The Demanding Patient at Walter Reed

Every doctor has been there. The patient who insists on an unnecessary X-ray. The mom who demands amoxicillin for her child’s viral cold. The guy who refuses to leave the ER without a prescription for SOMETHING because otherwise why am I even here?

And every doctor has had to decide, how much do I fight this? I’ve got five patients in a holding pattern. It’ll take me 30 seconds to write the script or 10 minutes to talk this patient down, and the insurance company doesn’t have a billing code for “10 minutes of rational conversation.”

Mostly, I think, we do the right thing. We recognize the fear that motivates the factually baseless request. We say, “no.” We explain why. We move on.

But every once in a while you get a patient who digs in their heels and threatens to call the hospital president or contact the guy on the billboard down the road asking if you’ve ever been hurt by a doctor, or they let you know in no uncertain terms that their uncle is a member of the board of this hospital, and you damn well better do what I want.

So against your better medical judgment, you throw up your hands and go: fine, sure, here, whatever you want, now go.

Can you imagine what it would be like to have Donald J. Trump as a patient? He knows more than the generals. He knows more than the scientists. He knows more than the doctors. He was saying this would go away “like a miracle.” He demanded and took drugs that had no proven value. And of course, bleach. (And nope, for once, he was not being sarcastic.)

I don’t know much about his physician, Dr. Sean P. Conley, except that he wears a crisp white jacket with the title “Physician to the President” embroidered in elegant script on the left breast and a big old Presidential Seal the size of a highball coaster on the right breast.

That and he can’t seem to get his stories straight about what is going on with his patient. He wasn’t on oxygen at all, except for the time he was. And he’s doing fine so we’re giving him four drugs including an experimental one. Now of course, every patient has a right to privacy under HIPAA regulations. However, as the Leader of the Free World, the president also has an obligation to let his doctors tell the citizens of this country about his health status.

Can you imagine how THAT conversation went? That, and of course, the conversations about what treatments he would get? This president is not known as someone who practices delayed gratification or tolerates an image of himself in anyone’s mind as vulnerable. So I’d speculate it sounded something like this:

“Give me the drugs! Give me ALL the drugs! All the BEST drugs! Give them to me NOW! Let’s get this over with! And don’t tell anyone I’m really sick because I’m really not! Tell them I’ll be out by Monday! No bad words because that makes it bad! Upbeat, Conley! UPBEAT! Or you’re gonna be cleaning bedpans in Gitmo! Now bring around the SUV!”

Donald J. Trump is the quintessence of the Demanding Patient With The Power To Get Whatever The F — k He Wants Even If It Kills Him.

A patient with this much power surrounded by a medical “team” (make of the quotes what you will) is a recipe for disaster. When it comes to medicine especially, there is a huge difference between Quality and Quantity. Good Medicine is way different from Lots of Medicine. And I can tell you that every one of my colleagues I’ve seen commenting on this case on social media are saying the same thing. To boil it down: “WTF are they DOING?!?”

One of the most basic tenets of medical practice and patient care that I hold most dearly and try to adhere to most closely I remember hearing from my Pharmacology professor in my second year of medical school over 40 years ago. He said, “For every good effect a drug has, it has at least ten bad side effects, so you better be DAMN sure that that good effect is good enough to outweigh all the bad stuff.”

From what I’m reading about what’s going on at Walter Reed, they seem to have an everything-including-the-kitchen-sink approach is combining drugs and therapies that are generally given at different times during the natural history timeline of full-blown COVID-19. They are also including drugs like the monoclonal antibody cocktail that has been used only experimentally. Its side-effect profile by itself is not well-known, much less how it may adversely affect a patient in combination with other drugs.

Of course, Dr. Conley is being so cagey about what how sick the president really is (doubtless due in large part to a profound insistence on the part of his powerful patient to paint a rosy picture) that we really have no idea of what’s going on. If he truly is sick enough to need all these drugs now, he has no business being discharged from Walter Reed on Monday, and if he is not all that sick, the drugs themselves will likely cause him some unforeseeable side effects which may be quite serious.

In any health care encounter, the patient and the doctor have a dual responsibility. The doctor is charged with giving the patient expert advice on the pros and cons of each therapy for their condition and advocating for a plan of care appropriate to the individual patient. The patient has a responsibility to take the advice of their doctor seriously and sometimes to allow therapies that might be difficult or even embarrassing in order to maintain or restore health.

There is often a power differential between patients and doctors with doctors perceived as having the upper hand. I spend a great deal of my time discussing this with my students and residents, working with them to help put patients at ease and helping them find ways of letting patients and parents know that we can only promote healing if we find ways to share power.

This president has shown time after time that he is not at all interested in sharing power. Indeed, he works tirelessly to amass power, belittle others, and dispel any notion of his personal vulnerability. Thus, the power differential between him and his doctors is immense. Whatever personal demons have shaped his behavior, this hubris is surely what led to his becoming infected, and now it may lead to him thwarting appropriate care that could save his life.

As this very patient said himself in another context last Tuesday evening, “This is not going to end well.”