You Can’t Bargain With Biology—But You Can Inform Us

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Most of us entered medicine because we excelled in what we now call STEM subjects and wanted to help people. For many of us, the subjectivity, biases, and unpredictability of law, business, or marketing were less appealing than the immutable truths of biology. Speaking personally, one of the most compelling aspects of a career in medicine was the idea that I would only have to learn one anatomy, one physiology, one biology—unchanging throughout my 40-plus-year career.

Some patients, however, often seem to believe that biology is negotiable and that it is the physician dictating the rules, not biology itself. But biology, not the physician, determines the course of therapy. For example, we know that propulsive gait plays a significant role in the development of diabetic forefoot ulcers and that total contact casting eliminates this gait pattern, thereby promoting healing. Yet patients often refuse to wear these casts, despite their demonstrated cost-effectiveness. Similarly, we know that reducing ambulatory venous pressure is critical in managing venous ulcers, but how many patients say they cannot wear compression, use their CPAP device, or participate in physical therapy?

As a vascular surgeon, I have treated patients who go to great lengths to preserve a nonviable toe or to avoid surgery altogether. I understand, and make allowances for, denial. But at some point, one must confront reality. Sometimes it feels as though the patient believes the clinician is inventing these recommendations. Of course, the word “doctor” derives from the Latin docere, meaning “to teach,” and to some extent it is our responsibility to educate. Yet the questions our patients ask often reflect a profound lack of medical understanding. We cannot teach them in minutes what has taken us a career to learn.

Consequently, patients may default to the tactics they use when negotiating with a contractor or car dealer, seeking alternatives even when those alternatives offer poorer outcomes. They consult the internet and artificial intelligence. In some cases, such as with rare diseases like pyoderma gangrenosum, they may become their own best advocates. They form support groups, searching for hope when they feel we have failed to offer it. Listen to them. Search alongside them. Partner with them. Let them bargain with you.

But when you recognize that the patient is bargaining for the easier but far less effective option, it is your duty as a health care provider to guide them toward the right decision. This responsibility is amplified by the fact that in most cases, it is the collective "we," not the patient, who pays for the therapy. While patients have autonomy, they cannot bargain with biology. They can only bargain with the human caregiver before them.

When they do be kind, be honest, and remain faithful to what you know.