Professionals vs Protocol-Pushers


Had a great chat with an interested patient today, at my office for a free meet-and-greet appointment. She asked me two questions that I did not have black-and-white answers for, and she seemed pleasantly surprised.

She asked me how I feel about flu shots, and how feel about antibiotics for colds.

My answer for both is that It Depends. It depends on what is most appropriate for a specific patient under whatever circumstances apply at the time of the query.

I do not practice in absolutes: I did not pursue a terminal degree and five years of post-graduate training to cram people into pre-written checklists. Professionals train to exercise judgment. Protocols are for assembly lines.

Sure, we have what we call “evidence” — data and statistics — which has value in that it lends information about what happens to a majority of a specific group of people under a specific set of circumstances. This evidence is used to dictate what guidelines are published, which in turn drives insurance to consider what is worthy of coverage in terms of tests and treatments. But there are bell curves involved in the results of every published study, described in technical-sounding terms like “confidence intervals” and “p-values.” A particular outcome for a proverbial 51% of people in a study looking at a few thousand people, having eliminated anyone with potentially confusing additional conditions from the study, does not absolutely predict the outcome for one-in-a-million You.

Patients seek physicians because they want an educated human being to evaluate their individual health and medical needs. Patients don’t always benefit from paternalistic dictation without explanation, and they also don’t need information spewed at them in percentage values that end in 3s and 7s just to justify that the spewer has memorized more numbers than the patient. Patients need and deserve to hear the possible risks and benefits of pursuing a management plan, and the possible risks and benefits of doing nothing. Then, based on what a doctor knows about that patient via a developed Relationship, it also helps to hear gentle guidance about what path seems to correlate most closely with a patient’s value system.

It may just be my opinion, but that is what it means to behave as a professional in my field. It frankly doesn’t matter what I believe. What matters is what will be most meaningful for a patient. No checklist can predict that.

As an aside, to shed a little more light on my answers to her questions:

Flu shots are a public health measure recommended universally in order to protect *populations* as well as individual patients. There are groups of people at high risk for very bad outcomes – including death – as a result of contracting influenza: the very young (infants), the very old, and the chronically ill. Folks who are generally healthy might feel like they “don’t need” a flu shot because they “never get the flu.” Or they may not want it because it “gave me the flu” (which is impossible – it can cause symptoms similar to flu by generating the same immune response triggered by the actual flu virus, but without contracting the actual infection which is not contained in any injectable form of the vaccine). Often these folks don’t realize that they may very well become infected with influenza and thus can pass it along with a single cough, sneeze or failure to wash hands in a public restroom, because their own immune systems are strong enough to make the flu feel like a bad cold. Thus the virus may travel from healthy person to healthy person to healthy person with newborn baby, or healthy person working in a nursing home, etc. Then someone catches it who has a very bad outcome. That is what universal flu shots are meant to prevent, or at least reduce, which is why I *generally* recommend them.

Meanwhile, I know patients (and even friends) who have had straight-out adverse reactions to the flu shot apart from the standard fever/fatigue/aching, known as Guillain-Barré syndrome which is an alarming paralytic condition and in rare situations potentially life-threatening. People like that should never go near a flu shot again. And there are other reasons not to get it. So… It Depends.

When she followed up the flu shot question with asking about my take on giving antibiotics for colds, I essentially gave her the spiel I started with. Sometimes what feels like a respiratory infection is an allergy. Sometimes a blaring bacterial infection is so obvious that it practically grabs me by the shirt collar just chatting with a patient on the phone. Most of the time it’s somewhere in between and can only be determined by doing an exam, which is why I have no answer. It Depends.

Should you have me or someone who practices like me as your doctor?

Only you know what matters most to you in terms of needing access to a medical provider who you can reach easily around the clock, takes time to hear your story and answer your questions, and provides management according to your individual needs. Some people honestly aren’t looking for that.

So… It Depends. 🙂