When you have a hammer, everything looks like a nail
When the problems and solutions don't match up in medicine
I recently reconnected with a friend from college whom I hadn’t seen in 10 years. As we talked over coffee on a beautiful spring morning, she told me about her work founding her own civil rights law firm.
Her work, to me, sounded deeply meaningful and good. But while my friend was proud — rightly so! — of the work she did for her clients, she bemoaned a problem that felt familiar.
“My clients want justice,” she told me. “And so often we just get them money.”
“There’s sometimes a mismatch between the problem my clients have and the tools I have at my disposal,” she went on to say.
She represents clients who are deeply deserving of legal and social change. Kids who are bullied because of their gender identity. Couples facing racist housing discrimination. People trying to exercise their religious freedom.
Most of the cases she represents end in settlements. That is, her clients get paid. Which is important. Critically so. But it isn’t the same thing as changing the system.
It was a familiar problem, the gap between the problems of the world and the way we try to map them on to legal, medical, educational frameworks.
My lawyer friend tries to turn civil rights violations into money for her clients.
And I, as a primary care doctor, try to turn everyday injustices into medical problems I can neatly solve with medical solutions.
There’s an aphorism I learned in medical school that I quote all the time:
When you have a hammer, everything looks like a nail.
I confess I mostly use it to describe my surgical colleagues. (Love you guys!) As in, “Obviously the knee replacement specialist is going to want to replace your knee!”
Doctors are trained to identify and solve problems. If you have a particular solution at your disposal — say, knee replacement surgery — you’re going to want to use it. I would argue that’s more likely to be true the more technologically specific and lucrative the solution is.
Sometimes, of course, the hammer and the nail are precisely matched. Your knee is a metaphorical nail, and you need a hammer — possibly a literal one, in the case of orthopedic surgery — to fix it. Sometimes a knee replacement does exactly what is intended. It totally cures your knee pain.
But sometimes it doesn’t. Sometimes the surgery doesn’t fix anything at all.
It’s not just the surgeons, though, who are guilty of hammering things that shouldn’t be hammered. Primary care doctors like me do it, too.
Two obvious examples come to mind, although there are many more.
First:
We turn stress and systemic injustice into a biomedical problem that can be treated with a medication.
Before I say more, I want to clarify from the outset that mental health care is one of the most rewarding parts of my job. I love being able to help my patients with mental health concerns. I love being able to explore the space between the narrowly biomedical and the psychological.
I also love being able to prescribe mental health medications that — full stop — save lives. It is enormously gratifying to be able to offer my patients psychiatric medications that can do profound good. Basically: I love SSRIs!
So with all that being said — I sometimes think primary care uses a narrow biomedical lens to address what is actually better characterized as systemic inequality and discrimination.
I met a patient for the first time the other day who came to establish care with me after a difficult hospitalization. She had been diagnosed with a heart rhythm abnormality and then had severe GI bleeding from the blood thinners she was started on to help prevent a stroke after the cardiac arrythmia was diagnosed.
She was medically stable. Modern medicine is great at treating problems like these. But she was overcome by sadness and anxiety.
During her hospitalization, the stressors started piling up. She hadn’t been able to work while she was sick, so she had been fired from her contractor job as a janitor in an office building. (Yep! Happens all the time. So many of my patients have zero job protection if they get seriously ill.)
Then the bills started piling up. Her landlord was getting antsy about her missed rent and had started talking about eviction.
Then, while she was sick, her adult son had started using fentanyl again. She was trying to get him back on Suboxone, but he kept not showing up to appointments and avoiding her calls. She would lie awake at night, terrified he’d have an overdose.
The icing on the cake? Her air conditioner stopped working, right as it started getting unbearably hot in New Jersey. Her landlord, waiting for her rent payment, refused to fix it until she paid.
So what did I do with all this? Well, first, I tried to listen. I handed her a box of tissues, as I had always been taught to do, as she sobbed in our little clinic exam room.
And then I said: “Do you think a medicine might help you feel better?”
My patient said sertraline — a very common antidepressant in the SSRI class — had helped her in her 20s, when she had been an overwhelmed new mom. So we talked about it, and we agreed that she’d try sertraline again.
I hoped it might help the racing thoughts that kept her up at night, make her feel a little more equipped to tackle the challenges she faced. But I knew, of course, it wouldn’t fix all the sources of stress in her life. She knew it, too.
Depression medications have pretty minimal side effects and often help people feel better. So in scenarios like this one, I usually offer them. They’re low harm, and they might really help.
But there’s one downside I worry about, one that’s more amorphous and hard to characterize compared to a side effect like, say, nausea or fatigue.
I worry that by prescribing a medication for depression — by endorsing the biomedical model of my patient’s stress, by essentially saying, “Yes, I think this is a problem with your neurotransmitters” — I am absolving us of collective, societal responsibility for the systemic injustice that caused so much of her depression in the first place.
Another obvious example of the hammer and the nail phenomenon: GLP1s.
I saw a patient last fall who made an appointment to discuss weight loss.
I practice medicine from an anti-diet framework, which means I typically don’t recommend weight loss or use BMI in my medical decision-making. But I work in a very general practice, and many of my patients want to lose weight. I’m not in the practice of denying their bodily autonomy or trying to bully them into body positivity.
So in this scenario, I usually rely on two grounding principles: 1) objective disease biomarkers other than BMI and 2) gentle, probing questions about body image and where the desire to lose weight comes from.
This patient had no evidence of cardiometabolic disease. Normal blood sugar, normal liver function, normal blood pressure. No diagnosis of sleep apnea. (Those are situations where I’ll proactively — and enthusiastically — recommend a GLP1.)
But she did have a lot of concerns about her body image. And she told me she wanted to try a GLP1 to fix them.
We dug a little deeper. She had recently moved to New Jersey from the Dominican Republic, and she knew nobody other than her husband.
Her husband was working very busy hours, but she hadn’t yet found a job. She also didn’t drive, and she felt it “wasn’t safe” to walk in the park or to walk to church, although she had loved being a part of a church community back home in Santo Domingo.
As we talked about how she spent her days, she, too, started crying. I tried my best to listen. I passed her the box of tissues.
She was desperately lonely. She spent her days watching TV in English she could only partially understand and scrolling on her phone. She also wasn’t eating like she did when the lived in a multi-generational household; instead of home-cooked meals she turned to the corner store and the shelf-stable foods she could buy there.
“I’ve gotten so fat, Doctor,” she said. “If I could just get my body under control, everything would be so much easier.”
Once again, there was a mismatch between the problem and solution. What she faced was complex, although not insurmountable: social isolation as a new immigrant, living in a small city that was difficult to navigate without a car, figuring out how to feed her body when the nearby stores didn’t offer much in the way of fresh fruits and vegetables.
But what she focused on was her body size. Her BMI was in the “obesity class I” category, which she had fixated on as a source of shame and despair.
She had turned those overwhelming challenges into a biomedical problem that could be treated with Ozempic.
Because she met Food and Drug Administration criteria, I prescribed her a GLP1. (I typically don’t use BMI categories to guide my clinical decision-making, but I will use them as a diagnosis if, even after an in-depth discussion of goals, risks, and benefits, the patient wants to proceed with a GLP1.)
I didn’t withhold the medication. I find that rarely does much good. But it was rejected by her insurance within 15 minutes of me sending the prescription. We were back at square one.
And again, I was left with a nagging worry about that hammer and nail mismatch.
Was I implicitly telling her, by prescribing a GLP1, that I thought her body size was the problem, when clearly what was going on her life was actually about so much more?
I’m so curious what you think. Are these band-aids that shift systemic problems onto individuals? Or are they reasonable tools to try to help resolve suffering?
What are the forces that make us reach for biomedical treatments even for problems that aren’t exclusively biomedical in nature? Let’s get into it in the comments.
A friendly reminder: All stories about my patients are fictional composites. The essence of every story is true.
What I’ve been reading this week:
The tragedy of trying to live well. (I always love Maybe Baby essays, but this one really resonated with my particular season of life.)
State level abortion bans and the health care workforce.
Sometimes it’s easier to think of systemic sexism as something a supplement can treat. (Related to today’s post.)
How care changes dads’ brains. (Great convo between Darby Saxbe and Lisa Sibbett.)
The Bee Sting. I laughed; I ugly cried. In another life, I’d love to get a PhD in contemporary Irish literature!
Are there downsides to providing medical solutions to problems that are clearly beyond medical in scope?
I do what I can. I have a hammer and the problem has a nail component so I do some nailing and something use the hammer as a shovel or mattox, even though that's not how it's designed. How many times a day do I say "There's only so much medications can do," meaning that we both know what the real problem is, but sometimes the goal is to tolerate the current situation until the patient can wiggle out of it.
The situation I see with SSRIs in my practice frequently is people who are in relationships they might like to leave and might be better off leaving (or might be better off staying, I can't predict the future), but my observation (based on seeing this play out over and over) is that an SSRI will allow them to tolerate staying. Is this necessarily good or bad? I don't know, but I do try to pull this topic into the open so at least they're making an aware decision.