I recently was at the office of a specialty doctor for a skin problem I have had for some time. He is a distinguished clinician and teacher in his field and I have consulted him for seven years. My appointment was a routine monitoring visit to check to see if my condition was the same, better or worse.
Dr. August (name is fictional) saw me promptly, a great courtesy not achieved in many a busy doctor's office, and took a careful history and inquired thoughtfully about how I was doing. He examined me thoroughly and concluded from history and examination that, in fact, I was doing better. He said so reassuringly to me. There was a resident in training with him so he took the time to explain matters to her as well as to me. I was a very satisfied patient. But then he reached into his white lab jacket pocket and pulled out a prescription pad to offer me a topical medication that I really did not need, might produce some minor side-effects, and of course would cost me money, if not directly at the pharmacy then through the insurance premiums I pay. I politely explained why I did not want the prescription and he put the pad back in his pocket - I think a little surprised. He suggested I return in six months for another monitoring exam, I thanked Dr. August for his help, and I left a very satisfied customer.
But I had to say no to the prescription of the medication. Imagine what someone who is not a physician would have done? Likely, dutifully taken the prescription to the pharmacy and began the treatment.
Why, I wondered, did this happen? This was a fine doctor with a patient who had his needs met. One common explanation of excessive medical care (and expenditures) in this country is the belief that more is better: more lab tests, more high tech imaging diagnostics, medications and more medications, and more invasive procedures. I don't doubt that in general but I think what happened with my doctor was different. I am a psychiatrist, you know.
Doctors are givers, as rule. The profession is meant for people who want, even need, to do something for other people. I fear we as a profession have lost sight of the fact that doing something can be all that my doctor did before he took out that pad. He did not keep me waiting, he thoroughly inquired and examined, he explained and reassured, and he made clear he was there for me by inviting me to return at a reasonable follow-up interval. I happen to think that was a lot. But I suspect that he felt the need to "give me" something - something more tangible than all that he had already given, namely a prescription. It was as if he was responding to Rousseau's caustic remark "bring me medicine but not the doctor."
For a busy general practitioner with eight to ten minutes to see a patient or with a busy psychiatrist often spending less than fifteen minutes seeing a patient there is one thing they can "do" - namely, write a prescription. With scarce time to investigate and precious little time to be a trusted physician who listens and discusses matters with a patient many a doctor is apt to want to "do something". And many a patient has come to equate leaving with a prescription as having been cared for.
As we rethink health care in the country, I hope we are thinking about the doctor as a doctor, not just as someone who orders tests, does procedures and writes prescriptions. Someone who listens and explains, assesses, and invites participation in the tough work of taking care of our health - and someone who is there when needed. Seems to me like a low cost way to get off the unaffordable health care conveyer belt we are on. As has been said, the most expensive doctor's tool of all is his or her pen.