Are we over-doctoring?: Thoughts on bedside manner

Peter R. MacKean

Twenty-four years ago, fresh out of a family medicine residency and eager to apply my trade, I entered a previously established practice in a small town in Prince Edward Island. My predecessor spent more than a month introducing me to as many of “his patients” as possible and even took me on his regular “housecall run” to make sure that these patients would continue to receive the quality care that he had already been providing.

Over the following years, my own availability and experience in the practice flourished. Patient-physician relationships grew ever stronger in this setting of cradle-to-grave care. It seemed as though these patients were somehow becoming part of my extended family.

A year an a half ago, however, those relationships had to change somewhat. I began to suffer from an illness where I had a series of epileptic seizures, forcing me to reduce hours, cancel many appointments, and discontinue home visits and intrapartum care. Although the illness was treatable, rumours of my imminent demise ran rampant. At one point, whenever I would enter an examination room, my own queries were pre-empted by “Well, how are you?” or “Actually, you look better than I thought.” I was beginning to realize that I should simply have started a blog just to save everyone’s time!

As the seizures continued, the questions began to change: “How are we ever going to manage without you?” Of course, this partially reflected sincere thoughts regarding the possible upcoming end of our patient-physician relationship, and even underscored its importance. And knowledge of the shortage of family physicians and the difficulty in obtaining a new one was obviously another reason for concern. Yet most of my patients had been given reassurance regarding interim and probable follow-up care. What, then, was the source of so much fret?

Separation anxiety

I also started to encounter a surprising sentiment frequently uttered: “How will we ever cope at all without you?” Read “How will we ever receive reassurance regarding our myriad health symptoms, help with our family or personal challenges, and seek information regarding health warnings? How do we find out if the ‘see your doctor to find out if this product is right for you’ advertisements apply to us? How do we garner opinions on new media-hyped discoveries related to our condition?”

I eventually realized that a substantial number of my patients would be unable to cope without constant attention from their personal family physician. Although I did not undertake a methodologically validated analysis of the practice roster to confirm this perspective, my impression was that, in addition to patients with personality disorders or substance abuse problems, a large number of my patients would fit into a “feeling helpless” category. I was quite surprised, as I believed that I had employed methods to avoid this (eg, verbally encouraging patients to take charge of their own health, employing Prochaska’s Stages of Change model, giving out exercise prescriptions, and offering nonantibiotic advice).

Reflecting on these newly expressed responses, I concluded that many of these patients were dependent on me. And, although the current generation’s sense of entitlement clearly played a role here, I unwittingly contributed to that dependence by allowing excessively close relationships to develop over the years. I now believe that this could be considered a form of “over-doctoring,” which could perhaps be compared with “over-parenting.”

Loosening the strings

Lately my seizures seem to be coming under control owing to a combination of new medications. It appears that I will actually be staying in practice, at least for now. I have started, therefore, to make some changes in my approach. In particular, I am now trying fervently to encourage my patients to use other “old-fashioned” methods to deal with their health issues, such as practising a life-balance approach, using common sense, and allowing their own family and friends to provide support, as well as more modern approaches like using reliable Internet sites to obtain information, rather than automatically coming in for an appointment. I encourage them to try a little harder on their own, similar to what we are taught in parenting classes to prevent over-parenting. In spite of this, we need to remember that many children do occasionally come back to the nest even after they have spread their wings. And, in practice, just a little of that will still be very appropriate.