Crafting My Own Safety Net
As I guide my car through the evening traffic, I feel tears on my cheeks.
I am a doctor who plans ahead: I write out plans for my patients. This has led to my nickname, "Plan Doctor."
Each of my consultations is carefully crafted in separate steps. The conclusion is laid out in my own neat copperplate handwriting on a plain white page. (My father taught me to write copperplate. For hours every evening I would copy stencils of words he'd written out. At the time I felt persecuted; now each day, as my writing flows, I marvel at his wisdom.)
Each plan leaves the room with the patient, melded with his or her hopes. It is real--you can hold it in your hand. Some patients tell me they put their plans on the fridge; once an elderly lady brought in a crumpled one dating from nine years earlier.
I always share plans A and B with my patients and hold plans C and D in reserve. The plans are clear, unambiguous. I put in time scales: "review in 5 days if still has fever." I put in specifics: "take with food." The plans vary greatly, obviously. They always have a line at the bottom "review in ___ days/weeks...."
As a teacher, I tell my residents, "ALWAYS have a follow-up plan. It is the patient's safety net; it is your safety net."
I give my students a page of one-line case histories for which they must fill in follow-up times: "four-week-old with fever, two-year-old with fever, sixty-two-year-old with fever..."
The follow-up plan is a guard against cockiness, against arrogance--against the disease of overconfidence. In the past I've suffered a bit from these conditions myself, but as the teeth grow longer and the crows' feet track down my cheeks, I've become less certain. I encounter more obscurity, fewer textbook histories. Perhaps my growing open-mindedness comes from my ongoing pursuit of listening well.
Ah. Another of my favorite traits--listening.
Suddenly I realize that this is why I am crying: I don't think my doctor was listening to me.
He has a malignant case of overconfidence, I decide. He didn't register my unspoken cues.
For example, it was I who initiated this follow-up visit. Someone else took my son to his music lesson so that I could wait patiently in the sterile waiting room. And if you, the doctor, hadn't planned a follow-up visit for a patient, isn't it significant when the patient schedules one?
I came back because his plan A didn't work. My unexplained pain is still gnawing every morning; it's my wake-up alarm. It's relentless, and it seems to be growing, like a tumor. (Don't tumors get worse when you lie down? Don't tumors march forward with steadily intensifying symptoms? Don't tumors pinch on like this and not let go?)
When I told him why I was back, did he hear my new words--"reaching up to my shoulder," "lasting longer" and "ten weeks now"?
I don't think so, because all he did was to reiterate plan A, his mantra for pericarditis: "The lining of your heart is inflamed." (Didn't he register that my cardiac tests all came back normal? Did he hear that the treatment didn't work?)
On this visit, he spoke a little more clearly, a little slower a little louder, as if perhaps my English is wanting.
There, in his office, I withered into my role as the dutiful patient and nodded quietly. Now, driving home, I am not sure where to go.
Later in the evening, my brother (who is studying to be a paramedic) phones me to ask about my pain. We'd brushed upon it while skiing together last week, and he remembers. He understands my uncertainty, my concern.
My friend, a general practitioner, also phoned. She too sees my dilemma, offers her thoughts and seeks a resolution.
My specialist doctor--my doctor--didn't even re-examine me. He told me tales of his skiing adventures and his recent knee injury.
He gave me no new plan, either in words or on paper. My hand opens and closes upon the emptiness he gave me.
I feel lost. What will I say to my family when they ask, "What did the doctor say? What do you have to do?" How will I answer when they ask, "Why did you pick that doctor? Why didn't you convey how worried you really are?"
I wonder how many other patients have left these rooms feeling empty, answerless, fearful.
It is frightening to chart your own way, to have to write your own plan when you're feeling so unsure, and no one else around you is sure.
And the stakes are high. My children are young. Who would smooth the roughness off my beloved, spiky oldest son if I were not here?
Suddenly I recall that I've encountered this situation once before, many years ago. Heavily pregnant with my third child, and wanting my midwife to deliver this baby at home as she had so gently done my other two, I slammed up against a specialist doctor's deafness. His consultations had no silences in which I could voice my uncertainties. I felt disappointed with that doctor--for not meeting me where I needed to be met--but also with myself for being too polite to break through his words and speak my thoughts.
Now that the memory returns, I also remember my solution. In the last month of my pregnancy, I found a listening doctor--a generalist who left silences in the conversation, who invited my story with curious eyes and who respected my relationship with my midwife. And, ultimately, I experienced a beautiful childbirth.
Now I need another such doctor who'll help me find answers about this mysterious, persistent pain.
The next day, I phone an old colleague and mentor.
"Come straight over after you finish work," he says. "I'll see you today."
A feeling of trust wells up inside and warms me; the relief is indescribable.
Now I feel confident that no matter how ugly the road ahead, I'll have a doctor who will listen, one who will offer me a safety net.
And I know that I will have a plan.
About the author:
Nicola Holmes is a general practitioner and medical educator in New South Wales, Australia. She currently works at Headspace, a community-based youth clinic focusing on early intervention for mental health problems in patients ages twelve to twenty-five years old. "I've always had an interest in writing, and it was rekindled by working in an Aboriginal Health Service program with patients who are such good storytellers. I find writing a way to debrief and let go of the tensions that work sometimes brings. I have three children and a wonderful Irish husband, and enjoy being out and about in nature. Regarding this story, I can't yet report a conclusion because I'm still on a medical roundabout, with a test scheduled for Wednesday."