A Therapist's Treatise on Social Issues, Part 7: Medical Necessity for Treatment
Continued from part 6.
In treating any condition, healthcare providers must listen to their patients, but this does not mean accepting the patient’s self-diagnosis. The provider should gather information about the patient’s symptoms, history, and any possible contributing factors. They may also deem it appropriate to run tests before confirming a diagnosis. It is up to the provider, not the patient, to assess the condition, issue the correct diagnosis, and recommend an appropriate plan of care. In doing so, providers must limit treatment to that which is considered “medically necessary,” which usually means starting with the minimum treatment that has the potential to be effective, and only increasing the intensity and invasiveness of the interventions in a stepwise manner as it becomes apparent that this is necessary.
As an example, suppose a patient sees his doctor for symptoms of laryngitis, and he asks her for antibiotics. It is up to the doctor to know that laryngitis could be either bacterial or viral in origin, and run tests to determine which it is. She should only prescribe antibiotics if the condition is indeed bacterial in nature. If it is viral, then antibiotics will be of no use to him; indeed, they may destroy helpful gut flora, causing him digestive pains and fatigue.
Another patient sees her dermatologist for a small growth on her skin. She is worried that she has skin cancer, and she has lost sleep playing through scenarios in which she has to have surgery and chemotherapy. But her dermatologist finds the mole is benign. Chemotherapy would be aggressive and unnecessary, and any doctor prescribing it would be subject to a malpractice lawsuit and potential revocation of licensure. Noting her anxiety, her dermatologist may recommend that she see a therapist.
The patient sees a therapist. He is now responsible for helping her determine what plan of care will best help her anxiety. If she has suffered for years and tried many tools to little avail, he may recommend that in addition to weekly talk therapy, she consult a psychiatrist who may prescribe an anti-anxiety medication. If, however, the patient has only suffered from anxiety for the past month due to a particularly stressful event in her family, she may simply need to get things off her chest once a week, and be reminded to prioritize sleep.
Another patient with a lifelong history of complex trauma sees that same therapist following his third suicide attempt and. For this patient, weekly talk therapy is insufficient. The therapist refers him to a DBT clinic, where he will attend two group therapy sessions a week; work with a therapist trained in DBT who coordinates with the group; be given homework to help stabilize his mental health between visits; have access to a 24/7 crisis line just for patients of that clinic; and see an in-house psychiatrist with access to his full therapy record. Six months later, the patient’s life has stabilized considerably, and he is ready to step-down to weekly therapy. While he likes all his providers at the DBT clinic, continuing to participate in such a thorough program is no longer a good use of his time, or their resources.
These stories illustrate the concepts of medical necessity and minimum necessary treatment. Somehow, the medical and mental health fields seem to have abandoned these standards of care in their current approaches to gender dysphoria. In rushing to embrace medical interventions that are invasive, long-lasting, costly (whether to the patient or to their insurance), and involve significant side effects and risks, we abandon the physician’s adage, first, do no harm. We neglect our responsibilities as adults to protect young people from making life-altering decisions before their brains have matured, and our duties as trained professionals to evaluate our patient’s complaints in light of our expertise. We waste medical resources. We incur significant risks. This trend cannot be expected to continue for very long before a tidal wave of lawsuits push in the opposite direction.
