Doctors: If We Aren’t “Providers,” What Are We?
By
Leonard Zwelling
https://www.wsj.com/opinion/transgender-treatments-distort-the-purpose-of-medicine-ccd6e513?mod=Searchresults_pos4&page=1
In a sterling op-ed in The Wall Street Journal on June 24, Dr. Farr Curlin of Duke University makes the case that gender-affirming treatment of young people goes against “the purpose of medicine.”
Dr. Curlin says that our job as doctors is to bring people who are ill back to health. That’s the purpose of medicine. In other words, our primary role is as healers. Gender-affirming care is based on the concept that the patient and the patient’s parents are demanding a treatment that would turn a healthy body into a diseased one. Giving a boy androgens may be indicated to make that boy a healthy boy. But giving a girl androgens will turn her into neither a healthy girl nor a healthy boy. Likewise, giving a healthy boy estrogens will result in neither a healthy boy nor a healthy girl.
The argument made by those in favor of gender-affirming treatments in the young is that the patients have gender dysphoria and are thus ill. They have been born in the sex of one body, but wish to have the body of the opposite sex. Making this transition will make the patient healthier mentally.
But, is that so?
According to Dr. Curlin, the patient is far too young to grasp the future consequences of his or her decision as a teenager and some of the changes produced by gender-affirming treatments are irreversible. In fact, one could say that’s the goal of the therapy.
As readers of this blog know, this has been something with which I have struggled mightily. I have no trouble concluding that any XY human has no place in women’s sports, regardless of when puberty-blockage was started or what “her” testosterone level has fallen to.
But let’s go a little deeper. When did the doctor get removed from the equation of what the patient ought to be treated with? Surely, I believe paternalistic medicine where only the doctor decides on the treatment is wrong, but when did the patient get to decide what the doctor would prescribe? Is this really the model Hippocrates envisioned?
My own health care, which, unfortunately, is quite complex due to a multiplicity of real illnesses from my back, to my heart, to my brain, and to my gut is administered by several superb clinicians who integrate history, clinical findings, lab results, imaging, and deep knowledge to recommend what I should take in the way of pharmaceuticals. Uniformly, they give me choices. Uniformly, I get to choose. But uniformly, they advise me on the best course of action in their opinion as physicians. And, almost without exception, I go with their recommendation.
If a physician is being guided in his or her prescribing solely by the desires of the patient, he or she is no longer a doctor. He or she is a provider—providing a customer with services on demand as well as being judged with a patient satisfaction instrument. A provider is a vendor.
Throughout my short clinical career (1973-1984), I was never a provider whether I was being a general internist at Duke or an oncologist at the National Cancer Institute. Yes, I gave my patients choices, but I came to the bedside or the clinic with a plan that I thought best. The patient could change it, and sometimes, the patient was right and I was wrong (I was a very naïve oncologist). But even in my stubbornness in one case in particular, I was not a provider. I was a trying to be a healer.
The issue occupying this op-ed, gender-affirming hormonal care, is a tough one. (For a lengthy discussion see our podcast, A New Prescription #9: Biology, Identity, And Politics—A Conversation On Sex And Gender With Sneha Chaturvedi.)
Many of these young patients really do feel trapped in the wrong body. I am not sure if the Supreme Court is the place to resolve this conflict, but that is water under the bridge. The Court, in U.S. v. Skrmetti, has determined that Tennessee’s denial of the use of such treatments is constitutional. Whether or not gender-affirming hormonal therapy of young adolescents is a good idea is a tough one. But, I’m willing to leave it to doctors. Not to providers and certainly not to judges.
8 thoughts on “Doctors: If We Aren’t “Providers,” What Are We?”
My sister’s spouse Lauryn (originally born Harold) was taking estrogens and had a stroke in her early 60’s. A year later her internist told her she needed to stop taking estrogens and her response was “I’d rather be dead”. She died on the table in the cardiac cath lab at the age of 65. Her choice, but not the right one for her physically. Mentally, maybe. I agree totally with you about doctors vs. providers.
Kathryn: A truly tragic story and the kind of narrative that gives one so much pause about this issue. I really feel for the people who feel trapped in the wrong body and also for their doctors trying to navigate the right path with them. Best, LZ
This year’s Greenfield Memorial Lecture at Duke was given by Dr. Lidia Schapira, MD, FASCO. It was titled: “Medicine and Mindset: Exploring New Targets and Re-Imagining the Clinical Encounter.” Unfortunately, Duke has not posted the video. Among the many excellent points she made was the irony that students go to medical school to become doctors. Upon graduation they are immediately demoted to “providers.” She also mades the case that a subtle, and insidious, force behind physician “burn out,” is constant moral injury. The system demands doctors use a record keeping system devised to capture billing (see the excellent Acquired podcast: “Epic Systems (MyChart): The Complete History and Strategy”), compulsion to see more patients, institutional policies and pressures, and even fear of losing their job for noncompliance. Thus the lament, “This is not what I signed up for.”
Sundance:
I totally agree with her. I am not sure that I could function in today’s world and certainly not being a physician as I was taught to be by people just like you. Including you! I will be forever grateful for being 16 when the Beatles came to America and training at Duke when the “giants walked the wards.”
From one giant to another.
LZ
Leonard, I clearly remember when I knew I was headed out the academy door. Each month the Department Medicine Chair gave the “Attending of the Month” award at the end of the departmental faculty meeting. Traditionally it was given for a notable publication, grant, or some award. For the month of June it was given to a very nice person, but clinical medicine was not his forte. He was scheduled for the month when the housestaff was most seasoned, and he was paired with the strongest housestaff team. When the Chair announced him as winner, silence filled the room, and then the chair said, “This is because on not one occasion did he fail to adequately document a chart.” I felt like Benjamin Braddock in The Graduate, when he said, “I feel like I’m playing some sort of stupid game, and the rules are being made up by the WRONG people.” (I did return to academia, but that was to teach the Western America Survey Course at the University of Colorado-Boulder. So I went from teaching medical students, MD’s, and PhD’s to teaching undergraduates–clearly my academic career was floored in reverse.) Thank you for the kind words. It warmed me with nostalgia. CS
Charles: You were one of the best docs I ever knew and a truly gifted teacher. But, mostly, you always made me feel like a part of your team. However, your lecture on Butch Cassidy and the Sundance Kid may be your high point in teaching. You are also a really good person interested in more than just medicine. One of these days I need to do a Grand Tour of Colorado as I have Duke friends in Boulder, Carbondale and Durango. I know these are not easily networked by car especially for a an old driver, but I may have to find a way. Be well, Sundance.
The Kid
I’ll private message you about my efforts to keep my head above water in negotiating the human experience (themes of malignant mimesis, shadow work, and “comedy isn’t always pretty.) Re what we’ve both encountered in our profession, there’s a reason Dante placed betrayal as the final ring before Hell. It was worse than murder in that the victim survived to suffer*. On a different note re. your message, I just got back from the Steamboat Springs history museum. There was an exhibit on Harry Tracy, a member of The Wild Bunch. Synchronicity baby!
*queue up Linda Ronstadt, “Poor, Poor Pitiful Me.”
I like Warren Zevon’s version and he wrote it.
leonard.zwelling@gmail.com