“I Know You Don’t Want to Be Here…”

It’s been an interesting year. Eight months after having a large kidney stone removed, I was diagnosed with very early stage cancer—small, low grade, etc. The treatment (surgery) would very likely cure the cancer. The specter of cancer meant that I found this surgery physically easier, but emotionally much harder.

The aftermath of the surgery was interesting in unexpected ways, too.

Six months after surgery, at one of my periodic follow-up visits, I was sitting awkwardly at the end of the exam table, dressed in the standard patient gown and sheet, and waiting to see Becky, the nurse practitioner I’d been assigned to that day.

When Becky came into the room, she logged into the computer, introduced herself, then said, “I know you don’t want to be here today, except that we made you come back.”

Her statement was true.

I didn’t want to be here: It was a gorgeous late-summer afternoon, and I’d much rather have been exploring the outdoors, or even dealing with my own in-basket, than coming for an appointment.

I didn’t want to be here: I’d never wanted to be a cancer patient, even one with a low-risk, early-stage malignancy, presumably cured by the surgery.

I didn’t want to be here: Walking into the building brought back all the anxiety I’d felt when I was newly diagnosed and going for my first consult with the surgeon.

I didn’t want to be here: I didn’t want to see a different provider at every visit; I wanted to be seen by someone like my primary-care doctor, who would start the visit by sitting down and asking me how I was doing, and who would take time to really listen to the answer.

As Becky ran efficiently through the checklist of questions on her note template, I wondered what she’d really meant by her comment.

From my point of view, her sentence’s two clauses each implied several possibilities:

The first phrase and its corollaries went like this: “I know you don’t want to be here today, and so…

…we won’t talk about how you feel about being a cancer patient.”

…we won’t talk about how you feel about having needed surgery.”

…we won’t talk about your fears that I’ll find a recurrence.”

…we won’t talk about how common it is for patients to feel anxious about coming here.”

The second phrase and its corollaries went like this: “…except that we made you come back, and…

…given how often you’ve rescheduled your follow-up visits, and that you’re two months late for this fourth-month visit, I don’t think you understand the seriousness of your diagnosis.”

…I don’t have time to address any obstacles you may have faced in coming for an appointment.” (She might have been willing to hear about them, if easy solutions had existed.)

…there’s nothing we can do to make this appointment more pleasant.”

Sitting there and reflecting on all of this, I also recognized how fortunate I was that my cancer had been caught very early, with a favorable prognosis. The surgery itself had very likely been curative; I was probably one of the healthier patients Becky was seeing that afternoon.

From her demeanor, I understood that she was trying to be friendly and reassuring by normalizing my presumed discomfort. Unfortunately, in doing so, she had preempted my chance to express that discomfort. And by preempting any discussion of my worries, she’d also denied herself the satisfaction of seeing my relief at having a normal exam—of seeing an anxious patient turn into a happy one.

I in turn, as a family physician, began to worry about how often, in attempting to reassure my own patients, I might have shut down their questions or concerns.

Becky didn’t know how many times, late at night, I’d reviewed the relevant medical literature to assuage my moments of panic.

She didn’t know how many times a day, while explaining physiology to a patient, I’d felt acutely aware of my own missing organs.

She didn’t know about the frequent changes in my work schedule that had forced me to reschedule several follow-up appointments.

I thought of the times I’d precepted family-medicine residents who were struggling to complete all of the required tasks in a patient visit while also connecting with the patient on a human level. My suggestions to be curious, or to ask patients more about their lives, seemed insensitive to the residents’ workload. Becky’s workload was likely just as overwhelming; how could I begrudge her the need to be efficient?

I also felt acutely aware of the many extra tasks that are added to doctors’ clinical checklists, supposedly to measure quality, and regardless of their practicality—such as counseling patients who live in food deserts to incorporate fresh vegetables into their diets. Becky likely had similar tasks to complete, again taking away time that she could have used to build a connection with me.

I knew how often I look at an “easier” patient visit as an opportunity to catch my breath; why should I not expect that she’d approach my appointment in the same way? Why should I ask for a lengthier visit, when I knew her time was needed for sicker, more complicated patients?

The reality, of course, is that every patient needs a sense of connection, regardless of the severity of their diagnosis or the length of the clinician’s to-do list on the electronic medical record.

Trying to trim time by minimizing the human connection is a false economy. Moving immediately to the official, prescribed visit agenda denies both patient and provider the opportunity for the kind of genuine connection–even if it’s relatively superficial–that makes patient care richer and improves everyone’s experience.

Simply starting the visit with “How have you been doing?” would have offered me the chance to mention some of my fears, if I’d wanted to. Becky could, perhaps, have offered me a referral to a support group, or have simply acknowledged my actual emotions as opposed to my presumed emotions, which would have felt healing. I believe that she is a good-hearted person who was trying to be reassuring, but her words left me feeling shamed and alone with my fears. The visit was medically perfect, but I didn’t feel cared for.

As I contemplated this, sitting in the exam room, Becky finished up her questions and completed the exam, asking, “Do you have any other concerns?”

I thought for a second, then decided simply to answer, “No, I’m all set.”

Arriving home, I received a message that Becky’s note on the visit was available for review. I scanned the note and saw the last line.

It read: “All questions answered to the patient’s satisfaction.”