Piece of Work
"You're a real piece of work!" he spat at me. He was a patient named Martin; I was the supervising physician, trying to role-model for a second-year resident how to conduct a difficult conversation with patients like this.
So far, not so good.
At first glance, Martin seemed an ordinary-looking older man, with close-cut gray hair and plain-framed eyeglasses. But I was struck by his scowl--he was expecting an argument, perhaps because during his interview with the resident he'd already encountered some pushback.
He'd brought a long list of laboratory tests that his biofeedback "doctor" had instructed him to get, saying that his fatigue and other symptoms were caused by "adrenal dysfunction."
I scanned the list--thyroid, blood count, chemistries, vitamins, adrenal function. "Testing for vitamins," I thought. "Are they kidding?" Normally, we test for only a small handful of vitamins; would our lab even know how to test for the others?
Outwardly, I tried to look neutral. "If I order a lot of tests, it's statistically very likely that one will come back abnormal," I said. "That may not indicate a real problem; it could only mean that you'll end up having more tests."
"I want all of them. That's what my doctor said," Martin replied.
"Which vitamin was your practitioner concerned about?" I inquired.
"All of them, and minerals too," he said.
Taking a deep breath, I tried to explain the difficulty of testing for every single vitamin and mineral. Martin sat scowling, then erupted with his "piece of work" comment, following up by accusing me of being a "pill pusher" with links to the pharmaceutical industry.
I wasn't thrown by his verbal abuse, having seen my share of angry, slightly nutty patients. Mentally, I buttoned up my austere white coat, then responded that I wasn't pushing any medications, and that--unlike his biofeedback practitioner--I had no financial interest in the treatments I prescribed. Furthermore, I added, no one had forced him to seek our help.
"You're the only one who can order the lab tests," he retorted. "That's why I'm here."
Finally I said, "I've explained which tests I feel comfortable with, but I won't order every single one." I couldn't help tossing in that there was a reason why his biofeedback practitioner wasn't allowed to order labs or write prescriptions. Then I left the room.
Later I commiserated with the resident: "I don't know why he bothered to come, if he thinks so little of us. Patients like that can be really frustrating." If Martin's complaints reflected anything, I thought, it was probably a mood disorder--not something organic.
I was surprised to learn, a few days later, that Martin's lab work had revealed chronic lymphocytic leukemia, a potentially deadly disorder.
My feelings ran the gamut, from dismay and guilt to near-indignation that Martin's fatigue was due to a real medical condition (one I would have tested for anyway if he'd come to us first). But I felt ashamed that I had belittled Martin for distrusting me, with my white coat and official title. Not only had my scorn damaged our relationship, past or future; it had diminished me in my resident's eyes, making me seem less professional and compassionate.
Now that the resident had to tell Martin his diagnosis and discuss possible treatments, I also realized that my exchange with Martin had compromised their relationship too. Maybe now Martin wouldn't listen to either of us.
In the days that followed, I kept turning the encounter over in my mind, like a loose tooth I couldn't leave alone.
Most of all, I had to admit, my professional pride had been stung. Martin's suspicion, his choice of an alternative practitioner and his overbearing attempts to exert control over our interaction had wounded me. But when I reflected on my own behavior, I ached even more: it was nothing to be proud of.
One of family medicine's challenges is the uncertainty that surrounds some physical complaints. Is someone's fatigue caused by cancer or by depression? How many tests do I order for a symptom that I'm pretty sure is related to emotional stress? When I forge a good relationship with a patient, we can then discuss the pros and cons of a potential intervention and reach decisions together--and it keeps each of us from feeling alone as we cope with the uncertainty.
My interaction with Martin had robbed us both of this relationship. Seeing no clear way to build rapport, I'd retreated to a comfort zone: being the medical expert. Then I was left trying to give a know-it-all explanation for a notoriously elusive symptom--fatigue. And when we did find a definite explanation for Martin's tiredness, my expertise wasn't backed up by a therapeutic relationship that could bring him into treatment. It made me realize that no number of "right answers" can substitute for forming a strong bond with another human being--a bond that enables you to provide care in every sense of the word.
Since that encounter, I've made a point of inviting patients to express their concerns and beliefs--and to question my recommendations. Some respond with the traditional "You're the doctor; you decide." Others take the opportunity to tell me what they really think about the practice of medicine.
I've become more open to my patients' beliefs, even those I consider off the wall or just plain wrong, and more willing to meet them halfway in negotiating what kind of care they'll receive. This approach helps them to feel better taken care of--and it allows me to mentally take off my white coat and feel like a true caregiver.
About the author:
Jennifer Frank is a faculty physician in the University of Wisconsin Fox Valley Family Medicine Residency Program. "I've always enjoyed writing, but have turned more and more to the storytelling aspect of writing as a way to process difficult patient encounters and the feelings these evoke. I feel so fortunate to have the opportunity to learn from my residents and patients--they continue to challenge me to be a better person and doctor."