As a physician, I am privy to knowing a lot of personal information about my patients. I have the moral and ethical responsibility to use that information to help the patient make the best choice in his or her care. Three patient stories stand out as I reflect on how the ethics of choice play out in a typical week in my medical practice. Each of the following patients presented to my office, wanting me to do a procedure. Each procedure is reasonable, medically approved, non-experimental, and within my skill-set. Yet, I advised each of these patients against the procedure he or she requested. Why? The sum total of the fees for these procedures would have paid my mortgage payment two or three times over. In this economy, that is not something to take lightly. Certainly, I enjoy doing procedures. I am a techy kind of physician. I enjoy operating and using laser equipment. Also, I am a problem solver. This is true of most surgeons – give us a problem we can remove or repair and we are happy. However, physicians must make decisions each day, not for our best interest, but for our patients.
First, a lovely young woman with beautiful smooth skin, a pretty smile, nice eyes. She is planning to marry in the near future. Sadly, what she sees is very different from what I see. She sees flaws that she feels she must hide with her hair and a hat. She has already found two other physicians who have performed invasive laser procedures to improve these “flaws,” but she isn’t happy with the results and now she wants another, aggressive laser procedure. We looked in the mirror together and I showed her her beautiful face. I told her she has lovely skin. My words meant nothing to her–she sees scars and ugliness. (Honestly, they aren’t there.) She pleaded with me to do the laser procedure, but I gently refused and suggested counseling. Sadly, she will find another physician who doesn’t see her lovely face, but sees $$$ from a procedure. I pray that she will seek help, but I fear that she will continue to pay money for procedures which, though fairly safe, do carry risks of infection or scarring and will not cure her. This makes me very sad. What is her story? How did she end up with this warped vision of herself–where she looks in the mirror and someone else looks back? Is it the result of years of abuse–I hope not. Is she the victim of too much television and media hype about what a young woman should look like? I’ll probably never know and I will probably never see her again. She doesn’t believe me and she will continue her search for some other physician who hasn’t learned the art of saying “no.”
Patient number two is a self-professed plastic surgery junkie. She has had numerous cosmetic procedures over the years and is ready for another “tune up”. Unfortunately, her prior treatments have made it risky to proceed with more aggressive laser procedures. Again, these ARE in my skill set. They are FDA-approved procedures. But, in my opinion, they are not worth the risk to her. She accepted the advice and thanked me for my honesty.The third patient needs a cancer operation. This would seem fairly straight-forward, but he has delayed treatment due to some social and family challenges. The procedure he requires is technically within my skill-set, but his delay in treatment has made the planned procedure much more difficult and I have advised him to have surgery at a teaching hospital or tertiary care center. He and I have a good doctor-patient relationship and he told me he’d feel more comfortable with me, and that he had heard many good things about my skills. I told him that part of being a good physician is to know when to say “no” and that I should refer to someone with more expertise for the required procedure. He acquiesced and is on his way to getting the appropriate care.
This type of situation comes up not infrequently. Doing what is right is not always easy, especially if it means giving up something fun, interesting, challenging, or financially beneficial. But it is always right to do right by your patients, friends, family and staff. Sometimes that means saying “no,” politely, kindly and gently.