AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2012, Volume 14, Number 1: 13-16.

Clinical Cases

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Writing an Excuse or Educating the Patient

Patients who have been encouraged to think of themselves as consumers and a medical system that is driven by individual demands rather than big-picture planning can undermine fairness in the distribution of vaccines.

Commentary by John J. Frey III, MD

Dr. Sanders is a family physician practicing in a private clinic in Wisconsin. In autumn of 2009, Dr. Sanders was inundated with questions and concerns from patients regarding the H1N1 pandemic, especially since over 2,000 cases had been identified in Wisconsin and neighboring states. In fact, many deaths had been attributed to the virus, mostly in young children, the elderly, and pregnant women. Dr. Sanders and her staff struggled to assuage patients’ concerns by providing up-to-date information on the virus and administering the H1N1 vaccine to all high-risk patients. After several weeks, though, the vaccine supply had run low, and some who wanted the vaccine were unable to get it.

One morning on her walk to work Dr. Sanders met two patients, Mrs. Alcott and her 12-year-old daughter Jessica. Mrs. Alcott expressed anxiety about Jessica’s safety and asked Dr. Sanders if she could give them both the H1N1 vaccine.

“Unfortunately, our supply of the vaccine has been used up,” Dr. Sanders explained, “and we don’t have any more to give to even our high-risk patients. Neither does the hospital’s emergency department. I’m sorry to say it seems like it may be a week or longer before we get more.”

Mrs. Alcott’s eyes widened. “A week? And there are so many unvaccinated people. This is too dangerous. We’re just going to have to stay home until we can get the shots.” She asked Dr. Sanders to write both of them doctor’s notes excusing them from work and school for two weeks.

Commentary

Over 35 years ago, Ivan Illich first used the term “social iatrogenesis,” which he defined as “designating all impairments to health that are due precisely to those socio-economic transformations which have been made attractive, possible, or necessary by the institutional shape health care has taken” [1]. Social iatrogenesis, in his view, is an historical “contract” that medicine has made with society whereby many problems of life are medicalized in the institutions and in the physician’s control, putting doctors in the position of creating a wide variety of clinical and social dependencies.

Most of us who have practiced for any length of time have seen the dramatic increase of forms, permissions, papers, and other required material that serve a patient’s needs to interact with the society in which we function. These forms are examples of social iatrogenesis. Physicians “certify” everything from driver’s license restrictions, maternity leaves, and competence to a patient’s level of disability, administration of medications to school children, and excuses from a type of work for myriad reasons. When we decided on medicine as a career, we most likely knew little of this societal function of doctors. But our social iatrogenic function—deciding for society on who is “worthy” of what treatment, what excuse, or what diagnosis—is something I would venture to say none of us understood prior to finishing medical school. This function has become a burden to both us and our patients and increasingly feels out of control.

When I practiced in the National Health Service in Wales for a year 30 years ago, I anticipated a paper-free life compared to my work in a community health center in the U.S., and, to a great extent, the experience met my expectations. No bills, no insurance forms, no prior authorization, and so on. But what surprised me was the flood of patients who required nothing more than a work excuse for a common illness. Work slips consume a large proportion of the general practitioner’s (GP) work—one study calculated that letting discharging doctors give illness excuses to patients leaving the hospital rather than the current understanding that such excuses could only be written by GPs would reduce GP visits by 518,000 yearly—or free up 42,000 GP work hours [2, 3].

Societies, not doctors, should arrange for conditions to deal with short-term illness without requiring patients to sit for hours in doctors’ offices to get a piece of paper. Workers deserve to have sick days without having a doctor’s excuse. But the same situation exists in the U.S. today for many people. Many hourly workers in our society need a sick note to miss work while higher-paid white-collar workers can take sick days on their own. For many patients, the threat of losing a job either forces them to work when they should be home recuperating or makes them come to the doctor for a work excuse.

The case of Dr. Sanders and Mrs. Alcott and her daughter shows another perspective on the physician as an agent of society, dealing with the consequences of a failed system of public health and public education. Prevention is commercialized, often promoted by “helpful” commercial entities like pharmacy chains and grocery stores which, as a marketing tool, buy up flu vaccine and give it to all who are willing to pay, regardless of evidence-based public health advice. And, as the case suggests, emergency departments seem to have shown the same lack of priority setting by administering shots to whomever shows up and helping to add to the shortage for those who truly need rather than just want it.

The combination of poor communication to the public by the media and vaccine producers, who often underestimate the necessary number of vaccines doses, created a dilemma for Dr. Sanders.

The “correct” advice to Dr. Sanders’s patient is that she and her daughter are low-risk individuals and that efforts should be made to use any available vaccine for high-risk members of the community. The issue is one both of good public health practice and social justice. However, what Mrs. Alcott sees in the community is a rush on immunizations that she has missed for her family, and she is left to worry, unreasonably, that they might suffer adverse consequences. Dr. Sanders can review the medical priorities and seek to reassure Mrs. Alcott about her and her daughter’s risk, explaining that effectively quarantining themselves will not eliminate risk and, depending on the length of time to obtain more vaccine, might last much longer than a couple of weeks.

Dr. Carson’s appeal to the patient’s request for an excuse is a plea for reasonableness. As Norman Daniels states, requiring “accountability for reasonableness makes it possible to educate all stakeholders about the substance of deliberation about fair decisions under resource constraints. It facilitates social learning about limits. It connects decision making in health care institutions to broader, more fundamental democratic deliberative processes” [4]. Our current society is driven more by individual demands than the collective social good. The response of the “market” to patients as “consumers” who, even if expressing unreasonable demands, need to be served cannot deal in a fair way with problems of rationing of important resources like flu vaccine. If we as a society can’t do it with flu vaccine, how will it deal with larger issues such as high cost-technology, screening for disease, or Medicare costs?

Dr. Sanders can work against the flow of the market and patient as consumer, using a scientific approach that emphasizes individual and societal risk. But that may not be enough to dissuade Mrs. Alcott. For the sake of her own integrity, the doctor needs to take that risk. Dr. Sanders could write a note for Mrs. Alcott describing the unavailability of vaccine and the time it may take to obtain some, but not advising Mrs. Alcott and her daughter to stay home. Advocacy for Mrs. Alcott for an irrational position for both her and her daughter would not be appropriate in this instance.

Mrs. Alcott could take the note describing the unavailability of vaccine to her work or her daughter’s school and let the job or the school decide what to do. It is consistent with Illich’s point about social iatrogenesis that we not create “sickness” where there, in fact, are only conflicting beliefs and opinions in a society. Dr. Sanders’ position also might be that, as a physician in a community, she has obligations to help move informed policy back to where it should be—in the institutions like workplaces and schools where the public, not individuals, decide who is sick and who is well.



References

  1. Illich I. Limits to Medicine: Medical Nemesis, the Expropriation of Health. New York: Random House; 1976: 40.
  2. Public Sector Team, Regulatory Impact Unit, Department of Health (UK). Making a difference: reducing general practitioner paperwork. Cabinet office public sector team regulatory impact unit; 2001. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_078471.pdf. Accessed December 15, 2011.
  3. Walker CA, Gregori A, O’Connor P, Jaques K, Joseph R. Sick notes, general practitioners, emergency departments and fracture clinics. Emerg Med J. 2007;24(1):31-32.
  4. Daniels N. Accountability for reasonableness: establishing a fair process for priority setting is easier than agreeing on principles. BMJ. 2000;321(7272):1300-1301.

John J. Frey III, MD, is a family doctor and professor of family medicine at the University of Wisconsin School of Medicine and Public Health in Madison, where he was chair of the Department of Family Medicine from 1993 to 2006. He is the medical editor of WMJ: the Wisconsin Medical Journal and associate editor of the Annals of Family Medicine. His interests are in community-engaged research, social determinants of health, and medical humanities.

Flu Vaccine Recommendations and Dosages, November 2003

Is Mandatory Vaccination Legal in Time of Epidemic? April 2006

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.