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Who is the worst patient?


I am pleased that the title captured your attention, but there are no worst or best patients out there; it's all just people like you and me, people who need help. The problem that I want to talk about is a counterintuitive observation that medical professionals, as well as wealthy individuals and celebrities with unlimited access to healthcare, sometimes tend to have an increased probability of poor treatment outcomes compared to the average person.


How can that be?


By being a physician and professionally existing within the system I might have a head start advantage. I might know exactly where to go for what type of treatment. Or I can call up a friend from the hospital who is a specialist and get informal advice and opinion over the phone within minutes. Also imagine that I am a wealthy celebrity. I can go to any doctor I want. I can pay for the most expensive experts and the most advanced care. I can travel the world and get treatments that might not exist within the USA.


All of this is good, right? Well, no!


Let’s think about it. Clinical diagnostic and therapeutic guidelines are formulated based on statistical data, guiding us toward interventions that generally yield the optimal outcomes for the greatest number of individuals. These guideline algorithms streamline decisions and interventions that typically prove most effective for the majority of individuals, encompassing both you and me.


If I am simply making that phone call and getting the advice from a buddy of mine instead of say, going to the hospital and getting a comprehensive exam done, I am cutting corners and deviating from the standard of care. If I am very wealthy and don’t like what the doctor advised me, I am free to see 10 more doctors and eventually find one who will agree to give me what I want, no matter if it is a pain medication, stimulant, antibiotic, or surgery… even if that is not in line with the standard of care and even if it is not in my best interest. There is also a possibility that even with out any patient driven special request, doctors and medical teams treating VIP individuals might have a bit of a different approach then what the standard of care would advise.


Now that I've got you thinking about this, I'm sure you can come up with "medicine gone bad" example of your own. You probably remembered a celebrity who clearly had one aesthetic intervention more than what would be considered in his/her best interest. I assume that numerous doctors said no to whatever was requested, and then eventually there will always be someone who will agree and say yes. Maybe someone traveled to another part of the world where licensing and quality control are not as rigorous, and where you can simply get what you want and what you paid for, without many questions being asked. We have all heard of celebrity death speculations and rumors that it might be in some way related to the complications of treatments provided, or medications prescribed by their physicians. I do not go as far as making any type of conclusion that these treatments were wrong, or complications illegitimate but in many cases one might argue that they were quite different from your average standard of care. Can the standard of care approach end badly ? Absulitely, but taking everything into the account it is still (at least as far as statistics is concerned) your best bet most of the times.

Lastly it is important to ask "Can the doctor deviate from the standard of care?" Not just that we can and that we should but we must. What works for the most does not work for all. Still when I decide to deviate from the standard of care I must ask myself why? and I must be able to provide a clear answer to that question first to myself as a clinician, then to the patient and if need be to the peers from medical and scientific community at large if the question ever arise.

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