Wednesday, 21 Aug 2019

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Prescribing Hope


It’s the one thing you should be able to give every patient.

Imagine your body has gone wrong, you don’t know why. You do your best, but still don’t have an explanation or solution. What can you do? You hope. Most will hope the wrong will right itself. After all, we get over the cold, walk off the ache and sleep on that which distresses us. Time brings hope. Time appears to fix all, or at least most, problems.

But the problem persists.

So you seek advice and input from the accessible, the trusted and the understandable. This may be a friend, spouse, neighbor or someone who's lived it. A trip to the library has been supplanted by Google searching for hope.

Ultimately some seek a doctor for help. Some are seeking a cause that can be conduit to resolution. Some want a diagnosis, but is a diagnosis satisfactory?  A diagnosis can be interpreted as something you have but don’t want. Sometimes a diagnosis will suffice in lieu of a cure or cause.

Although unsaid, I believe many are really seeking hope. In the least, hope is as crucial as the answer. Does she love me or not? Hope is as important as the answer.

Does hope trump the others? Why should the physician spend the time delivering hope? I do know that a diagnosis doesn’t always results in patient satisfaction. Similarly, providing a reason, cause or explanation tends to be followed by a course of intervention, testing, trial and error – and these generally don’t lift a patient’s spirit.

In the course of a medical visit or consultation, requisite questions, evaluations and reviews need to be done to document and enact an assessment, plan, prescriptions or investigations. There’s barely any time left for Q & A. Thus, despite the good work, novel treatment and authoritative answers given, patients often leave without hope and instead with info-overload, multiple prescriptions (on top of existing unwanted multiple prescriptions) and an ominous concern about their well-being.

The lack of optimism turns negative by well-intentioned interlopers, television ads, glum pharmacy visits, medical bills and the firm belief that medications can’t be good for you and my labs don’t look as good as the doctor says they do (“what’s with those red out of ranges”).

So the prescription goes unfilled or the medicine only tried and half taken. Although patients accept your prescription and orders, it’s like you accepting your grandmother's pitch to taste her rhubarb pie. Even before you accept your face goes sour and you think “thanks but no thanks”.

Imagine if you offered hope to every patient, maybe even at every visit. Sometimes hope needs to be delivered with goals or rules. Hope, goals and rules are a positive, smart prescription that positively engages the patient and makes them partly responsible for their own outcomes.

Giving hope may involve:

  • Discussing the range of possibilities
  • Expressing alternative or creative options that are better aligned with the patients realities or sensibilities
  • Discussing a time table for results, response or doctor-stuff
  • Relating another patients story germane to the problem
  • Making yourself available to the patient and their family

Sure there are times when hope is not appropriate; but open conversation, rules and goals can be as comforting as hope.

What is the worst thing a physician can say to a patient? “There’s nothing that can be done for you”.

Conversely, hope may be be the best thing you can give your patient.

Hope is the art part of medicine. The quest for excellence in medicine is sometimes at the expense of hope. Patients are more likely to listen to hope than science.

Shouldn’t they be given both?

Everything will be alright in the end; and if it’s not alright, then it’s not yet the end.
– Suni Kapoor (from the Best Exotic Marigold Hotel)

The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
Dr. Cush is the Executive Editor of and also Co-Edits the online textbook 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

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