Geriatrics & Aging Presents a Debate on Doctors Treating Their Near and Dear
C.J. Olson, BA, MD
The essay: " On Not Doctoring the Family" by A. Mark Clarfield, MD in your July/August issue iterates time honoured sentiments that I have seen occasionally over the years, but I can't recall any attempt to question them. It is time to throw down the gauntlet and challenge some of the comments made in the essay. En garde, Dr. Clarfield.
The first issue is his reference to the statement of the American Medical Association, a hundred years ago, that a family member's illness "tends to obscure judgment." He adds that: "Attitudes have not changed much since then." The key word is "attitude" and I think we should all realize it is no more than that. Also, longevity is not a supportive argument for such a theory. When we consider the changes that have occurred in all aspects of Medicine in the past century, we should simply view this as a rock in the midst of the river, immobile and unchanging, because it has never been seriously challenged.
The second point is trying to decide just where Dr. Clarfield wants to draw the line between what is acceptable and what is not. On the one hand, he feels it appropriate to examine, diagnose, prescribe medication and advise on surgical procedures for family members--procedures which may not be as innocuous as he thinks. I was uncertain whether he does these because he feels they are acceptable, or that he feels they are acceptable because he does them. At the other end of the spectrum, he feels that performing (major) surgery on family members is inappropriate. In between is a large grey area--such things as minor surgery, spontaneous vaginal deliveries and assisting in the operating rooms are examples--in which he does not take a stand. This seems to be sort of 'no man's land' into which no one wants to venture for fear of stirring up controversy.
One problem that bothers Dr. Clarfield is the Heimlich manoeuvre and measures related to CPR. He quotes Dr. Howard Bergman, who feels these are acceptable because they are a knee jerk or 'reflex' response. This is simply not true. Some of us take a one evening course in CPR every year or two, but I think we are in the minority. The procedures are filed away, because we rarely get a chance to practice them. When the occasion does arise, the response is certainly not a reflex one; it "gives furiously to think," trying to remember all the details of something we have rarely had to do in a real life situation. Only emergency Physicians and Paramedics, who do these things regularly could be considered as doing them "by reflex", but even this is doubtful. Why Dr. Clarfield felt it necessary to justify these measures in the first place puzzles me. It is proper for anyone, under any circumstance, to perform such procedures whether or not he or she is a physician, just as long as they know what to do. I can't see why we should justify it amongst ourselves.
My greatest concern is that Dr. Clarfield is convinced that, faced with such a crisis in the family, physicians turn to jelly, become irrational and cease to function as intelligent beings. There is no evidence for this at all. What he does not realize is that the real stress comes when dealing with relatives of a colleague. There, one has the feeling that everything one does is under both a spotlight and a microscope, and stress is truly great. One problem is that a specialist, having such a case referred to him, may feel obligated to "do" something, and I have seen quite a few unfortunate results in consequence. Within my own family I have had, believe it or not, seven occasions when I have been asked by family members to intervene when things have not gone well, and can state without equivocation that the result has in every case been good. I wish there were space here to elaborate; it would give the reader pause to think.
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to the suggestion that we should stop parroting the myths and fables that are passed down from one generation to the next, and take an in depth look at them to see if they are valid. |
One other point, admittedly aside from the main issue, is Dr. Clarfield's reference to calling in a "real" doctor. I should point out that the only real doctors in this world are those who have gone through the arduous process of obtaining the degree of Ph.D. We in Medicine have completed four years in Medical School, which qualifies us for a Bachelor's degree in Medicine and Surgery. Upon graduation, we are granted the honourary degree of Doctor as are dentists, veterinarians and chiropractors, but we certainly haven't earned it.
Where is all this leading? Quite simply to the suggestion that we should stop parroting the myths and fables that are passed down from one generation to the next, and take an in depth look at them to see if they are valid.
We must first be aware that Medical Theory differs very much from theories in sciences which depend entirely on the scientific approach. There, hypotheses are proposed, subjected to experiment and research, argued (sometimes bitterly) and publicly debated. General acceptance is slow--witness the history of Atomic theory, and the Theories of Evolution and Relativity.
Medical Theory, by contrast, is based upon the Galenic approach. One of our number somehow gains recognition as an authority on a subject, states a Theory based on his attitudes, belief and experiences, and expounds on it at length. It appears, like Athena on Mount Olympus, full blown and fully armed. It is bolstered by such arguments as "It stands to reason that
" or "It is obvious that
" when in fact it is not at all obvious, and has never been seriously challenged by reason. Others pick up the concept, adding their support and soon there us a consensus and extensive literature to back it up. Some may disagree, but few--faced with this formidable array of talent and support--are willing to speak out. The worrisome thing is that if the first person who said it was wrong, then the whole thing is a house of cards. Such theories therefore rely on consensus, silencing any opposition, and discouraging any attempt at experimentation or research.
What we should do is rephrase our Theories as hypotheses; offer them as ideas to be investigated (without a lot of rhetoric) and try to find out whether they are valid or not. A good example would be the study mentioned by Dr. Clarfield, which was done by Dr. John La Puma and colleagues. The frequency with which various procedures was done by physicians was recorded, and Dr. Clarfield has stated in his opinion whether these were "acceptable" or "weird", but these are purely subjective impressions. What I cannot understand is why no attempt was made to determine whether the outcome was good or bad. This would have been a simple and much more instructive approach. Surely someone must have thought of this when setting up the questionnaire! Was it because no one wants to know? Let's face it--we need to know.
Dr. Clarfield takes up the Gauntlet
In response to Dr. Olson's chivalrous en garde, I take up the gauntlet with verve and answer as follows. First, I would like to thank him for taking the time and energy to read my piece and for reacting so emphatically. The worst fate for any writer, of course, is to have his words ignored.
Let us begin where Dr. Olson and I are indeed in violent agreement. It is true that much, if not most, of what I had to say was subjective--as were all of Dr. Olson's claims as well. And that was the whole point of my article: indeed it is difficult for most of us to be objective with those patients to whom we are related.
If Dr. Olson and his ilk are steely enough to look after wife and child--especially when things get critical--more power to them. I do know that in such a situation, in comparison to what occurs with the patient with whom I am not involved emotionally, I turn to jelly. And I believe that most physicians are more like me than Dr. Olson. However, I do agree with him that the topic deserves more study.
And as a card-carrying member of the evidence-based mafia, I once again see eye to eye with Dr. Olson in his plea for appropriate, methodologically sound research into these hypotheses. My piece in Geriatrics & Aging, with all of the pride that I can muster for my work, was clearly not meant as a research paper but as a thought-provoking opinion piece. That it elicited a reaction from Dr. Olson is clear.
With respect to the Heimlich manoeuvre and CPR, once again I am at one with Dr. Olson that it is preferable that these techniques should be studied, learned and practiced as much as possible. My point was that in a true emergency any doctor would, and should, do whatever was necessary to save a life--regardless of how he felt about the patient: love, hate or indifference. But when one has the choice, by dint of the situation being less than life threatening, I think that most practitioners would, and should, prefer to let someone who is more objective look after the patient.
Regarding caring for the family members of colleagues, once again I concur with Dr. Olson's point of view. This is indeed a difficult issue and in a way is tangentially related to the point I have made. In both cases, but for different reasons, the physician is struggling because of a loss of objectivity. I agree that looking after a colleague's family is not easy, but I never found it as difficult as looking after family--perhaps because, despite the lack of complete objectivity, appropriate emotional distance can still be kept to enable sound judgement to prevail.
I too look forward to more research into this important field. But, when my family turns to me for medical help--except in cases of medical trivia or dire emergency--I will refer loved ones on to my friends. Let them sweat it out!
Yours Sincerely,
A. Mark Clarfield, MD
