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Control Issues

September 20, 2013

I hate being told what to do.  I will scratch and claw when ordered around.  It takes a conscious act of will to smile and say “sure, I’ll get going on that right now”.  This is a problem since, as an anesthesiologist, I get told what to do all the time.  My kids order me around all the time.  When I was a nurse I used to bristle at the term “order” as in “Doctor, can you please write an order for tylenol”?  Most of us have lives in which a certain amount of following orders is inevitable.  There are very few people who get to do whatever they want all the time and never follow an order.  Queen Elizabeth maybe.  The thing about being told what to do is that it gets to the core of what everybody wants, which is CONTROL.  If you are doing what someone else wants, you are relinquishing a little bit of control over your actions to that person.  We do this all the time as part of the social order, in order to maintain peace, in order to get our kid to stop crying, to prevent car accidents, to keep and succeed in our jobs.

In the context of medicine, CONTROL is at the center of much of what is frustrating doctors and patients right now.  At the doctor-patient level the doctor wants the patient to do something and the patient wants the doctor to do something.  Hopefully they are the same thing, but if they are not somebody has to relinquish control.  Your doctor can say “I want you to start taking this blood pressure medication”  what he is really saying is “Do this”.  If you do it, that is, if you fill the prescription and do as “directed” (read “ordered”), you relinquish a little control to him for the benefit of your health.  If on the other hand you have no intention of doing what the doctor says you maintain control at the expense of your health, but the doctor must now accept the fact that he doesn’t have any control over you and seek to come to some understanding with you over how you can work together.  Doctor-patient relationships that don’t work don’t work because the doctor or the patient has not sought a way to share or relinquish control.

On an institutional level doctors do what the administrators say in order to keep the business going and make things run smoothly.  What has happened is that the doctor has had to relinquish more and more control to the administrators in order to continue to get paid.  When the balance of power shifts too much in one direction people start to feel that too much control has been lost.  Frustration and burn-out are the result.  Patients feel the same way when they have to enter the health care system because of illness or injury.  They feel carried away by the grinding gears of testing, imaging, and treatment without any sense of control over what is happening to their own bodies.

On a policy level we start to see that being told what to do gets more painful as the entity doing the ordering becomes more remote and faceless.  Governmental and credentialing regulations are especially annoying because doctors are losing control to a larger machine, with no recourse.  People are more willing to do what they are told, ie, to relinquish control, when the orders make sense, are not arbitrary, and are made by persons or groups that bear some of the burden of the order.  This is the problem with, for example, Meaningful Use.  To the Users, it is Meaningless, and therefore doctors will resent their lack of control over maintaining a patient record that is useful and meaningful without having any way to say “no”.

I could take this all the way to Obama and Assad, but you get the idea.  In order to start making our health system better, we have to start realizing that we are human beings who like to have control working with other human beings who like to have control.  I personally will start with my own interactions with my patients.  Anesthesiologists LOVE control.  But if you are the patient on the stretcher being asked to relinquish control over your own basic functions of consciousness and breathing to someone you’ve only met 5 minutes before, you have control issues like you never had before.  I must understand that.

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