Taking Off the White Coat
So, Millennials and many of the rest of us are asking doctors to please take off those white coats. For example, my son is a Millennial and his encounters with the health care system have made him angry and skeptical. His expectation of a hospital, given his experiences, is that it will make mistakes to his detriment. Most of his experiences are with the emergency room in a major city at a teaching hospital. He does not understand why he had to wait to get treatment for a stomach ache in the ER for eight hours, but then did get treatment after his appendix burst. This resulted in surgery, staying in the hospital for ten days, with a tube down his throat, no food, and a bill for $60,000. He does not understand why another visit to the ER ended up with workups involving four sequential interns and residents asking the same questions, including whether he had had a tetanus shot. When the real doctor finally emerged after four hours, he asked the same questions. My son wondered why they had not communicated among themselves. He could see his electronic medical record, but wondered if he was the only person who looked at it. He believes that he is just as likely to get worse, as to get better, in a hospital.
This is not an idiosyncratic story. It has probably happened to you or somebody in your family. It even happens to world-renown experts in the field of health care. Read or watch Don Berwick’s account, Escape Fire, of his wife’s hospital experience, including medication errors, disagreements among doctors, extreme lateness in getting medications needed, and oh-so-non-patient-centered care.35
It is, perhaps, understandable that mistakes can be made in health care. Don Berwick says, “It’s not bad people; it’s bad systems.” Health care is complex, not well coordinated, under pressure financially, and the list goes on. But, there is something else going on with the culture of medicine. Eric Topol, in his book The Creative Destruction of Medicine,36 refers to a new era where physicians are no longer regarded as “high priests, holding all the knowledge and expertise and not to be challenged or questioned by the lowly consumer patient” and that “doctor knows best” will no longer be a pervasive sentiment shared by patients and especially physicians.” He insists that the digitization of the human body along with other cultural shifts will democratize medicine and that medicine will no longer be practiced in a paternalistic way.” However, he admits that “If there were ever a group defined by lacking plasticity,* it would first apply to doctors.”37
Many of us want to take responsibility for our health and do not want to have important decisions made “about us, without us.” But physicians as a profession have resisted reasonable approaches that allow patients and families to make decisions about their own care. Physicians have resisted DIY (do-it-yourself) testing and treatment on many fronts. In the past, they have resisted home-based, over-the-counter, pregnancy tests, HIV tests, genetic testing, and automated external defibrillators (AED), all of which have provided good benefits with little risks to patients. Even today, the battle continues on whether patients can have access to their lab reports without first going to the physician.38
And the medicalization walls continue to come down. In response to the heroin epidemic and the related surge in deaths due to overdose, people can now administer a very effective treatment on their own, without physician oversight, to save lives. An amazing handheld device, Evzio, delivers a single dose of naloxone, a medication that effectively reverses the potentially lethal effects of a heroin overdose.39
It is similar in size and simplicity to an EpiPen, which is used to stop life-threatening allergic reactions including anaphylactic shock. It is the size of a pen and can be tucked into a pocket. Evzio is designed with the consumer in mind and even provides audio instructions on how to deliver the medication. The needle is retractable and not seen by the person using it.
Clearly, the potential is great for DIY innovations to save lives. Another potential use is thrombolytic therapy to break up blood clots and save lives for people with heart attacks. Time is critically important and administration of the drug as early as possible is important for survival and good recovery. The question is: To what extent should people’s home-based first-aid kits expand beyond Neosporin and Band-Aids and include a variety of reliable and easy-to-use, self-administered treatments? And to what extent will physicians oppose them?
People have other questions. Why is it not possible to communicate with their doctors via e-mail and why is an office visit needed when many concerns can be addressed over the phone or by e-mail, in just a matter of minutes?
So, doctors need to take off their white coats, except when they are in surgery, drawing blood, or getting stained in other ways, and “get down” and establish relationships with patients that include listening, shared decision making, respect for patient wishes, and trust that they can be partners to take care of themselves, including reading a lab report and performing a test without their oversight.