Doc On The Run Podcast: Paternalistic Medicine Fails Runners

Paternalistic Medicine Fails Runners

Subscribe: iTunes | Android

Paternalism Fails Runners.

During a sermon one Sunday morning in 1896 in Dayton, Ohio, Bishop Milton Wright said, “If man was meant to fly, God would have given him wings!”

Lucky for us, his sons didn’t listen. Had Wilbur and Orville actually taken their father’s admonitions to heart, it would certainly take us a lot longer to get from San Francisco to New York.

As a father myself I cannot believe the good bishop was hoping to crush his children’s dreams. I can only assume he wanted to protect his boys. He wanted to protect them from what, to him, seemed to be a foolish idea of propelling themselves through the sky. He didn’t want them to die in the process of seeking an adventure.

In retrospect, it is clear Bishop Wright had the wrong idea. His kids wanted to fly. And so they did.

The doctor wants to protect runners from further injury. It’s part of the Hippocratic Oath: “First, do no harm.” It’s part of what they have sworn to do. But doctors should also encourage you to fly.

They should look for new ways to get you from point A to point B. They shouldn’t look at the old methods of healing and recovery and think it’s enough for an injured runner.

Nobody wants to ride a donkey from San Francisco to New York.

It’s the doctor’s job to help you look to the sky. It’s the doctor’s job to help you fly.

Paternalistic Medicine

Medical paternalism is a set of attitudes in which the physician thinks he has the right to decide what is best for the patient, and therefore a patient’s wishes or choices should not be considered or honored.

“In the 18th century, medical paternalism was considered necessary. It was believed that only a doctor could properly understand symptoms and draw useful conclusions.”  – Wikipedia1

In the last couple centuries all of that has changed. Not only are patients no longer considered passive recipients of healthcare delivery, we all agree doctors and patients have to have a functional working relationship more similar to an athlete and a coach. This is all the more true with athletic patients.

Even 50 years ago many patients had limited access to the information accessible to physicians. Today virtually every patient who has a cell phone or a laptop can almost immediately gain access to diagnosis algorithms and treatment regimens.

Patients show up in the treatment room armed with information. Most of the runners have already tried a number of treatments on their own before they even seek the help of a doctor.

The days of injured runners simply following advice are over. And they should be.

Every injured runner is a unique physiological and biomechanical specimen. No two runners have the exact same goals. No two running injuries are exactly the same.

Given the fact that we are all physiologically different and have varying goals, it seems absolutely ludicrous that any specific injury pattern should have the exact same treatment thrown at it.

We are not automobiles with busted radiators or failing batteries. We are all physiologic systems all in varying levels of fitness and/or disrepair.

So you as an injured runner have to take your goals, state of fitness, anxieties and concerns and present them to the doctor. And then you have to brace yourself for the inevitable barriers of communication that can diminish your interactions with your doctor.

Every day I am reminded that runners often get more discouragement than encouragement when they go to the doctor. You’re told to not run. You’re told to do less. You’re told you need to rest. And all of that advice goes in the runner’s ears, enters the runner’s mind and once it gets processed it is filed away as discouragement.

The runner takes this “advice” as disparagement.

The disconnect happens on both ends. The doctor doesn’t understand the runner’s perspective. The doctor doesn’t understand that the runner will actually start to feel worse during a period of inactivity.

It’s common knowledge among runners that we gets stiff, achy, anxious and even grumpy when we skip several days of exercise. We need to run to be happy. We need to run to be limber. Our bodies revolt whenever we sit still.

If you don’t believe me, just ask your doctor this question.

“Doctor, if I’ve been training for an Ironman and I have been ramping up my mileage for several months, what would you expect I should feel like physically during the three week period where I taper and gradually decrease my activity in preparation for the race?”

You as a runner know you shouldn’t expect to feel good. It’s common knowledge among endurance athletes that you start to feel stiff, achy and anxious during your taper. You feel sluggish. You don’t feel like an athlete. You certainly don’t feel ready to run your race and come away with a new personal record.

Many, if not most, doctors would expect you to feel better. They think rest will make you feel better. After all, rest makes most sedentary individuals feel better. Particularly after months of heavy physical activity that a sedentary physician might label physical abuse.

The runner understands the way her body feels. But the runner doesn’t always understand all of the physiology behind healing.

As a board certified sports medicine podiatrist with extensive training in reconstructive foot and ankle surgery I spent a total of 13 years in school after high school. That’s a lot of time learning about how a runner’s body works.

But all of that knowledge gained from formalized education, medical school and residency training certainly creates a very lopsided perspective on my behalf. Even as a lifelong runner, I have to work persistently and diligently to keep my indoctrinated medical brain reasonable. I have to work to incorporate what I actually know about running and balance it with what I know about medicine.

As an injured runner, it is very difficult to not place excessive weight on how you feel.

It may be helpful to remember how you felt during your last taper. About how you became concerned that the taper was actually hurting you. That perspective can help you maintain peace of mind and rest assured that you will eventually heal and get back to running.

You had to listen to your coach and stick to the plan when you were tapering. And when you get injured, sometimes, you have to listen to the doctor and stick to the plan.

Having said that it isn’t always necessary to just take your doctor’s advice, and swallow it like a bitter pill. In fact you shouldn’t swallow everything that tastes terrible.

The most important thing you can learn here is that you have to communicate clearly and effectively with your physician. You have to understand what the doctor is telling you, but your doctor also has to understand you.

Doctors see all kinds of patients. But if you live in America the overwhelming majority of patients that wander in to a doctor’s office are unfit, out of shape and often at least moderately obese.

Most patients are not runners.

Most runners exhibit an almost inhuman level of fitness compared to the average American.

When a physician sees an ultra-fit runner who suffers an injury, the runner is so far out of the normal frame of reference for the physician that the doctor can become bewildered or even confused. The doctor doesn’t know what to do with you.

The doctor listens to your story, “I’m training for an ultramarathon and I’ve been ramping up my mileage and doing well. However I start getting this pain in my calf when I get to about 30 miles.”

The doctor silently thinks, “Okay, you get pain in your calf when you run 30 miles. Why in world do you need to run 30 miles?”

But you silently think, “If I don’t get this pain to go away I’m never going to get to 100 miles.” The both of you are silently thinking. You’re not communicating.

You have to spell out the discrepancy between where you are and where you want to be.

It is your doctor’s job to understand how to fix your problem. But it’s your job to make your doctor understand how big that problem is, and why it’s a problem in the first place.

You cannot assume your doctor understands your perspective. In fact, you should assume that your doctor is almost incapable of understanding your perspective.

Runners don’t fit well into insurance-shaped-boxes.

One unfortunate reality about healthcare in the United States is that health insurance companies contract with doctors offering access to patients and increasing volume. In exchange, doctors agreed to accept lower reimbursement rates. The only way this can work for the doctor is by increasing speed and decreasing time with patients.

So the doctors create specific treatment protocols to handle standard scenarios. I did this myself when I had a standard practice. I still have a very thick three ring binder that has all the treatment protocols I wrote. Every morning we would review the incoming patients on the schedule with the staff. Base assumptions would be made about patients before they even showed up in the office. The patient with heel pain was presumed to have plantar fasciitis, until proven otherwise. So basically, the staff would set up everything in the treatment room in order to deal with plantar fasciitis.

If you don’t think this is happening, just think back the last time you went to the doctor. Did it seem like your doctor had come to a conclusion before you even finish telling your story? Did they give you some prewritten handout on instructions for your condition?

Of course as a runner you have a unique set of circumstances. In many cases you even have a unique injury. All stress fractures are not created equal. Tendinitis comes in varying forms. The severity of all those injuries can differ significantly depending upon how fit you are, and what you were doing when you sustained the injury.

But if your doctor agreed to contract with an insurance company, and by doing so agreed to accept a fraction of her usual consultation rate, just because she accepts your insurance, you simply cannot expect her to take an hour out of her day to figure out the nuances of your condition. You cannot expect her to take an hour out of her day when she has 40 patients on the schedule just to discuss various strategies for you maintaining your fitness and getting back to running sooner. It’s just not realistic.

The truth is that I believe standard protocols work very well for the overwhelming majority of patients. I really think that about 85% of all patients who wander into doctor’s offices have standard injuries that can be treated in a standard way.

Of course, these are standard patients. They are usually sedentary patients with limited levels of activity. They’re not runners. They are not athletes. They don’t have lofty goals of running across the Grand Canyon or qualifying for the Boston Marathon.

For those patients, standard treatment protocols seem reasonable and acceptable. They really can get by with the lowest cost, least time intensive delivery of medicine.

And although paternalistic medicine is basically dead, this is one scenario where it seems reasonable for the doctor just to give the patient a quick summary and hand them a sheet of paper that tells them what to do.

But again, this just doesn’t work for runners. Runners have too many questions. And questions don’t fit into the paternalistic model.

Your desire to run makes your doctor’s job significantly more difficult.

Whenever I lecture at medical conferences about running injuries I always ask the doctors in the audience who likes to see runners, and who does not like to see runners. It may not surprise you to h

ear that the overwhelming majority of physicians at these conferences don’t really like to work with injured runners.

I always pick some doctor in the audience and ask him why. Here are the top three responses I hear:

Runners just want to run.

Runners think they know everything.

Runners always read stuff on the Internet before they come into the office.

 The first of these responses is certainly reasonable. After all, by definition runners should want to run. I still don’t understand why that is actually a problem for the doctor. Unless you consider that it does take more effort to help you figure out how to run when you actually have a running injury.

The problem with this situation is that the doctor is trying to figure out how to heal your injury. The doctor is not really trying to help you figure out how to run. Again, this comes back to a paternalistic attitude.

You want to run. You get a running injury. The doctor thinks if you can just forget about the running part, it will be a lot easier to heal the injury. So the doctor suggests you should stop running so that you can let the injury heal. But again this is just the doctor telling you what to do to make the doctor’s job easier.

A doctor telling a runner not to run makes no more sense than a lifeguard telling a swimmer not to swim.

The second thing I hear from doctors is that runners think they know everything. And runners may not know everything, but based on industry research runners are of a significantly higher education level than the general population. So we should assume you are well educated.

The whole process of running forces a mindset of analysis, evaluation and resetting of expectations. That’s what we do as runners to get stronger and faster. That’s how we achieve our goals. We study. We learn.

All of that learning does give us a knowledge base about our own bodies and how they respond. We show up in the doctor’s office explaining what we know works and what doesn’t work, with us with certain treatments. Our insistence of including our own knowledge base in the discussion sometimes can be off-putting to doctors.

The paternalistic doctor thinks patients should be passive recipients of healthcare. Rightly believe we should be equal partners in the development of a plan. Sometimes doctors perceive the interjection of our experience and the knowledge we gained as runners and athletes as offensive.

And that brings us to the third problem. Doctors seem to get irritated by all of the internet based research we do before we go to see a doctor. This one frankly still confuses me.

If the doctor really wants to save time it seems like it’s to the doctor’s benefit to have you educate yourself about anatomy, disease processes, the nuances of different types of injuries all before you ever see the doctor. At least you are both speaking the same language at that point.

I think it’s extremely helpful when patients have done a lot of research on the internet. In most cases they have already ruled out certain problems. They’ve evaluated their own injuries and tried to correlate them with symptoms that fit with certain injuries.

Effectively what the injured runner has done is narrowed what doctors called the differential diagnosis. They’ve taken a huge list of possible problems that could affect the foot and then reduced it to just a few. Of course it was done logically. You have compared the signs and symptoms of a certain injury to your specific injury. You eliminate the diagnoses that don’t match up. And you don’t have to be a doctor to figure out how to scratch some conditions off the list of possibilities.

Part of the reason some doctors get offended by this is that there is some sort of remnants of paternalistic attitudes that make the doctor think only a doctor can make those determinations. Of course, as you and I both know, this is archaic thinking.

When we get injured we runners try to learn what’s going on. We research. We analyze. When we show up at the doctor’s office we are armed with questions. And that’s a fair fight

No matter who your doctor is, you have to be prepared to share your goals. You have to be prepared to stand up for yourself. You have to insist that your doctor understands your goal is bigger than healing the specific injury. You have to make your doctor understand that your goal is to run. And you have to make your doctor understand that your goal is to run sooner, rather than later.

  1. Medical paternalism. Accessed 11/23/2017.