Which side are you on?
“Which side are you on? I really need to know”. This was the question and entreaty posed to me by a patient in my office last week, an elderly woman who had been my patient for many years. She was coming in for a follow-up evaluation of her previously poorly controlled blood pressure. After years of neglect, progression of her renal disease to stage 4 CKD has finally convinced her to take her medication and to take her hypertension more seriously. Finally she was under much better blood pressure control. Unrelated to her blood pressure, however, she wanted to know where I stood.
The question came completely out of the blue, with no context or relevance to any of our discussions or items we reviewed at this visit, so her questions – or perhaps it should be considered her gauntlet that she was throwing down – were clearly planned. She came to the office with a defined agenda so she could have this “discussion” with her physician of many years (me) and find out where he (I) stood. And as soon as she asked me, I could feel my forehead knot and my neck muscles contract, because I knew what she wanted. And I didn’t care for it.
Out of context, her question really isn’t very disturbing. I have been asked this question or various reincarnations of this inquiry many times over the years. Sometimes it is related to sporting events where someone is establishing relationship-building banter. At other times it has been based on various current medical controversies, and often it has been in the context of consultants’ recommendations. I’ve always enjoyed the discussions when patients asked me about my opinions prior to deciding on a diagnostic or therapeutic strategy that subspecialists have recommended. It shows that we have built a strong relationship over time, and that medical care is going right. It is usually a sign of someone willing to engage in an important and thoughtful discussion. That simple question, “where do I stand?” – or some version thereof – has always represented to me that my patients are active participants in joint decision-making, that they are comfortable in communicating with me, and they trust and value the conversation that follows. In the past, this type of question has always been a homerun. Maybe even a grand slam. Deepest apologies to those of you who are unfamiliar with baseball terminology
But not this time. I truly cringed when I heard it because it was not the first time in the last several weeks that I have been asked this, with different words but exactly the same agenda. After the first two, I knew what was coming this time, and even as disappointingly anticipated what was coming next, she did not disappoint me. She followed in lockstep with the path I had seen with my two similar patients. People whom I thought I knew apparently better than I really did.
She wanted to know if I would prescribe her hydroxychloroquine. Not today, but in the future when she would determine that she wanted it. She wanted to be sure that I could be counted on to prescribe this lifesaving medication to combat SARS-CoV-2 infection to her and save her life. She advised me that she had sources and she had done her research, and she was aware that this medication was effective. She clearly did not need or want my opinion about its effectiveness, her research was convincing. And she already knew that it worked.
Just as significantly, the same sources who had educated her about hydroxychloroquine advised her that many physicians were conspiring together in a political cabal that was diametrically opposed to providing good quality care. The rampant theory was that even though hydroxychloroquine is proven to be effective, the physician community was involved in a grand conspiracy denying its effectiveness solely because of the president.
These conspiracy theorists were pushing the fabrication that it was important to deny the effectiveness of this useful medication in order to keep the president from taking credit for being the first one to become aware of its effectiveness. The concept is that the medical community would let people die if it made the president look bad, and it would withhold a treatment that the president spouted, because there is a presidential election coming and this is the proper and ethical way to involve medical care in deciding a presidential election. Preposterous? Demeaning? Ridiculous? Antithetical to everything we stand for? Inconceivable? Insulting? Yes, yes, yes, yes, yes, and yes – to any rational person, but clearly these evils have now seeped into the fabric of our country and filtered down frighteningly to a meaningful subset of our population.
I had already learned that self-deprecating humor would not work. Comments such as “I missed that meeting of the cabal, tell me what I was supposed to have learned” could not make any headway with her or her legion of cohorts. Normally it should diffuse the situation and let us move on. Likewise, a didactic discussion of how hydroxychloroquine had already been shown to be ineffective, would most likely produce an outright fight. Normally evidence works, but now we live in times where “evidence” is individualized and some people feel that whatever evidence you choose to believe then is the standard to go by. I settled for a simple explanation that whenever there was an issue as to whether prescribe any medication, I would make that decision using joint decision-making and based on the best available information and evidence that we had at the time. Thankfully, she accepted that without further argument, and it is now becoming my preferred response for these situations.
For some reason, I have always assumed that my personal, private, patient centered encounters with my long-established patients would be a protected zone. The nonmedical pollutants of the outside world such as politics would not become part of face-to-face medical care. More importantly, I believed that it could never undermined the trust and long-standing relationship between a primary care physician and a long-standing patient. Now I am beginning to rethink my own assumptions. Maybe the world has really changed even more than we thought, or at least more than I thought.
Methinks I think I am not in Kansas anymore – none of us are.
