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Emergency Medicine News:
doi: 10.1097/01.EEM.0000271272.75647.ac
Second Opinion

I'm the Doctor, Not You!

Leap, Edwin MD

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Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at www.edwinleap.com.

This is the age of intellectual democracy. In a frightening departure from millennia of human tradition, everyone is now an expert in everything. Turn on the television or surf Internet news services. We somehow believe that polls of individuals are useful for guiding policy in everything from international politics to morals and religion. Legislators and marketing experts trust this information, as if masses of humans had extensive experience in diplomacy and warfare, in economics and federal tax structures, rather than what so many do have expertise in: video games and the accumulated outtakes from American Idol.

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It's especially odious in the world of medicine. How many times do we argue with patients that they don't need an antibiotic or x-ray, admission, or laboratory test? A family once skeptically asked me to show them the x-ray I had taken of their child who swallowed a coin. Once they saw it, they were satisfied that I hadn't missed anything. They weren't radiologists, but they were experts. Any idiot can be a physician, right?

Many things have contributed to this maddening state of affairs. On some level, it's good. Americans should be a people willing to ask questions. This willingness to stand against authority is what made us and continues to make us a great nation. It's also what drives other countries crazy; we don't just settle for platitudes and “because I said so” on either side of the political spectrum.

But there's more. Some of this sense of general expertise also stems from the business and customer service model that permeates everything from retail stores to medicine and government. It teaches people that because they are the customer, they are always right. They can complain, cajole, refuse to pay, and endlessly badger anyone in a business or position of authority. And because we dread to tell them no, to disagree, to (God forbid) not believe them, they get what they want. And they become tiny little tyrannical experts in everything from cell phones to angioplasty.

The Internet has blossomed with information ready for the taking. Go to any medical information site, and you can learn enough to ask endless questions of your physician and leave him miserable, even though what you have is just that — information. It isn't the same as experience, and it doesn't compensate for years of practice. Add to that the explosion of assorted ancillary health fields and the millions of people yearning to “work as a medical professional,” and we are inundated with patients and their assorted spouses, parents, in-laws, and cousins twice-removed, all of whom have completed a medical assistant programs, and suddenly know as much or more than do we, with our pathetic little DOs or MDs.

I have conversations with patients who say, “Well, I know you don't think anything is wrong, but my sister is in LPN school, and she says I have pneumonia, and I need antibiotics!” Let's see: LPN school, one year. Board certified emergency physician, 11 years, plus 13 years in practice. I can see why the LPN is smarter than me! I don't have enough education or experience! Or I don't wear cute scrubs with bunnies or John Deere tractors on them. Sometimes patients look at me, and say, “I think I need some more tests done.”

‘Fine,’ I say, “What tests do you want?”

“Oh, I don't know. You're the doctor!”

Precisely the point.

The plain truth of the matter is this: We are the experts. After sacrificing years to be educated and surrendering much of our health, longevity, and sanity to work at all hours and learn the complexities of treating sick and injured humans, we deserve the respect we have earned. We have surrendered it too easily to insurance representatives with business degrees who can deny care over the phone, to consultants in marketing, to intermediate care providers and assorted health care administrators. But when it all comes down to brass tacks, whose name always shows up on the chart? Who goes to court? Who is accountable for all of it? The physician. The expert. The final word.

It's time we took it all back. We are the ones who know the way a person looks when he is about to die. We know how to interpret the x-rays and electrocardiograms. We know whether to worry about that blood pressure. We know when to operate and when to send someone home. We physicians know intimately the way the human heart sounds and the way the pulse feels in the well and in the afflicted. We recognize the smile of the sick child and the blank stare of meningitis, the blue cast of blood from a ruptured spleen and the gasp of the pulmonary embolus.

It is our education, coupled with the experience of practice, the experience of touching, smelling, seeing, and listening to thousands and thousands of people in every phase of living and dying that grants us the right to say no and yes to our patients, to agree or to disagree with their myriad and often unreasonable desires. It is this that should, if we were wise, put us in the driver's seat of the future of medicine, rather than letting it be guided by the mass of people or the tottering inefficiency of government guidelines.

So here is our announcement. Attention patients and families of patients, regulators, government officials, commentators, angry bloggers, and reporters: I am the physician. That makes me the expert. I realize that we live in the age of polls, surveys, empowerment, and self-help. I realize that the opinion of the masses generally matters more than the opinion of the educated. But as one of the educated, as one of those who considers his opinion more valid than many others, let me say what most physicians are too nice to say. Medicine is not a democracy. I appreciate your opinion, and you may accept or refuse anything I offer. You may even tell me what you think, and what has worked before. But I get the final vote. I have earned that vote through years of caring for the sick, and I am accountable for my mistakes, as is evident by my very expensive malpractice insurance. You may refer me to any of your resources or family members, but in the end, like it or not, one unassailable fact remains: I'm the doctor, not you.

© 2007 Lippincott Williams & Wilkins, Inc.

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