Dr. Abigail Zuger explains how “medicine delivers nothing but mixed messages.”

When is my patient not my patient? When he is Kevin, for one. I have cared for Kevin in both senses of the word for years now, but he still has his previous provider’s fingerprints all over him: he takes medications I never use and has health-maintainance routines I find somewhat perplexing.

Kevin is doing fine, but even so, I often find myself trying to reorganize him into a more familiar form. Invariably, he makes a sad face: He and his former doctor were very tight. Sentiment prevails, I give in, we move on.

Sometimes, though, in similar situations, patients and I do not move on. Instead, we square off. Former providers have left behind situations I cannot live with: orders for tests I consider unnecessary, medications that strike me as bizarre or prohibitively risky. I can’t refill those for you, I say. The responses vary, but no one is ever pleased.

I dread these confrontations and always feel guilty. After all, does it not verge on fraud of the bait-and-switch variety for two representatives of the same profession to contradict each other with implacable authority, one snatching away what the other has provided, leaving the consumer dangling apparently at the mercy of individual whim rather than clear-cut policy?

Still, no one can make me do what I think is wrong – not the state licensing me, nor the profession credentialing me, nor the patient hollering at me. So when I stumble over a too-high testosterone dose, or magnetic resonance imaging orders for a long-gone headache, or a perplexing combination of drugs that is likely to do more harm than good, it is my absolute right to just say no.

Unfortunately, when it comes to professional consistency, medicine delivers nothing but mixed messages, with doublespeak at every level of oversight.

Hospitals and professional societies now provide long lists of guidelines for the management of various conditions in hopes of achieving some reliable uniformity of action. Still, we will never all march in lock step, little soldiers in the army of best practices, because everyone, even the biggest guideline enthusiast, eventually learns that some patients do best when a doctor decides to ignore the rules.

When it comes to drug prescribing, all licensed practitioners choose from the same collection of approved prescription drugs whose formal indications are carefully and explicitly stated. Yet everyone develops idiosyncratic habits, and doctors remain free to prescribe a substance “off label,” with individual judgement trumping federal policy.

Malpractice is defined as a failure to meet a standard of care, yet the law fully acknowledges the multiplicity of paths to that standard. “Medicine is an inexact science,” one South Carolina judge advised a jury, “and generally qualified physicians may differ as to what constitutes a preferable course of treatment. Such differences due to preference under our law do not amount to malpractice.”

After all, second opinions have been a part of our medical care since time immemorial and remain a clear indication that different approaches to the same problem are valid and valuable. And when doctors for reasons of personal conscience think they cannot care for a patient, they generally must transfer the case to a doctor who can.

How would we ever manage without a little professional inconsistency?

Take it from me, that sentiment does not soothe the patient who is sobbing or threatening mayhem because I will not refill the prescription a predecessor supplied without a blink.

Maybe I should just give in? I presented the dilemma to the ethicist Thomas H. Murray, president emeritus of the Hasting Center and a person who knows better than most of us how to navigate tangles of obligation and expectation.

Dr. Murray said that to him, it seems I owe the unhappy patient exactly what I owe any patient: suitable, competent, cost-effective care, free of harmful interventions or those of questionable benefit. Ethicists do not support a patient’s right to receive a particular test or treatment when a doctor disagrees with it, and Dr. Murray saw no reason for requests reflecting the policies of a previous doctor to merit special treatment. “You are the one who has to make the call,” he said.

However, he added, a little compromise never hurts: “If possible, wean them over to a different way of doing things, a little at a time.” And in situations with many good options rather than one best option, as in Kevin’s care, there is really no reason not to leave things alone.

If compromise is not possible, it may be time for doctor and patient to part ways. Fortunately (let’s hear it for inconsistency), somewhere out there is a patient for every doctor and a doctor for every patient, in sickness and in health, for better or for worse.

June 8, 2015

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