Searching Questions and Inappropriate Answers

be seen, this test provides immediate quantitative bacteriology to the clinician to allow him to make therapeutic decisions about the patient. Previous studies by Teague et a12 using an unprotected sheathed catheter, and those of Flatauer et als using simple bronchoscopic aspirates showed how useful and accurate the Gram stain can be when nasopharyngeal contamination is ( presumably ) worse than with the protected catheter. Since the nonpathogenic bacteria in the lower respiratory tract seem to be present in low numbers ( < 104/ml), they should not be visible on Gram stain. Numerous studies, in addition to that by Wimberley et al, have shown that bacterial pathogens in patients with untreated pneumonia are present in concentration in excess of 105 per ml and usually in excess of lo7 per ml.4p5This suggests that unlike the problem with expectorated sputum, all that is required of the reader is the ability to perform a Gram stain correctly, to distinguish the various possible cellular components ( polymorphonuclear leukocytes, macrophages, respiratory epithelial cells, and squamous cells) and to distinguish red from blue. Another potential problem with the sterile brush technique is the possibility of a sampling error. If there are no secretions in the airway where the brush is placed (either because of suctioning, coughing, or the lack of pneumonia in the area of lung which drains into that bronchus), then the sample obtained may not reflect the underlying pathologic process. This always has to be considered when the obtained secretions reveal no idammatory cells or bacteria. The problem of an inadequate sample could be avoided when no secretions are obtained, by flushing nonbacteriostatic saline through the catheter (without the brush) and then aspirating with a syringe, such as is done when no sample is obtained on a 'ITA. The final question to be answered is when and where the sheathed sterile brush should be used. Because it requires a bronchoscopist to obtain the sample, it would appear to have greater limitations than the 'ITA. This would appear to be more than compensated for, however, by the reluctance of the private practitioner outside the teaching medical center to use the 1 T A and his ready acceptance of the risk of fiberoptic bronchoscopy. This technique would appear to provide a viable alternative to l T A when routine sputum is unobtainable or nondiagnostic, a specific diagnosis of the etiologic agent of pneumonia is important, and a specialist trained in use of the fiberoptic bronchoscope is available. Whether the more expensive plugged sheathed brush is better than the nonplugged variety has not been shown in oioo, CHEST, 81: 5, MAY, 1982

and both still require careful attention to the Gram stain and quantitative bacteriology if the information obtained is to be of any clinical usefulness. Richard 1. Wallace,Jr., M.D. Houston Jderson Davis Hospital and D e artment of Medicine, r of Medicine. Microbiology and Immunology, ~ a y g College ACKNOWLEDGMENT: The author wishes to thank Dr. Daniel Musher for reviewing this manuscript.

Reprint requests: Dr. Wallace, Depurtment of Medidne, B ~ College h of Medidne, Houston 77030

1 Fossieck Jr BE, Parker RH, Cohen MH, Kane RC. Fiber2

3

4 5

optic bronchoscopy and culture of bacteria from the lower respiratory tract. Chest 1977; 72:s-9 Teague RB, Wallace Jr RJ, Awe RJ. The use of quantitative sterile brush culture and Gram stain analysis in the diagnosis of lower respiratory tract infection. Chest 1981; 79: 157-61 Flatauer F'E, Chabalko JJ, Wolinsky E. Fiberoptic bmnchoscopy in bacteriologic assessment of lower respiratory tract secretions. JAMA 1980; 241:2427-29 Guckian JC, Christensen WD. Quantitative culture and Gram stain of sputum in pneumonia. Am Rev Respir Dis 1978; 997-1005 Thorsteinsson SB, Musher DM, Fagan T. The diagnostic value of sputum culture in pneumonia. JAMA 1975; 233:894-95

Searching Questions and Inappropriate Answers of physicians contend that there is A number increasing disenchantment with the medical

profession. Koosl reported that the majority of farnilies he questioned were dissatisfied with their doctor-patient relationship. Jensen2 described a deterioration in physician-patient rapport and attributed this phenomenon to "medical school dehumanization" and increased consumerism. Problems do exist, and as clinicians, we have the responsibility to ask thought-provoking questions about traditional physician-patient relationships. However, it is hardly constructive to offer superficial answers to candid questions. Consider, for example, some rhetorical bombast provided by Preston3 under the guise of "solutions." He writes, Insist on being an equal partner in a11 decisions, using the doctor's knowledge and skills but not giving him control over you. Remember always that the best intentioned doctor can have financial and professional interests that are in conflict with your own, and if you and your physician do not minimize these conflicts, you will be the worse for it. You want your medical care to be patient-centered, not doctor-centered.~*ll

Elsewhere he stresses, Call your doctor 'Mr.', 'Ms.' Why do you call the physician 'Dr.' when you call everyone else 'Mr.' or 'hlrs.?' Why do you accord this special status? If doctors are not superhuman, wouldn't it be better to address them as you do other respected members of so~iety3p'Oo

Preston attacks presumed physician negligence in the application of scientific methodology for assessment of therapy. Science plays a limited role in the actual practice of clinical medicine. The clinician, who applies biological knowledge to the problems of patients, does not apply it scientifically, but subjectively. He uses the technical fruits of science but resists its method, which would challenge the supremacy of his clinical judgment and reduce him from a godlike figure to a m e d i d technician.lls

As evidence of this deficiency, he quotes examples of improper or unsupportable conclusions in medical literature. However, a study4 upon which Preston relies has an epilogue. Editorial instruction to authors by consultants and editorial boards resulted in significant improvement in the statistical sophistication of clinical investigators and in their written reports. As an editor, I have observed that clinicianauthors have demonstrated a profound improvement in knowledge in the fundamentals of clinical investigation and specifically the controlled clinical trial. It is far more rational to institute courses in the methodology of clinical investigation in medical schools and continuing education programs than it is to propose that laymen should be the arbiters of what constitutes good or bad research. Perhaps Preston's anger and resentment is most evident when he discusses the difFerence between the healer and one who cures. Preston admonishes the patient, 'Learn not to substitute curing for caring. Find out what your problem is, and whether it requires curative therapy or whether you can heal yourself with sufficient emotional support.''@" In the same vein he asserts, Learn not to couch psychological problems in somatic terms. If you are upset over a family matter and have a headache as well, tell your doctor about your emotional state as well as your headache. If you want warmth and consideration and caring, fine-go get it; but don't confuse it with curative medical care.P*1°

These are unrealistic recommendations. The patient with recurring headaches may be entirely unaware that psychic elements play a role in his somatic debility. Probably the majority of patients who experience psychosomatic symptoms require the assistance of a physician for the acquisition of insight 534 EDITORIALS

and an awareness of the basis of some of these symptoms. Much of the practice of medicine is concerned with the evaluation and management of patients' emotional needs, as well as their physical status. It is both calloused and simplistic to suggest that the patient "can heal himself." The indissoluble link between the psyche and bodily ills (and the clinician's role in treating both) is not a new phenomenon. Eight-hundred years ago a masterful physician-philosopher urged patients to seek emotional support from physicians: What is the corrective for those \vho are sick in soul? They should go to the wise who are physicians of the soul and they will heal their maladies by instructing them in the dispositions which they should acquire till they are restored to the right path (hiaimonides in the Mishnah Torah ) .

Over and over again, Preston stresses that the patient's belief in the magical powers of the physician leads to a therapeutic contract which is inimical to both the professional "partner" and the consumer. Preston states, The physician assumes that his superior knowledge and experience enable him to judge what the patient needs. Since the patient is presumed to be unable to make an informed decision and likely to choose wrongly even if fully informed, it is standard practice for physicians to manipulate information in order to persuade patients to accept recomrnendadations-in reality, the patient's best interests are served when he, not the doctor, decides what he needs to know.~;a

With this philosophy as a proposed basis for medical practice, it is not surprising that Preston takes exception to my concept of consumers' rights. I wrote recently, "It is astonishing to hear demands that the patient should be allowed to make major therapeutic decision^."^ This statement is derided by Preston; he claims that adherence to my philosophy means that, "The patient may learn from the doctor how to take care of himself but may not participate as a healer."(^^^) I find it difficult to understand how the patientphysician relationship can be enhanced in a constructive way by abrogation of the physician's responsibility to be the decisive individual in h s ing therapy. I have always encouraged maximum ( albeit judicious ) disclosure of information to the patient, and whenever possible, this should include detailed information about the character of the disease and the diagnostic proccdures to be used. Long before it became fashionable, I directed pharmacists to identify medication by use of the phrase 'label as such." I discuss in great detail with my patients CHEST, 81: 5, MAY, 1982

the rationale for the type of medication I am prescribing and potential side effects, as well as therapeutic actions. The clinician should share with the patient full disclosure of the proposed therapeutic plan and alternative forms of therapy. However, there must come a time in the management of the patient when it is neither necessary nor wise to list an infinite number of alternate therapeutic approaches, whether medical or surgical. At this stage the physician must say, "I recommend this treatment for your disease." It would impose an intolerable emotional hardship upon many patients to force them to make ultimate therapeutic decisions no matter how knowledgeable they may be. Indeed, the physician who becomes a patient often chooses to transfer this privilege to the colleague who becomes his clinician. Informed consent is a contemporary phenomenon; fortunately, valid consent has become a moral and legal necessity. This process of self -determination permits the patient to have the final choice in deciding his treatment. However, many patients cannot or will not make such a decision. The resulting physician-patient relationship is labeled, "Patemalism with permission," by Cross and Ch~rchill.~ The authors note that this represents the more typical situation in which decision making powers are returned to the physician. When the roles are reversed, a clinician must recall that, Paternalism with permission, far from being easier, is more difficult to implement than traditional informed consent. It requires not to choose as the physician would for himself, but to choose what is best for the patient, whose pattern of living may be wry different.6

Others have asked the questions posed by Preston, but fortunately, they offer more reasonable solutions. Jensen2 suggests that in light of today's culture of consumerism, "A more workable model is the 'mutual participation' doctor-patient relationship in which responsibility and cooperation are shared." He urges that there be a change in medical school admission policies so that increased consideration may be given to applicants whose personal characteristics would make them amenable to this approach. In the years ahead we will undoubtedly emphasize prevention of noncommunicable diseases

CHEST, 81: 5, MAY, 1982

by enlisting increased participation of the patients in such prophylaxis. Comroe7 defends the right of the individual to know the risk factors involved and then be free to decide whether he prefers the treatment or no treatment. He notes, *In the long run, a well-educated, well-informed citizenry will more often than not make the right de~ision."~ Serious issues confront us and sober suggestions must be encouraged. Traditional habits and attitudes should be re-examined and many will be modified willingly or unwillingly. A patientdoctor relationship which more resembles a partnership in health care will be a healthier environment for both physician and patient, particularly since such an approach does not encourage unrealistic health expectations in both the healing and curative phases of management. We must choose candidates for medical schools with the full realization that their capacities for compassion and empathy are as important as their knowledge of basic science. The critical role of exemplar by medical school faculty and all teachers of younger physicians should be used to encourage humanization rather than dehumanization of medical practice. Courses in biostatistics and the discipline of clinical research should be key elements of the cumculum in the training years. These changes in education and practice are reasonable responses to the questions raised by Thomas Preston. Alfred Soffer, M.D., F.C.C.P. Park Ridge, Illinois

1 Koos EL. "hietropo1is"-what city people think of their medical services. Am J Public Health 155; 45:1551-57 2 Jensen PS. The doctor-patient relationship: headed for impasse or improvement? Ann Intern Med 1981; 96:76971 3 Preston T. The clay pedestal; a reexamination of the doctor-patient relationship. Seattle: Madrona Publishers, 1981 4 Schor S, Karten L. Statistical evaluation of medical manuscripts. JAMA 1965; 195: 1123-28 5 Soffer A. Consumer's rights in medicine. Arch Intern Med 1978; 138:905 6 Cross AW, Churchill LR. Ethical and cultural dimensions of informed consent; a case study and analysis. Ann Intern Med 1982; !38:110-13 7 Comroe JH Jr. The road from research to new diagnosis and therapy. Science 1978; 200:93137

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