Tuesday, August 26, 2008

Paternalism in Medicine

When a patient describes a doctor as “paternalistic”, it’s the social equivalent of calling him a baby panda rapist. The implication is that the doctor is demeaning, condescending, and insensitive to your individual or cultural needs.

For you chuckleheads who never took Latin, the root of the word is “pater”, which means “father”. A nice definition of paternalism from dictionary.com is: “the system, principle, or practice of managing or governing individuals ... in the manner of a father dealing benevolently and often intrusively with his children”.

To be clear, I am NOT condoning paternalism with the historically negative connotations related to racism, sexism or anti-libertarian governmental policy. What I am arguing for is a retreat from medical relativism: some courses of action are scientifically sound and others are clearly not. "Respecting" those that are not, in the name of cultural or individual sensitivity, is not in the patient's interest.

I’m sorry to burst the PC bubble, but the doctor-patient relationship is NOT one of co-equals. The patient comes to the doctor for help and not vice-versa. The patient is typically not a medical expert; the doctor is. A good doctor bases a diagnosis and course of treatment based on the best available, scientifically validated evidence; and will strongly push the patient to follow this course even if cultural beliefs and individual sensitivity are somehow ‘violated’.

The classic example and the one I have heard several people complain about is the doctor telling the patient: “You are obese and need to lose weight. Here is why and here is how to do it…”

“I mean, what a paternalistic jerk! Telling me I’m fat! The nerve!”

Listen, chunky, eating deep-fried Snickers bars and a 2 liter Coke as a pre-dinner ‘app’ is bad for you. If you consider ‘exercise’ the crunches you do sitting up off the couch to pick up the X-Box 360 control, you are wrong.

Yes, I get that you are an adult and these things are ultimately your choice, but guess what, I’m not your friend and I’m not here to support you in your decision to treat your diabetes with chiropractic manipulation and aromatherapy even though “it worked” for your yoga instructor.

So, grow up and listen to your father.


  1. Deep-fried Snickers? Oh, I must try one. Immediately.

    I've always defined "paternalistic" as a good thing...yanno, father-like. Kind. Caring. Like my own doc.

  2. I would not want a friend that told me what I wanted to hear if it wasn't the truth, and I definitely wouldn't want a doctor to do that. Sometimes you need to hear something that makes you unhappy in order to make changes that should be made. Can you imagine what kind of medical care people would get if doctors just said what the patients wanted to hear or were always trying to be nice instead of pointing out changes that could do some good? I don't think it would be very good! It seems like it would be a wasted trip to the doctor if you weren't told all the changes you could make to get better.

    I'm with Lynn, I always thought paternalistic was a good term. My doctor's partner (who I saw pretty often too when I was dealing with the cancer stuff) treats me like a daughter, and I wouldn't want it any other way.

  3. This comment has been removed by the author.

  4. DEAD. ON!

    I do not want my doctor to be my equal. I want him (no bias, ladies, my doc just happens to be a him) to be my superior, and behave accordingly. If I did not think that my doctor was superior to me in knowledge and ability, why would I waste a perfectly pleasant day seeking his care?

    "What!?!" I hear the reader exclaim, "are you actually suggesting that, just because someone has met the requirements of being a physician, he or she is better than the rest of us?” Well, philosophically and theologically, maybe not. However, in all matters regarding health and disease, damn right he or she is better than the rest of us! THAT IS WHY WE GO TO THE DOCTOR WHEN WE ARE SICK! Now, be gone, oh execrable imaginary interlocutor!

    Thank you, doctor, for sacrificing so many years, and so much effort, to achieve your invaluable superiority. Now, write this order that I need to take care of my patient, and let me get back to work!

  5. I didn't know exact meaning of "Paternalism" since English is my second language.. So I went online and found the definition. The below is the excerpt from Wikipedia.
    ***Paternalism refers usually to an attitude or a policy stemming from the hierarchic pattern of a family based on patriarchy, that is, there is a figurehead (the father, pater in Latin) that makes decisions on behalf of others (the "children") for their own good, even if this is contrary to their wishes.

    It is implied that the fatherly figure is wiser than and acts in the best interest of its protected figures. The term may be used derogatorily to characterize attitudes or political systems that are thought to deprive individuals of freedom and responsibility, only nominally serving their interests, while in fact pursuing another agenda.

    So, yes, I believe patients should listen to doctors who know better than us when it comes to medicine..

  6. That anyone would be annoyed at their doctor for informing them what needs to be done for optimal health is absurd. Why go?

    That being said...I am not always compliant..but I would NEVER be annoyed at them. I would lose respect for them if they didn't do their job.

    I like that paternalistic feeling I get from my docs. I also feel like an equal in some ways. Obviously not in education/career but in our communications and my 2 favorite docs..PCP and urodoc..work "with" me and yet I also feel taken care of and I love it.

    I have SO MUCH respect for them and am grateful for all that they have done and do for me and I would tell the world to go to these docs if I could...and when I am not compliant it is a weakness in me... but I sure as heck don't get mad at them for guiding and helping me.

    DFS-very funny! Are they on a stick? ;)

  7. ok, just so we're clear here."but the doctor-patient relationship is NOT one of co-equals. The patient comes to the doctor for help and not vice-versa. The patient is typically not a medical expert; the doctor is" Get off your high horse buddy. You are providing a service, your patient is paying you, therefore yes you should seek to SERVE your patient in a manner that is not paternalistic.

  8. Well then by your very comment, then couldn't all professions who are there to provide help to people be called or considered or lumps into the paternalisitc category?

    Fire fighters, paramedics, lawyers, judges, government in itself, isn't that all patenalistic?

    Please correct me if I'm wrong, but the way Laura phrased her comment, the way doctors are sought out for a service, don't we do that with the few professions I listed above?

    We are not professionals or experts in those fields, that's why we seek them out, right? I mean, if I could put out a fire by myself or settle a lawsuit, I wouldn't need them. Much like if I could cure my own Athelets foot, I wouldn't need the skill, knowledge or precision of a doctor. And if I got the athelete's foot I am seeking out was caused by something stupid, I would not expect the doctor to fawn all over me and not tell to not repeat my stupidity over again.

    Yes, we seek out doctors when we are sick, or hurt, but I expect to be treated like an idiot when I act like one. I don't think that's paternalistic, I think that's just your duh moment.

    A lot of doctors act like that regardless. They just have a big ego, and need some humility to bring them back down. Not all docs are like that though. I think it's kind of bad to lump all medical professionals into that category, because once again, it gives medicine a bad name.

  9. ok laura...

    Sir, weighing 600 pounds and smoking cigarettes is, for most people, a bad thing, but for you, well, I'm here to serve. What asshole called you 'fat'... I will have them killed. That about right?

  10. That is a good idea Etotheipi, tell your patients they are fat. Aren't they dead already? Tell them to quit smoking too while you are at it! OR hey watch out for that train, impact is gonna be a bitch.

  11. As a critical care RN, I completely agree with the author of this post.

    To "laura", A doctor isn't providing a service that is akin to a grease monkey changing your oil. They have YEARS and YEARS of specialty training and deserve to be on a "high horse". They know things and do things that you and I cannot do. Show them some respect, please. And while you are at it, push away from that deep fried Snickers bar.

  12. Something I remember from the 15 minutes of Statistics we got in Med School. Those Insurance Weight Tables are based on DEAD PEOPLE!!!! Stay buff the reason I do, to look good for the chicks.

  13. I worry about an actual inversion of the MD-pt relationship in the current climate, when as a resident I'm actually instructed to treat the patient as a 'customer' and to 'thank them for choosing our facility as we are aware you have many choices in today's market'. Sorry, but pts are not customers, they are patients. Especially in the ED.

    It is possible to have authority, tell people your considered and educated medical opinion, and not be a jerk. I see it all the time in most attendings who are great.

    I've had great, appropriate questions from patients, like, 'if this were your daughter, what would you do?' That's still respectful but helps the MD-pt relationship.

    Nice post.

  14. Laura:
    I like it up on my high horse. The view is great! Except the only time I want to see the top of your head is when... uh, I'll stop there.

    By your logic, I should not treat patients ... I'm sorry, I mean "customers" who can't pay. Great! Now I can do 40% less work right away!

    Maybe you don't consider what I do "serving", but I sure like to be "serviced".

  15. I like it when my doctor tells me what to do. It makes me hot. RAWR.

    Just kidding, if you saw my doctor, he looks like the father from Mary Poppins, but skinnier.

    I want a hot doctor. Where can I find one?

  16. amy-all my doctors are hot. But don't tell me if you end up with any of mine. In my brain they are all mine and I don't want to share.

  17. You doctors need to come over to my site and tell me who McCain's VP should be. I have two polls up on this. Also don't tell me I can't eat deep fried snickers. I eat whatever (clutches chest and falls over dead)

  18. i completely agree with u

    if u dont wanna hear it from ur parents or friends or anyone, then why seek help??

    people need to stop being in denial....

  19. Amy: My son just had a colonoscopy, and that gastro was world-class smokin' hot. I blushed just reading his fabulous lips. There is no way I'd want a doc that hot to be poking me THERE...and,*shaking head suddenly* oh yeah, I just got married.

  20. Know that deep fried Snickers bars are served at the Minnesota State Fair (now in progress). And yes, they are served on a stick.

    Once a year won't kill you.


  21. Hmmmm...a smokin hot butt and gut doctor. Not sure if I would go there.

  22. I am sorry, but I want to be able to look up to my doctor. I want him or her to be a leader in my healthcare. I want to have doctors and other providers that I admire.

    My doctors, and other providers, are all people who I admire and I follow their advise to the best I can.

    However, it is scary to be in an ER or urgent care place and not have the choice of who to see.

  23. Yes, I prefer my doctors to be not actually repellent but not particularly attractive either. Unless I get to keep all my clothes on, then it doesn't matter. I guess pathologists see you without, so see above guidelines.

  24. You had me at deep fried snickers.

  25. Well said! If I thought my doctor were my equal I'd find a better doctor!

  26. dear significant snail,
    i would ammend your comment as follows...

    'if i thought my doctor was my equal in terms of his medical knowledge and skill then i'd find a better doctor'.


  27. I like it when my doctor tells me what to do. It makes me hot. RAWR.


    In my future, I want to start picking my doctor by looks alone. =;o)

    Ah, *quick flashback to the hot lesbian surgeon that did my umblical hernia repair years ago*, I meant men - but you know...

  28. etotheipi,

    given that you are phenotypically male that aces you out of being able to comment on paternalism.

    i know also that you are genotypically european-mutt so there you go again, i'm sorry, but you are not welcome in today's political discourse.

    i recommend a vaginoplasty and pigmentoplasty... then go gay, only then will your voice be welcomed... maternalism, after all, is way good.

  29. IT is difficult to pick a good Doctor if you are a lay person. I know one Doctor who got kicked out of our hospital for being incompetent. But he was very friendly and had a great bedside manner. I also know an OB who I really don't like. But I would definitely have him do surgery on me or my family.

    I would not be comfortable with a hot Doctor. I remember having a really hot patient when I was a new nurse and I hated going into his room because I kept blushing. And he kept being naked.....Which made it hard for me to appear competent.

  30. dear pinky,

    you may not realize this but you have stumbled onto something that docs have been taught by lawywers.

    research, the good kind, has demonstrated time and again that a good bedside manner cures all manner of misdeeds. you are TONS more likely to be successfully sued if you are a jerk.

    luckily for surgeons the most time they spend with their patients is when they are paralyzed and sedated. i kid my colleagues but they do tend to have the most brusque manner.

    to me, as a dude, this makes little or no sense, but, i must admit, i would not continue to go to a general medical physician who was not nice or did not have a good bedside manner.

    if neurosurgeon-Z is the only dude in the world that can get that astrocytoma completely out of my squash and keep me from drooling on myself afterwards then he can cuss me up and down and spit on my kids and i'll let him have a go and pay him to do it.

  31. Ah, *more memories*, the cute pain specialist that did the post-botched-didn't-really-need-an-appendectomy nerve blocks two years ago. We had a really nice flirt going on in the hospital and my husband walked in on it.... *blush*

    oops, sorry, we're talking about deep fried Snickers. Digress.

  32. As far as that "customers" thing goes, I will say on this blog, anonymously, that I often choose destination ERs on a few criteria.

    See, I have a lot of influence on patients. They ask me, "Is this a good ER? Is that a good ER? Where would you go?" or I'll just go where I feel like it if they have no preference.

    It's one of the joys of a being a paramedic.

    But anyway, on to my criteria. Factors favoring me to come to your ER (fuck the patient, this is MY reasons as a paramedic):
    1. You're not douchebag fucks.
    2. Yum yum snacks.
    3. Attractive staff.
    4. Good AC.
    5. Comfy chairs.

    That's about it. If I roll in and we can get this care transfer crap squared away quickly, that's a bonus. I hate hospitals. The less time I can spend in them, the better.

    If staff aren't smarmy fucks, I'll come with good patients (multisystem traumas, complex medical patients) etc... if staff are smarmy fucks who are rude, I bring the obnoxious drunk assholes that throw feces and spit on people to your ER even if it's a longer drive.

    Attractive staff. I'm married, but that doesn't mean I don't enjoy leering at healthy staff.

    AC: It's hot. Poor people don't ever have AC. So I sweat my balls off in the summer. They're usually lazy, and it takes an insane effort to get some of these massive skin bags down a flight of stairs. My record is a 800 lb patient. There was so much fat we had to fold him up like a burrito. His skin wouldn't fit down the hall, so I had some helpers grab huge fists of skin and plop the excess on his chest and flop the tits up over his head. It was 95 degrees outside. Hence the need for good AC in the EMS room.

    Comfy chairs need no explanation.

    Long story short, if you think that the patient had much of a choice in this amazingly fertile sea of wonderful healthcare options, you're a fucking fool. It was probably only because the admitting girl was beautiful and you have yummy popcicles in the freezer.

    I'll admit this only anonymously. But I assure you that I'm not some dirty fuck outlier. This is how my coworkers operate. We're petty and vindictive. I know people have purposely brought the worst of the worst alcoholics, PCPers, malingers, ultra high need whiner patients to ERs that treat us like shit.

    Any greaseball hospital administrator who can't figure this out needs another MBA to jerk off on.

  33. *sniff* that's the most beautiful rant i've ever read... or, if not, the most beautiful one that i remember. please drop your meth addicts at our door anytime... i just want to shake your hand.

  34. Wow some post this is turning out to be.

    Well I personally don't have a clue about how the US healthcare system functions, but I've been reading Behabioural Sciences for USMLE and apparently, patients are given WAY too much power (imho).

    In India, although the law may say otherwise, the practical aspects of ethics are zilch. Doctors are Gods who are worshipped and can do anything and everything they want, as long as the patient gets better. The patient may have rights, but he surely doesn't have enough brains (most of the time) to make a logical decision. Every week we see numerous neonates with some infective diarrhoea, because it is customary to give honey to the newly born. In the month of Ramadan, considered holy by Muslims, we get to see cases of intestinal intussusception. Even diabetics fast all day long during this period, some continuing their meds/shots, others stopping. So we get delightfully suppurative diabetic foot cases as well.

    Do we really want to respect the beliefs of patients to the point where it ceases to have scientific and logical sense? Is respect for God so important that you can watch your patient die, cause his religion forbids blood transfusions? How many more cases of branding of infants must we see, before we can safely assume that the patient cannot be trusted for logical healthcare decisions?

    The answer, my friend, is blowing in the wind..

  35. I think the same people who refuse to accept the advise of doctors refuse to accept of advice from anybody. The know-it-alls approach everybody the same way.

  36. We had the wierdest patient today. She took care of herself, knew her medical history, had been taking her medication, was accompanied by a polite, calm, husband who gave a clear history with useful information, and had used EMS only when totally appropriate after doing her best to avoid emergency care.

    We didn't quite know what to do. Makes me realize the distorted cross-section of people we normally see.

  37. Absolutely the doc has the power/knowledge in the doc/patient relationship. Problem comes when doc gets greedy and orders tests not needed and because of the above the patient dumbly nods his head. Also in this type of relationship the patient doesn't have the knowledge to know when to buy and when to not buy - an essential part of market economics. Makes it a bit difficult to have medicine operating as a free market. Only problem is to find a better alternative. Bit like democracy - sucks ass but a shitload better than the other options.

  38. Actually, Swedoz, medicine did operate as part of a free market for many centuries, and it worked very well. Doctors, like other professionals, brought a high level of integrity to their practices, perusing the patients' best interests without exploiting his or her ignorance. Oh sure, there have always been bums in every profession, and even some outright quacks, but they are too few to skew the economics of medicine significantly. They are a problem to their unfortunate victims, but not a major economic problem.

    Physicians still have the same high standards of integrity today that they have had in the past. The problems with our current healthcare systems are precisely because it is no longer a market system. In the past, the doctor had duties to one individual: the patient, whose interests the doctor perused without regard to external issues. Today, for the first time in history, the doctor has two masters, the patient, and the payer. Any system that separates the role of recipient of services from that of payer for services, is not a market system, it is managed system. It forces the provider to fulfill duties to two parties, even if the interests of those parties are in conflict. And no, it does not matter at all whether the payer is an insurance company, a government agency, or the man in the moon. As long as patient and payer are separate, there will be conflict, and the physician will not be able to maintain the narrow, patient-centered focus that typifies professionalism. Those who advocate universal healthcare never address this obvious fact. They insist that the answer to the serious problems caused by our managed healthcare systems is to increase the management. This is insane. Doing more of what does not work will continue to not work, no matter how loftey the intentions of those who do it.


  40. Etotheipi; thank you for noticing.

    Joking aside, I am honored by your response, but my comments are not brilliant: they are simple and obvious to anyone who has read a little history, and is willing to spend more than 30 seconds thinking about this stuff. Why are we not getting this simple, obvious truth out there?

  41. MMMMM.... had deep fried snickers at the Texas state fair last year. Had the deep fried smores too. The damn like was too long for the chicken fried bacon. LOL gonna try that one for sure though this year.