From the desk of Dr. Harrington: “The bubble over my head”

One of the most irritating expressions a patient can use is… “I am supposed to…”

It is usually verbalized just after a diagnosis is made and a treatment plan is being considered.

For example:

“Mr. Smith, your CT scan shows extensive diverticulitis; and, although no abscess is demonstrated your abdomen is very tender; I recommend hospitalization and IV antibiotics.”

“But Doctor Harrington, I am supposed to go to New York for the weekend.”

The bubble over my head wants to ask Mr. Smith, “What are you going to do there… address the United Nations and finalize a plan for permanent world peace?”

Instead I say, “Well, this is inconvenient but in the interest of your health I think hospitalization is best.”

The dictionary defines supposed to to mean (in order of decreasing usage):

– pretended, alleged, held as opinion (believed)

– considered probable (expected)

– understood, made or fashioned by intent, required by authority, and given permission.

When a patient uses the term it is invariably to tell the doctor that they are obliged (required by some unseen authority) to be somewhere or to do something that makes following the medical recommendations simply impossible.

“But Doctor Harrington, I am supposed to go to New York this week, not to address the UN but for something more important: I promised my granddaughter to take her shopping.”

Other variations on such an obligation might be: “I am supposed to go to the beach, it is supposed to be a lovely week end.” Or “I am supposed to go to Nantucket for the summer; my family and I have done it every year for 20 years in a row.”

What makes this response, this quasi-rationalization, most irksome is that it frequently comes from someone who has lived well and has high expectations combined with a sense of entitlement.

Indeed, frequently their illness is caused or compounded by the richness and overindulgence of their lifestyle.

The case in point would be an overweight, former smoker, with diabetes, hypertensive heart disease and degenerative arthritis who develops a bleeding ulcer from alcohol and NSAIDs, while taking a blood thinner for atrial fibrillation.

This is the type of person who will bleed into shock, get resuscitated, have a surgery-sparing endoscopy to clip and cauterize the offending ulcer and then will question the recommendation that travel plans be put on hold pending observation of their clinical status. “But I am supposed to… ”

Compound this scenario with someone who thinks they have some insight into their condition and it makes the responsible physician’s head explode.

[A little wordy but I think he needs to get this rant out of his system. – Debbie]

Take the following vignette:

The phone rings at 2:00 AM on a Sunday. The answering service reports that a Mr. Jones has abdominal pain and needs an immediate call back. The call is put through.

“Hello?”

“Dr. Harrington here, I am covering for your primary physician, Dr. X. How can I help you, Mr. Jones?”

“I have diverticulitis and I need you to call in some antibiotics.”

“How do you know this is diverticulitis?”

“Well, this is just like the last time and my father was a doctor, so I know.”

After a few questions to clarify that the patient is not critically sick, does not take any problematic medications, has no allergies and has been symptomatic for several days, I respond, “Well, it does sound like diverticulitis, but there are other possibilities.”

The patient could indeed have diverticulitis (alternatively, and much less likely, the differential diagnosis would include bowel obstruction, colon cancer, a ureteral stone or early shingles).

I continue, “The best thing to do would be to see your doctor in the morning and clarify the diagnosis. Ideally you should have some blood work, an abdominal exam, and possibly a CT scan to exclude a complication, such as a mass or abscess, before committing to antibiotics.”

“But, doctor, I am supposed to leave for New York on the 9:00 AM shuttle. My doctor treats me over the phone all the time and my father used to do that, too.”

“What are you going to do in New York?”

“I am giving a speech.”

“To the UN?” I wonder, aloud.

“No, to a group of lawyers, colleagues.”

This is where my head threatens to explode.

Here is a well-educated man who has had symptoms for several days but calls for help at the last minute; indeed too late to actually get the proper analysis, and has the expectation that he should get free care because he is supposed to do something “important.”

Yes, under other circumstances his personal physician might be willing to phone in antibiotics because of past experience, but as a lawyer he should know that an on-call physician has a different obligation and in some jurisdictions it is illegal to prescribe without examining the patient.

After giving him a not-so-diplomatic lecture on the meaning of supposed to, the inappropriate timing of his call, and the pathophysiology of diverticulitis, I did phone in the antibiotics and did report off to his primary MD later.

The expectation that all illnesses can be successfully treated and the added expectation that they can always be treated within the patient’s schedule is a real problem in the well-heeled population.

It is encapsulated in the phrase: “I am supposed to…” When I hear that I know I have a lot of patient education to perform, starting with a reality check.

More later on the problems of “expectations.”