As a first-year medical student, most of my thoughts these days naturally revolve around various issues in medicine. I’m discovering that I have an unusual distrust of the health care system. Ironic, right? Compared to my classmates, I’m probably a lot more skeptical about a physician’s ability to really make a difference in a patient’s life. Now don’t get me wrong: if I didn’t think that I could do something useful in this job, I wouldn’t be making the sacrifices to be able to do it. I just feel that more often than not, I see the cases where “life” trumps medicine and renders science and reason completely useless. Perhaps I’m more sensitive to these situations, or I’m more exposed to them for some reason. 

Consider this patient: an Asian woman in her fifties. Hepatitis B carrier—she has been infected with the virus probably all her life. She’s never smoked; she doesn’t drink. Maybe her cholesterol is a little high, but whose isn’t these days? She goes to the doctor for the first time after a few years of being uninsured, has some blood tests done, and finds out that the virus is very active. This is bad. This is about the time in the course of chronic Hepatitis B infection that she will have increasingly worse liver damage. She may develop liver cancer. But now that she has health insurance, she can be prescribed anti-virals to control the infection, and they will slow the damage to her liver. Right? Right! That’s exactly what her doctor does. So she goes to the pharmacy and gets the drugs. And doesn’t take them. Even though she went to the doctor and asked for the blood test because she knew how important it was to monitor her HepB infection, she does not take the drugs that will control it. 

The drugs are expensive, and they must be taken for the rest of her life. Her Hepatitis B can’t be cured. She’s concerned that she may one day lose her health insurance. In that case, she won’t be able to pay for them on her own. Her doctor wants to see if the drugs will work and how well she will tolerate them, but she thinks that he is just blindly testing the drugs on her. She thinks, “He doesn’t even know if they’ll work! Plus, I am old and will die soon anyway.” She doesn’t have a good understanding of science or medicine. She’s not sure what to make of all this. She feels fine and wants to wait and see. She has a follow-up appointment a month later. Maybe the virus will stop growing on its own. 

At her next appointment, he looks at her new blood tests and asks about the drugs. She lies and says that she’s taking them. She lies and says that there are no side effects. He feels satisfied. She is taking her medications, and she feels just fine. He is doing a good job. He is helping her. 

Doesn’t this make you feel helpless? As a future physician, I look at this and wonder what that doctor could possibly do to change the situation. He has no idea what’s actually going on, and there’s nothing that would make him suspect that she’s lying about taking her medications. She went to him and asked about her Hepatitis infection. A reasonable person would conclude that she would care enough to do something about it. And okay, maybe they don’t have a great relationship because she’s a new patient, but she doesn’t distrust him, either. Soooo. What would you do? 

So much for science, right?

Note: Since I’ve been asked, yes, this story is true. 

More recent thoughts: 

What I learned from this scenario is that a physician’s job never ends. It’s not over when I make a diagnosis, or when (if) the patient takes her meds, or even when the disease is cured. I must keep asking questions and keep building on my relationships with patients. I must never assume that I know everything I need to know about my patients. All that is, unfortunately, easier said than done.