In a link/swipe/plagiarism of the fine blog “Can’t Medicate Reality” I note the author’s remarks at the end of his blog – yes, he’s closing it down. He took on the Pandemic of Narcissism that’s swept through America in the last fifty years, and how it takes a toll on medicine.
I felt a bit jealous reading his post, as I was all fired up and full of snappy ideas to talk about, on this topic, and here rolls this brilliant piece, with better examples than I have, too.
I’ll ask him if I can swipe the material, but since I can take it down, I will start with it, and wipe it at the author’s preference. It’s just so good.
“About 15 years ago, I was working part time at a Community Mental Health Clinic (CHMC) when I got into a bit of a tiff with a therapist, who then complained to the Program Director I was not helping patients. The Pgm Dir met with me to discuss the complaint, and the basis of it was such: a patient was upset that I did not write a Rx for a benzo, and the patient told the therapist I was denying care and being insensitive, but also the patient made a veiled threat of malpractice matters. Well, at least the Pgm Dir had the chart with him at the meeting, and did note my documentation that the patient was actively still abusing illicit drugs, and the request was not grounded in a reasonable and fair choice when there were less risky and more responsible choices to consider first.

But then, the Pgm Dir said something that just blew me away. “You really shouldn’t say “NO” to people, it makes them shut down”. I really did react with an incredulous “WHAT!?” His logic was basically that patients were coming to the clinic for treatment, and that as CLIENTS, they should have some say in their care. He then went on to note that when people hear “NO”, they just stop listening further. This really was the beginning of the end of my tenure at this CMHC, as my reply was simply this: I am a doctor, treating patients, and these are not clients or customers to me, so while they have a legitimate say in their care, they do not “run” it, or control it strictly on their alleged needs or wants. Care has boundaries, usually dictated by what are the STANDARDS OF CARE, and also equally important, the provider goes from least to most invasive. Also, I do not enable nor engage co dependently with people in the midst of addiction, so giving them what they WANT, and not what they NEED, is contradictory to the treatment process.

He then came off alleging we were at an impasse. Really? I had to remind the Pgm Dir I was paying for my own malpractice working at that CMHC, so my choices were my responsibility and my accountability, and I was not going to reconsider my choice when it was counterproductive to the care matter at hand with this patient. Then I had to throw out my concern with what was really being said between the lines in this matter: the clinic was taking on a business model to care, what with calling the patient a CLIENT in the discussion, and I challenged the Pgm Dir with “do you really believe the customer is always right?” He basically said “yes”, without so many (or in this case so few) words.

The patient did not come back for care. Not my loss. Believe it or not, the final straw that made me announce my resignation about 3 months later was when a different patient’s attorney threatened to sue me and the clinic for not declaring his CLIENT disabled (again, how ironic not calling the person a PATIENT). I ran the situation by my malpractice carrier, who completely agreed with my position that not only did I not know the patient well enough to write a review of that magnitude (having only seen her twice), but there was no basis to a suit about disability assessment matters that warranted a law suit regarding health care interventions. But, what I found so incredulous to hear again from this Pgm Dir when I brought the matter to his attention, he said “you can’t say ‘NO’ to people”.

Well, since I knew I was done working at this place, I told him exactly the folly in his alleged logic. “You are wrong in my opinion, you can say ‘NO’ to patients, but there are two points to “NO” that legitimize the statement. The first is simply ‘NO’ is maintaining a boundary in the care process that is not going to be efficacious or defendable to usual and fair standards of care if you as provider foolishly or irresponsibly say ‘YES’; and the second is almost always ‘NO’ is not absolute nor non negotiable. ‘NO’ is almost always saying ‘NOT AT THIS MOMENT’ but will possibly lead to a ‘YES’ when the circumstances to the current request being denied may change. At that point, both the patient and the doctor can agree on a future intervention or diagnosis that both sides of the physician-patient relationship can proceed with comfort and certainty.”

I didn’t say it exactly as above but am paraphrasing to make the point to you the readers now. I couldn’t believe he took the side of a lawyer who was being irresponsible and disruptive. My own personal lawyer actually advised me to file a complaint to the State Bar Association for the original letter of threat for the complete inappropriateness of it, but, I didn’t. I have no regrets leaving that clinic. Things from what I heard through the grapevine in the next couple of years legitimized my position about the Pgm Dir and that initial therapist who complained.

So why am I writing about this 15 years later? Well, I still hear this bullshit attitude among providers and patients today. This blind acceptance of the business model being shoved down the throats of health care professionals, who know better than to let that square peg be rammed down our round holes, is just astounding to witness. Let me just say this to readers, and I say it with respect but also absolute resolve: whoever came up with the adage “the customer is always right” needs to be taken out back and slapped around a bit to wake them up to the realities of why the adage is wrong.

First, the customer is never always right, but, the customer always has the right to speak up for oneself and not accept perceived inappropriate terms of the business one is trying to purchase a product or service,; and second, patients are never customers, nor clients (thank you, NOT, to social work for that pathetic and inappropriate term getting any traction in mental health care!!!). So, the next time you are at Sears and want a guarantee, well, good luck if it will be provided, and remember when you are at the doctor’s office, you are not at Sears. The only guarantee I will agree to if asked to give one is this: if you leave the office continuing the status quo that brought one in for care, I guarantee things will not change and doubt will get better. The patient came in for a diagnosis and possible treatment, so if said patient is not comfortable or happy with either or both interventions, you as the patient have the right to go elsewhere or reconsider the health care “contractual” interaction with the original provider.

However, if the request for services that I was trained to offer are not appropriate nor reasonable for what I see as a provisional diagnosis and treatment interventions that are standards of care for what I comfortably can offer, be prepared to hear “NO”. But, don’t shut down right after the word is said, because I will be saying in the next breath what I can consider in the near or more distant future that can be a “YES” that will likely be efficacious for what I can offer.

Just remember this to show the folly of why people who embrace the business model of “the customer is always right” and cannot be told “NO” are at the very least hypocrites: these same business minds are behind our politicians who obviously treat us as children and slaves and almost always tell us “NO” in nearly every law and legislative onslaught these past few decades. Republicans live by a mantra of “NO” while they do the exact opposite for themselves, and Democrats, while so pathetically over permissive with their agendas of late, equally say “NO” when they tell you simultaneously while there are no boundaries, yet, you have to accept this without any dissent. I.e., “NO”, you have no choice to what they do!

And for Maryland voters, just explain this little statistic to me: 96% of you said in a recent poll you reject the notion of new taxes, yet, over 60% of you vote for the same incumbent every two to four years who have been consistently raising your taxes for years. Maybe you can’t hear “NO” because you have no concept of what the word means.

Do I care if you don’t agree? No! Not until you step back and reconsider the facts that show people need to learn the simple concept of “consistency is the hallmark of success”!
And thanks and kudos to Dr. Joel Hassman MD, Professor Emeritus, Defense against the Dark Arts of Immaturity, Axis II esp. Cluster B Disorders.