I am often asked to reconcile my love for the Marine Corps and my support for our troops in Iraq and Afghanistan with the tenets of the Hippocratic Oath which, by conventional wisdom, seems to preclude a doctor from calling in an air strike.
There are many versions of the Hippocratic Oath and it is continuously edited to suit the demands of political correctness. One thing on which everybody can agree is that the oath enjoins us to “First do no harm,” meaning that nothing we do should intentionally make the patient sicker than he was when we first met him. I agree with this concept completely but, and forgive me if this is obvious, this only applies to one’s patients and not to the whole world. Only a small subset of the population, those whom we formally accept into our care, are our patients. The rest are strangers and to them we owe no obligation whatsoever. Dropping a laser-guided bomb on a nest of islamofascist vipers is as acceptable as providing them with their annual physicals. It’s the context that’s the thing.
(Hippocrates himself, as a Greek living in the 4th century BC probably owed some military obligation as a Hoplite for his polis and may have been involved in a campaign or two. Even philosophers, playwrights, poets, and others who would eschew military service today served in the phalanx when necessary.)
I mention this because it is not a requirement that physicians be social activists or professional busy-bodies. In fact, as much as doctors becomes these they dilute the only real authority they have, the authority to make medical decisions on behalf of the small subset of the population who are their actual patients. This is the fallacy of “community medicine” and every recent effort to turn doctors into organs of the dependocracy. The community, various ethnic groups, and even families are not your patients, the individual patient is. Even then his role as your patient is as limited as your responsibility for him. You can’t follow him home, you can’t pick his friends, you can’t heroically throw yourself between your patient and his pie, and you certainly have no influence on him outside of the quick talking you can do when you attend him in the clinic or the the hospital.
You can’t, in short, profoundly influence your patient’s lives even though that’s the paradigm being taught in medical school where nebulous concepts such as “wellbeing” are stressed to the exclusion of old-fashioned clinical and diagnostic skills. Not only will you not have the time but in many ways, your patient’s wellbeing isn’t even your business as it depends on many factors, over only one of which you have even a semblance of control. If the patient himself can’t get his life’s house in order, it is completely unreasonable to expect his doctor who sees him for twenty minutes every other month to do it. We have no special powers of persuasion denied to the general population. You’re just a doctor. Not a magician
Under various guises however, and in classes of different names at different medical schools, you will be taught to regard patients with an almost insulting paternalism predicated on the belief that they are helpless creatures who, if you only learned the art, can be hypnotized by your magical doctor voice to make good decisions. This is essentially what is taught in most standardized patient encounters.
For those of you who don’t know, a “standardized patient” is an actor pretending to be a patient against whom medical students are pitted. Apart from learning the mechanics of the patient interview, most standardized patient exercises are constructed to allow the student time to explore psycho-social issues they would be wise to avoid, both because there is no time in the real world to explore the intricacies of your patient’s convoluted lives and because there is nothing you can really do for him anyways outside of attempting to manage his medical problems (the successful achievement of which would be a small victory all by itself).
Medicine is not social work and you are not training to be a case manager. To believe you are is to fall for the propaganda being disseminated by the usual primary care culprits who, if they just stuck to the basics, would find justification enough for their jobs without dragging the profession into a sloppy bog from which it will never extricate itself. Society and your patients already expect too much from their doctors, goods that you cannot possibly deliver in the confines of a doctor-patient relationship.
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