Tuesday, March 23, 2010

Jennifer Frank, MD: Consequences

Sometimes being a doctor is like being a parent. You worry about your patients, you lecture, you cajole, you warn. Sometimes your patients act like children (and sometimes your patients are children). They do what you tell them not to do (“I told you not to drink while taking the Flagyl.”). They don’t really believe you when you tell them that if they don’t get their diabetes under better control, they will be starting dialysis. They often look up to you, respect you, and see you as an authority.

As a parent, I maintain a careful balance between preventing and allowing consequences. My kids are young, so I still have this power. “If you miss the bus, you will not get dessert tonight.” Action leads to consequence. I can also intervene to prevent the consequence. “Okay, you forgot your lunch, I will drop it off at school on my way to work.” I realize that as my children get older I will be less able to protect them from the consequences of their actions. This is one of the hard parts about being a parent.

As a doctor, I have less control over consequences. My interactions with patients are, in the grand scheme of things, relatively brief. I also am paid and duty-bound to prevent consequences – I don’t allow a person to get lung cancer to prove that smoking is actually bad for you. I do everything I can to prevent lessons from being learned the hard way.
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Despite my best efforts, consequences often find my patients. The years of overeating and lack of physical activity eventually lead to diabetes. Forgoing the statin and continuing to smoke leads to a second heart attack.

During a recent discussion with one of the senior residents, she revealed the struggle she is experiencing with seeing a patient suffer the consequences of a poor choice. The resident did everything right for her young teenage patient. She counseled her on safe sexual practices, the value of delaying sexual activity since she was so young, the need for contraception and barrier protection should she make the decision to have intercourse, and the importance of being prepared for “heat of the moment” decisions.

Despite a close therapeutic bond, despite a parent who was accepting and supportive of her daughter’s decisions, despite a prescription for contraception, this young girl is pregnant. The resident did everything right but could not save her patient from the consequences.

This can be heartbreaking as a doctor (or a parent). You wonder where you went wrong, what you could have said differently, if you missed something that could have prevented this from occurring. The sad fact is that our control (as doctors and as parents) is uncertain and often almost completely absent. We have influence but little actual power. Where we do have power is in our presence – walking beside our child or patient (or friend, sibling, spouse, or parent) as they face a consequence. As a family physician, this is a role I gladly and willingly take.

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