Why Are You Prescribing That, Doc?

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.