You visit the physician. You are overweight, and your cholesterol is high.
If I tell you this, I have accomplished nearly nothing. If I add that you should change your diet, eating less in general and especially eating less fat, I have also accomplished nothing. You will hear me, assent, try for a few days, and most likely return to your prior ways. If I prescribe a medication to reduce cholesterol, you will probably take it and your cholesterol will improve, and your likelihood of heart attack may go down.
Thus the goal is accomplished. And the system supports each step of the way. I have an office where the transaction occurs. An insurer pays for your visit and for the blood tests. In the pharmacy, you exchange my written prescription for a bottle of pills, which are also paid for. If my medical records are audited—and this occurs with increasing frequency, by the insurer or the government or malpractice attorneys, looking for breaches in medical, financial, or legal protocol—they will be unimpeachable. And if you go on to have a heart attack anyway, I will again be found blameless; I did all that was expected of me.
But what if, instead of prescribing the medication, I sat down with you and tried to help you figure out why you were eating junk, and how you could eat otherwise—what would be the outcome? The path is fraught with peril. First, I am not officially trained for this sort of enquiry. Second, I have acted outside protocol. You might be offended—you were not expecting this, after all. An auditor would find the visit unjustifiable. Third, the day’s schedule is not set up for this dialogue, which would take considerably more time than is allotted for a “routine follow-up visit” (CPT code 99213). Finally, if you did have a heart attack, I would be culpable of departing from customary practice. I could easily be sued—perhaps a million dollars would be the penalty sought, and such sums are frequently awarded.
But you might not have the heart attack, if we were to follow the second path. You might figure out why you were eating junk, might be able to change your life accordingly. One imagines coming face to face with Rilke’s Archaic Torso of Apollo, the calm, stone kouros: “You must change your life.”
What physician, and what patient, would dare to embark on such a path?
Charles Bardes is a physician who lives and works in New York City, where he teaches and practices general medicine at Weill Medical College of Cornell University as Professor of Clinical Medicine and Associate Dean. He is the author of Essential Skills in Clinical Medicine and articles related to medical education. (3/2006)