August 29, 2018
A surprisingly common part of my life: a patient asks me for a doctor’s note for back pain or something. Usually it’s a situation like their work chair hurts their back, and their work won’t let them bring in their own chair unless they have a doctor’s note saying they have back pain, and they have no doctor except me, and their insurance wants them to embark on a three month odyssey of phone calls and waiting lists for them to get one.
In favor of writing the note: It would take me all of five seconds. I completely believe my patients when they say their insurance is demanding the three month odyssey. Or sometimes they don’t have insurance and it would be a major financial burden for them to consult another doctor. Also, I’ve seen these other doctors and they have no objective test for back pain. 90% of the time they just have the patient stand in front of them, make whatever movement it is that hurts their back, ask the patient if it hurt their back, and when the patient says yes, the doctor says “That’s back pain all right, take some aspirin or ibuprofen or whatever”.
Against writing the note: I am a psychiatrist. I usually treat patients via telemedicine, which means that in many cases I have literally never seen their back. All I remember about back pain from medical school is that some people call it “lumbago”, a word that stuck in my head because it sounds like a cryptid or small African nation. I know even less about the ergonomics of chairs, or when people do vs. don’t require better ones. Any note I write about back pain and chair recommendations is going to be a total sham, bordering on medical fraud. I could demand my patient take time off work to come in for an examination, sometimes from several hours away, just so I can do the thing where they bend their back in front of me and tell me it hurts. But that’s kind of just passing the shamminess a little bit down the line in a way that seriously inconveniences them.
In other words: the request puts me in a position where I either have to lie, or have to refuse to give people help that they really need and that it would be trivial for me to provide. It’s one of my least favorite things, and I would appreciate any ethical advice the philosophers here have to give.
But my latest strategy is radical honesty. I write a note saying:
To whom it may concern:
I am a psychiatrist treating Mr. Smith. He tells me that he has chronic back pain (“lumbago”), and asks to be allowed to bring in his own chair to work.
It’s too soon to have a good sample size. But it seems to usually work. I think it works because there is nobody at Mr. Smith’s workplace – maybe nobody in the entire world – who’s really invested in preventing Mr. Smith from bringing a chair into work. Someone wrote up a procedure for employees using special chairs, so that they’re not the sort of cowboys who make decisions without procedures. Someone else feels like they have to enforce it, so that they’re not the sort of rebel who flouts procedures. But nobody cares.
I think a lot about David Graeber’s work on bulls**t jobs. In an efficient market, why would profit-focused companies employ a bunch of people who by their own admission aren’t doing anything valuable? I’ve been wondering about this for a long time, and I try to notice when something I’m doing is bulls**t. I guess this fits the bill. It seems to be an issue of people spending time and money to create and satisfy procedures that degenerate into rituals, so that they can look all procedural and responsible in front of – courts? regulators? bosses? investors? I’m not sure. But I do wonder how much of the economy is made of things like this.