is with the physician.

Let me explain a little better: a patient commits/attempts suicide...people (which people? I don't know: People! Perhaps everyone. Lawyers, supervisors, family members, other physicians) will ask: Did the psychiatrist ask if he was having suicidal thoughts? A plan or intent? In the two clinics where I work, there is a check-off box on the doctor's progress notes regarding Suicidal Ideation. It's a good jog to the memory to remind us always to ask, but it's also intrusive. It must be checked off and the doctor doesn't have the space to decide it's inappropriate to ask that particular question on that particular day. Some might say it's always appropriate to ask about suicidal ideation, but when I'm seeing a patient whom I've known for years, who has never been suicidal, who tells me they are doing well, feeling fine, well, it sometimes feels a little weird for me to ask, "Are you having any thoughts about hurting yourself?" Them's the regs.

But it's not just suicide, or homicide, or any form of violence. It's other things as well. Roy mentions in his Xanax post that the doctor needs to ASK the patient about a history of substance abuse to find out. Oh, but patients can lie, or forget, and doesn't everyone know Xanax is addictive? Shouldn't a patient with a history of addiction volunteer this information to any doctor who may prescribe an addictive drug that will re-activate a past problem?

It's not mental health issues, it's all of medicine, though certainly, each specialist feels an obligation to attend to his organ system. Do internists second-guess themselves if someone walks out and has a heart attack: "Oops, I forgot to ask if he was having chest pain." Do they check their notes and hope they've documented an appropriate assessment for cardiovascular disease?

So what's my point? It's certainly not that we shouldn't ask questions. We should. And there are issues that might not be obvious to the patient, things they might have forgotten or may not know are relevant-- like asking about a past history of mania/hypomania before prescribing an anti-depressant. But, I think, at some level, we've taken on the burden of blaming ourselves (or our colleagues) if something goes wrong and the doc didn't ask. Maybe it's a fallout from the malpractice era: in terms of a lawsuit, it's probably not good form to have a bad outcome about something one didn't ask about. There is also that sense that if you asked, and the patient said No, then how could we know otherwise? It's not that we don't feel sad about a bad outcome, but if there's the sense that all that could have been done was done, at least there's not that feeling of responsibility.

Sometimes, though, it doesn't just feel like a moment of omission, it feels (to me, at least) as though we blame ourselves and each other for a bad outcome if we didn't ask the right question, as though it's our fault, like we've caused something bad to happen, or at the very least, failed to prevent it. We blame ourselves, we finger-point at our colleagues.

I told you I was going to ramble. Well, what do you think?