How Honest Should We Be?
A reader of my blog post in Physician’s Weekly recently took me to task for being ‘judgmental’ with respect to my trauma patients. He used the word pejoratively after saying “what a terrible, disrespectful thing to say about your patients”.
The comment that had earned his condemnation of me was a statement of fact – somewhere between seven and nine out of ten trauma patients are in the trauma bay as a result of their own stupid decision. It may have been driving while intoxicated or failing to take into account the effect of pavement on an unprotected head when riding a motorcycle or picking a fight with a stranger over a minor insult, especially while intoxicated, or some variation on similar themes. Only ten to twenty percent of patients on the trauma service on any given day are regular working folk who were blindsided by circumstances or bad luck. Perhaps my comment that trauma surgeons had become the “lifeguards at the shallow end of the gene pool” was a bit over the top, but I stand by the statistics.
So am I heartless and rude when I tell you that your skull fracture could have been a voided if you’d been wearing a helmet while riding your new Harley? Am I ‘blaming the victim’ if I take you to task for trying to drive with a blood alcohol level of 0.350 when legally intoxicated is 0.08? Or inform you forcefully that your chronic narcotic habit does not mix well with half a bottle of Jim Beam?
I don’t say these things because I think the patients are bad people. Hanlon’s razor says, “Never attribute to malice that which can be adequately explained by stupidity.” They are not evil people, only people who made stupid choices.. (I also see how the same statement could be used to refer to myself. Interesting observation, that.)
The care I try to deliver in the trauma bay is not dependent on my assessment of the patient’s choices. It’s all about the integrity of the work. That demands that I bring the same focus, the same attention, and the same respect to everyone. I may judge your action, but that isn’t to be confused with a bias against doing my best for you. I don’t care about your race, religion, sexual orientation, employment, job or any of the other criteria on which we divide ourselves.
I guess my tolerance for stupidity is waning, as I get older. Calling your decision stupid is different than calling you stupid. One is an action; the other is a character trait.
We are so afraid of being thought insensitive or uncaring or worst of all, prejudiced, that we can’t even be honest in our assessment of our patients. Honesty may offend someone. They might complain to the hospital administration. Our patient satisfaction scores will suffer.
Are we perhaps doing patients a greater disservice by scrupulously avoiding any criticism of their actions and thereby giving them our tacit approval?

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