It was just another busy Monday afternoon in the clinic. As I called in my 1 p.m. patient, a 79-year-old man with a complex medical history of coronary artery disease, diabetes, chronic kidney disease, and remarkably resistant hypertension, I was ready for the usual challenges. His blood pressure reading was alarmingly high at 168/92, despite being on a cocktail of medications – a diuretic, beta blocker, ACE inhibitor, clonidine, hydralazine, and aldosterone antagonist, having already ruled out calcium channel blockers due to intolerance. My options were dwindling, and I cautiously suggested a long-acting nitrate.
Reaching for my prescription pad, a glance at his medication list stopped me. Sildenafil. He was also taking sildenafil. The well-rehearsed lecture on the contraindication between nitrates and sildenafil began to flow. I detailed the risks, the dangers, the potential for severe hypotension. I emphasized the importance of blood pressure control to prevent stroke, heart attack, kidney function decline, and even death. After my earnest explanation, he listened patiently and simply declined the nitrate prescription. Sildenafil, he explained, was “just too important” to his relationship to forgo. This transient pleasure, in his eyes, outweighed the significant, long-term health benefits I had just outlined. I struggled to understand. How could this patient, with so many serious health issues, prioritize what seemed like immediate gratification over longevity?
This encounter sparked a crucial realization: the essence of Doctoring Meaning lies in the delicate balance between enhancing patient outcomes and nurturing their quality of life. Often, these two goals are in harmony. Consider heart failure management – medications not only improve clinical markers like readmission rates and BNP levels, which are vital to us as clinicians, but also enhance what truly matters to patients: symptom relief and overall well-being. However, there are times when these ideals clash, forcing us to confront the complexities of patient-centered care. The more I reflected, the more instances surfaced – the patient overwhelmed by her 24-pill daily regimen, or the patient who couldn’t afford essential medications due to financial hardship. These situations are pervasive, highlighting a fundamental question at the heart of doctoring meaning.
Whose Goals Define “Optimal Medical Therapy”?
We are quick to prescribe evidence-based, goal-directed treatments. But whose goals are paramount? Are we prioritizing our clinical objectives, or truly aligning with our patients’ values? When these objectives diverge, how do we navigate this conflict? How do we honor patient autonomy while ensuring they understand the benefits of our medical recommendations? Is there a way to bridge this gap, to realign what feels misaligned?
The Hippocratic Oath, a cornerstone of medical ethics, includes the promise: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” Every physician pledges this oath, yet in practice, we can unintentionally impose our own agendas. We strive for our patients’ “benefit,” but we must remember that “benefit” encompasses more than just reducing adverse medical events. It involves seeing the individual before us, acknowledging their unique circumstances, and improving not just the length, but the richness of their life.
Re-evaluating “Net Clinical Effectiveness”
Perhaps our concept of “net clinical effectiveness,” often discussed in medical meetings, needs to evolve to explicitly include “quality of life.” To truly serve our patients, we must introspectively examine our own hearts and be willing to adapt our definition of “optimal medical therapy.” Doctoring meaning isn’t solely about achieving clinical targets; it’s about understanding the patient’s lived experience and integrating their values into the care plan.
So, I ask my fellow healthcare professionals: How do you navigate these challenging situations? How do you counsel patients when a life-saving treatment diminishes their quality of life? What strategies do you employ when your treatment priorities conflict with those of your patient? Reflecting on these questions is essential to truly understanding and embodying the profound doctoring meaning in our daily practice.
Payal Kohli, MD is a cardiologist and a 2018–2019 Doximity Author.
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