Last year I was one of a few Canadian physicians granted an audience with one of the megastars of our specialty to discuss developments in women’s health, and postmenopausal health in particular. I use the term megastar without a single nod to Dame Edna—this was a megastar by common agreement. During the course of our discussion he made reference to a scientific debate he had recently participated in, pitted against one of the luminaries of the women’s health world who is well-known for her skeptical, if not hostile, views on hormone replacement therapy.
The megastar told us that while he sat with the luminary waiting for the show to begin, his knees were knocking. He was about to debate a woman who had all kinds of facts and figures at her fingertips, whose whole life was analyzing and criticizing the things that we do. But then he realized that, strangely enough, his adversary’s knees were knocking too—and not because she was pitted against a megastar. She was petrified because she was going to have to debate a clinician.
This anecdote came back to me this year when I (along with everyone else) was trying to digest the facts and significance of the findings in the combined HRT arm of the Women’s Health Initiative. This was terminated early because of a perceived increase in overall risk to the women on active treatment. Drawing on what contacts I had among the coordinators of this study, I wrote, e-mailed, and telephoned in an effort to fill in the many blanks in the initial report. What struck me in the contacts I made was the sense of triumphalism that the report seemed to engender among its principals. So what, they indicated, if publication of the report was going to cause anxiety in all and blind panic in some? Not our problem, seemed to be the theme. The clinicians can look after that—they were the ones who prescribed this stuff in the first place.
Pity the poor clinician. Everybody else is an armchair critic, and the correct course of action is so clear to them, but the clinician gets to carry the consequences of everything that our patients choose to do. The critics’ theoretical concerns become the clinician’s absolute responsibility.
If that’s so, then there must be acknowledgment that together with this responsibility comes moral authority. We should claim it. In fact, the highest moral authority in the whole messy health care debate lies with the physician-patient partnership—because that’s the health care coalface. That this final interface is so ignored is a tragedy. Shame on the politicians and the strategists for overlooking the obvious. Listen to the clinicians, before it’s too late.
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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