Tuesday, December 18, 2007

The Worst Patients Ever

Doctors make the worst patients imaginable.

After several months of being told I should start myself on Metformin for my Polycystic Ovary Syndrome (PCOS), I finally caved and took my first pill this morning.

To be fair to me, I did try to take Metformin the first time my OB-Gyn friend (take note that this was not part of a formal consult) told me it would be a good idea, but I had the most horrendous bout of GI upset after only taking 1 pill... and I swore off the drug completely, advice from my Endocrinology and other OB-Gyn friends notwithstanding. All this despite the fact that I already knew I was a textbook case of PCOS and had the ultrasound to prove it. You'd also think that since we have a very strong history of diabetes and high cholesterol in my family, I would be more cautious. Not so. As a matter o fact, I also threw the advice about diet modification, exercise, and weight loss out the window.

When doctors get sick, it's not a matter of not knowing any better. I think it's part of our medical education to live in some form of denial when it comes to our own bodies.

Take, for example, all the doctors who continue to smoke incessantly despite the very strong evidence that smoking can lead to lung cancer, bladder cancer, and other malignancies, chronic obstructive lung disease, heart disease, and a host of other medical problems. We've all taken the same classes, read the same books, seen the direct evidence of how smoking wreaks havoc on the human body. We all advice our patients with hypertension and heart disease to quit smoking cold turkey because we all know it's sound medicine.

But my smoker doctor friends keep on smoking anyway.

There are many instances when illnesses among medical residents are picked up relatively late simply because they either ignore their symptoms or decide they know what's wrong with them and treat themselves.

There's an interesting article here about a study done in Australia about doctors' health seeking behavior. Participants in the study believed it was acceptable to self-treat acute conditions. A good proportion of the respondents believed doctors are also reluctant to attend another doctor when he is ill. In another article here from the British Medical Journal (BMJ), a review of existing evidence suggests that doctors are less likely than other professions to take time off work due to ill health. The alternative is often self-medication or consultation with colleagues about their illness.

The BMJ article goes on to point out that, "a culture of ‘not being ill’ is seen as inherent within the medical profession." Simply put, many doctors feel that they are ‘not allowed to be ill’, because it is seen as a form of weakness. Heavy workloads and staff shortages mean that for many doctors, it is virtually impossible to take time off for ill health. In our world, if you don't go to work, your already overworked colleagues must take up the slack or else your patients suffer. So you treat yourself and keep on working - until you get well or get worse, whichever comes first.

Ironically, this culture of ‘maintaining a stiff upper lip’ ultimately impacts on patient care - not only are they treated by a doctor who is less than 100%, but doctors with communicable diseases also run the risk of passing it on to their patients.

I've had at least two batchmates who nursed fevers and headaches for at least a week treating themselves with nothing but paracetamol who eventually were diagnosed to have typhoid fever. One of them was eventually admitted for a few days for IV antibiotics. A couple of years ago, an entire batch of neurosurgical residents were noted to be losing weight - a rather normal occurrence for toxic would-be surgical specialists in training. After one of them ended up being admitted for shortness of breath because of having fluid in his lungs, everyone else finally got themselves examined. All of them turned out to have tuberculosis and needed to be treated for 6 months.

But the biggest irony of all is that many of us, especially the junior doctors, are unaware how we would access support for ill health. My resident friends who had to be admitted had to pay for their expenses out of pocket (or their parents' pockets). The expense had a considerable impact on their finances, given their meager monthly salary, slightly discounted bills, PhilHealth, and waived professional fees from our attendings notwithstanding. Medicines are still purchased at full price, and we don't have any drug samples to cover our full treatment. I did an informal survey among my co-residents, and it turns out that none of us have medical insurance.

Is it any wonder why we are in such denial when it is our turn to get sick?


Manggy said...

Interesting post. Unfortunately it just makes me sad to think about the last days of Ads all over again.

I had severe diarrhea once in the Pedia ER. I thought I could pull it together but eventually I had to leave as I would probably make the children sick and I was losing lots of time in the CR. I cried in the ER (and I DON'T cry cos of med) because I couldn't believe how miserable I felt. In any case, a few other blockmates also had diarrhea to some extent. So yeah, the Pedia ER is one of my most hated places in PGH (possibly the world).

I don't agree with the analogy to smoker doctors, though :) There's something very wrong with their neurochemistry already. If you ask them frankly if they will ever quit, they will probably say, "probably never." The only person I've known to quit cold-turkey is my dad, when I was just a kid. Now he hates the stuff, thank heavens.

I have an impacted wisdom tooth that needs surgery to extract. I've been nursing occasional jaw pain, because when I consulted at the PGH-Dent OPD, I heard the term "flap" and I freaked cos I knew how horribly wrong major surgery can appear sometimes. Could it be that knowing the risks makes us more averse? How the hell am I supposed to convince patients to go through difficult procedures? (to be fair, the rare jaw pain is a very small trade-off to thousands of pesos in surgery and the risk of (beautiful) facial disfigurement)

I think undermanning is a major contributory factor to the lack of health-seeking behavior. It doesn't help that your superiors make you feel like shit for having the audacity to get sick. We're not human, after all. Idiots. (angsty much? Well, if they knew Ads even a little bit, they'd know how I felt.)

dr_clairebear said...

What happened to Ada was devastating. It really made the administration more vigilant about protecting students from getting diseases from our patients. But you're already well aware that while their intentions are good, it has proven to be fiscally difficult to provide all students with protective devices. Residents are even worse off than the students when it comes to personal protection.

I know that it's the nature of our job to be at the front line of sickness; it would just be nice if we could be given the appreciation we deserve instead of being bashed as mercenary, self-serving so-and-so's for wanting better compensation and a chance at a better life. ooops... sorry, my frustration is slipping through! :)

Back to topic... yes, knowing exactly what is going on with your body, knowing the risks of certain procedures, etc... those definitely contribute to a physician's denial! It's much easier to suffer and pretend there is nothing wrong with you. :)

VeRTiTO said...

nice sticky post you have here.

i cant remember if it was the meds from PCOS treatment that 'somehow' regulated my wife's menstrual cycle, and 'fixed' those defunct embryos...that medically prepared my wife to have two more wonderful baby girls around.

i know how hard it is to keep up with these blog updates due to those toxic scheds, but this one is nice blog bump!

dr_clairebear said...

thanks for the comment! and to answer your question -- yes, it probably was. :) glad to hear you were able to have two lovely children despite your wife's PCOS!

Prudence said...

"Heavy workloads and staff shortages mean that for many doctors, it is virtually impossible to take time off for ill health."

-- Yes, I agree. I especially feel it since I started moonlighting. With my schedule, it's hard to just look for somebody to relieve me of hospital duties. I think this is one part of my medical life that some people, especially my parents, still find hard to understand. They cannot understand that I cannot simply "file a vacation leave" like ordinary workers.

Also, it is sad that here in the Philippines, doctors do not have insurance as part of benefits in working in a hospital. Sure you can have discount or waive professional fees from colleagues when you get hospitalized or when you consult as outpatient, but how about the laboratory and hospital expenses? Who's going to pay for it? Still ourselves, from our meager pay. People still think that all doctors are rich, but this isn't true, especially nowadays.

--- Prudence (http://tesstermulo.com)

Manggy said...

Ma'am Claire, there is NOTHING wrong with me! :) Haha, denial :) Di nga obvious ang frustration mo, hehe. Honestly, for all us Filipino's boasted warmth and hospitality, the taray in people is really coming through. They must think they get what they want by being jerks.

I at least hope you have no adverse reactions to the Metformin this time around.

Dr. Emer said...

I think "smoking doctors" is an oxymoron. =)

txmedicalfreak said...

Sorry to hear that you have PCOS, I have it as well and it is no fun. I too just recently started on Metformin. As far as I can tell, the only results so far is that for the first time in years, I went past my normal 19 days between periods (start to start). Keep me updated on your progress.

MegaMom said...

Claire, take the medication! Take it from me, if you don't, you may regret it later.
That doctors don't take care of themselves is multifactorial. Not just denial, also being busy.
It has nothing to do with insurance: even now that I have insurance, gano'n pa rin. Oh, and in real life, not just during residency, bawal magkasakit! Sabi ng mga anak ko, bawal eh.