The Marcus Welby Fantasy Lives in the Past

Many people fantasize about having a folksy doctor like Marcus Welby, M.D. An idealized physician, Dr. Welby didn’t have to worry about malpractice insurance, co-payments, political agendas, interference by government agencies, or bureaucratic matters of any kind. He could be fully present for his patients.

Dr. Welby was a fictional character. Robert Young, the actor who portrayed him, may have convinced us that Dr. Welby was real, and it wasn’t all that difficult for television viewers to suspend disbelief. During the 1970s, when the show aired, many of us had a doctor similar to Dr. Welby.

The closest thing to a real-life version of Dr. Welby in my world may have been Dr. Hayes, a neurosurgeon who decided to practice family medicine in my little rural Nebraska town in the 1950s. He was our Dr. Welby. Everyone felt they could share the most intimate parts of their lives with him. We trusted him as much as we would a member of the clergy.

Many people, in years past, had their own Dr. Hayes in their lives. That type of mutually respectful physician/patient relationship continued to be the norm for decades. However, the opioid crisis seems to have put an end to an era where doctors were trusted confidants and patients were respected as members of the doctors’ extended family.

Patients No Longer Feel They Can Be Truthful With Their Doctors

More than a decade ago, I created a self-assessment tool called the Opioid Risk Tool (ORT) for predicting who might develop aberrant drug-related behaviors if they were prescribed opioids. At the time the tool was developed, the literature stated that self-reported personal information was more reliable than that collected by a nurse or physician soliciting sensitive, and potentially embarrassing, personal information.

However, a recently published article about the ORT shows that patients are not as honest with their self-assessments as they once were. This suggests patients no longer feel they can be transparent and truthful with their physicians.

That’s as unsurprising as it is unfortunate, considering patients with pain understand they are being judged during evaluations. They often feel as if they are on trial for committing a crime. Patients worry that, if they tell the truth, they will be found guilty, and they might be denied an opioid prescription. They might also become branded as an opioid abuser.

The Story of a Patient Who Asked for Opioids

Siddhartha Mukherjee, MD, DPhil tells the story in the New York Times of feeling conflicted about treating a patient whom he refers to as “S.” He recounts that S was the first person with an addiction he treated. S suffered from headaches and requested painkillers.

Dr. Mukherjee writes that, although initially pleasant, S became increasingly belligerent when he hesitated to prescribe the opioids she claimed she needed. He wanted to help. However, he felt he could not prescribe painkillers without having more information. Her requests escalated to incessant demands, but Dr. Mukherjee wouldn’t provide a prescription solely on that basis. Dr. Mukherjee and S’s needs put them at odds with each other, and that prevented them from forging a trusting relationship with each other.

Dr. Mukherjee referred S to a pain clinic. But S refused to follow their treatment recommendations, because she felt her needs were being ignored. She fired the pain clinic. With few options left, Dr. Mukherjee prescribed methadone, but S stopped participating in the program.

Later, Dr. Mukherjee learned S had died of a drug overdose.

Dr. Mukherjee assumed in his editorial that S’s behaviors were signs of addiction, and maybe they were. It’s hard to say for certain.

Abuse can sometimes be the result of intractable or inadequately treated pain. It’s possible that S overdosed intentionally because of inescapable pain.

S appeared to be crying out for help, but she felt her voice wasn’t being heard. Perhaps the lack of trust between S and Dr. Mukherjee was a contributing factor to her death.

Statements of many people who present to a doctor with a pain complaint are not taken at face value. Too often, that person is first suspected of being a “drug seeker.” If a patient requests a particular opioid because a past experience has demonstrated that drug to be effective and without significant side effects, the request raises a cautionary flag.

Most medical students aspire to be a Marcus Welby or a Dr. Hayes. Yet, today, the structure of our healthcare system combined with the fear of contributing to an opioid disorder make it difficult for physicians to treat people with the respect and dignity they deserve. Worse, patients are often forced to suffer with their unmanaged pain or to have their opioid use disorder untreated. Both outcomes are tragedies.

Photo by Pablo García Saldaña on Unsplash