Guest post by Michael M. Rosenblatt, DPM
Leonard Bernstein smoked cigarettes until his very last day. Pianist and composer Sergei Rachmaninoff smoked at least 2 packs/day and died of cancer. It is astonishing how many pop/acting legends and entertainers fall into and die of self-destructive behaviors. It’s not an uncommon problem.
There are a number of reasons why you need to prepare yourself ahead of time to deal with self-destructive (SD) patients:
- They may propel a sham-peer review against you as a result of a bad result or “dumping.”
- They may propel a pharmacy board or DEA action against you concerning narcotics you prescribed.
- They may allege patient abandonment, a very serious board charge.
- They may file a malpractice suit for a bad result the patient himself caused.
- Some as yet unknown Obamacare rule/policy may ensnare you with abandonment new cause of action.
You may need a healthcare attorney’s advice if faced with these challenges. But, when you plan in advance, you are better able to deal with them. Paradoxically, in order to do this, you must first evaluate your own psychological makeup. The reason is that SD patients are deeply invested into the “Drama Triangle” (DT for short – not to be confused with delirium tremens). You undoubtedly have your own prejudices about SD patients. I know I do. SD patients want to suck you into their own Drama Triangle. It’s what they do…
Understanding the Karpman Drama Triangle
The Karpman Drama Triangle (DT) https://en.wikipedia.org/wiki/Karpman_drama_triangle
This interesting behavioral model is one of the most useful we have. It is not based upon arcane theories of Id, Ego, Super ego or your prior relationship with your mother. Rather, it is a practical, usable model for understanding your own behaviors and their relation to others. It is another road to adult decision making. When you fully understand the DT, you’re more likely to escape the negative consequences of entering it. Anytime you enter the Triangle, either accidentally or deliberately, you are automatically shifting roles and moving from point to point on the Triangle, usually unaware:
- Persecutor (Bad guy)
- Rescuer (Good guy or enabler)
- Victim (Pathetic or angry)
Through each of these positions flow blame, guilt, lies, pain, enabling behaviors and co-dependence. The advantage of learning it is that you can make a studious effort to avoid taking any positions on the Triangle in the first place. If you accidentally find yourself on the DT, you can make active decisions to extricate yourself from the downhill slope. Understanding it provides you with the tools you need.
Learning about but the Drama Triangle is well worth the time and effort. Here’s why:
- It’s what self-destructive patients do.
- It will help keep you from being forced into a position of taking on patients you really don’t want to see, or if you must, avoiding the DT.
- It will help you extricate yourself if caught.
- It is a highly destructive behavior pattern you must be aware of.
- If you are financially strapped you may be forced to take on SD patients. Your own DT behavior may be the cause of that.
Nobody can teach DT in a short article. But without understanding the foundation, you will never really quite GET how self-destructive patients’ work. The purpose of any article like this is to avoid psycho-babble and still provide insight. You can learn about it privately without going into any therapy. It is well suited to scientists because it is a graphical analysis of destructive human interaction..
Avoiding the DT
There are two high-level methods to avoid the DT:
- Develop a comprehensive pre-planned system on how to deal with SD patients.
- Use your knowledge of the DT to extricate yourself when you see it coming.
Knowing yourself
When you know yourself, you can avoid pitfalls that will put you into the “grasp” of the DT. Here’s one short example:
Any physician who becomes “compromised” in any way is a DT target. If you are over-extended financially, depressed, over-worked and frustrated, or have home and family stresses, you are at greater risk of getting sucked into it.
On the other hand, when you understand the DT, you see it coming from a mile off. Your understanding allows you to regain control, which will help you select a better course for you and your patient. Best of all, it will help provide you with some additional tools you will probably need with our new, as yet undefined healthcare system.
(Michael M. Rosenblatt, DPM is NOT a behavioral specialist or psychologist. This article is not intended for legal or psychological advice, but rather for your entertainment and interest. If you have any questions or need advice from a legal or psychological counselor, you are hereby advised to contact a licensed individual in your area.)
I have an easier solution: I don’t treat them. Before I’d accept a smoker patient with an unruptured aneurysm, I required that they stop smoking for at least a month–verified by blood testing–and that they commit to remaining stopped. Obviously I couldn’t make them adhere to the second criterion, but I could certainly refuse to accept them as my patient until and unless they complied with part 1.
Why do that? Because thromboembolic and vasospastic complications are far more likely to happen in smokers than in non-smokers. No one knows why, but about 90% of the presented complications at conferences were in smokers, and smokers probably represent about 10% of the population–if that. If the complication rates were the same, I wouldn’t care. They aren’t, and they’re so skewed in one direction that I thought it would have been unethical for me to treat them while they were smokers.
I always offered to refer them to docs who would treat them regardless of whether they stopped. Interestingly, not even one patient took me up on that offer. Not a single one.
It’s curious how things played out. Some just did what they had to do. Others simply faded away. One particularly stupid guy–with his family–agreed to do what they had to do, and they showed up, patient in gown, IV in place right outside of angio suite reeking of cigarette smoke. When I asked him what that was all about, he just grinned. We took out his IV and sent him home. He came back a couple months later–clean for the moment–and I treated him. No idea what else happened to him: lost to follow-up.
I could go on. Bottom line for me: I don’t treat self-destructive patients in elective situations. I have no need to try to feel like a hero by battling insurmountable odds. I feel like a hero by offering excellent care to patients and refusing to provide anything less. Might be a viable strategy. Who knows?
For a doctors own survival it is essential that she becomes expert in identifying and managing self-destructive patients. There are warning signs and one also has to listen to one’s own emotions and respect one’s own gut feelings. These patients are trouble.
Richard Willner
The Center for Peer Review Justice
http://www.PeerReview dot org
Excellent article and thought provoking. Thanks
UNTESTED WATERS
Dr. Horton refuses invasive cardiography to smokers. He even sent one home. I don’t know if Dr. Horton works for a group practice, the military or a large HMO. My sense is that he does not.
Right now he has the “option” of refusing to treat, or at least by invasive methods. That option may or may not be quite so available to those who work for a large medical organization or a government provider. One can make the argument that invasive treatment is dangerous for a self-destructive patient.
That certainly appears true in the case of smokers who are looking for a “magic cure” after years of self-abuse. At the least, it appears really necessary for a highly detailed chart note including the reasons for refusal of treatment. I should stress that Dr. Horton is not alone in this. I have seen a number of physicians, especially plastic surgeons who outright refuse smokers. Dr. Horton is only doing what he can. He cannot fix everything.
But the waters are murky here. Medical practice boards regard patient abandonment as a very serious charge. Plaintiff’s attorneys are now evaluating a new source of income in patient abandonment, which is a peculiar result of improved insurability of a class of patients previously consigned to the periodic dust bin of ERs.
This is an interesting subject for Medical Justice to weigh in on. I don’t know if there is any new case law on this, or if it is about to happen precipitously.
Mike Rosenblatt, DPM
One profession at risk that comes to mind is psychiatry, especially those that treat chronically but not acutely suicidal patients on an outpatient basis. Much has changed in mental health since policies that became common place during the Reagan presidency.
However, if these individual professionals do not take on these type of complex patients then who will?
The biggest problem I see with treating patients that are self destructive are those that are not so obvious that they are self destructive…and….they may even deny it. However, when one lives in a setting where there are two attorneys for every human being and many eager Monday morning quarterbacks sitting on regulatory boards it can become quite a problem for a physician that has essentially done no wrong and has tried to sincerely help these types of patients. Due to this setting it is most likely that ultimately these complex type of patients will have increasing difficulty getting access to a provider who may, in fact, do these type of patients some good.
For most doctors in most situations, refusing to perform an elective procedure on a smoker- if smoking objectively impacts the potential outcome – is both reasonable and defensible. I know plastic surgeons who perform urine cotinine tests to confirm the patient has stopped smoking as they promised.
Where this might evolve over time is if smoking is treated as a disability for ADA purposes. As best I can tell, at this point, “the jury is still out” regarding whether smoking itself is a disability. Addiction to alcohol or drugs can, under some circumstances, be regarded as a disability under the ADA. If a person’s addiction becomes so bad that it substantially impairs a major life activity such as working, walking, sleeping, seeing, or breathing, the addiction may be covered under the law. That said, even if smoking addiction is a “disability”, if the anticipated treatment is objectively made worse by smoking, and you elect not to treat, you should be on safe grounds.