For all intents and purposes the visit was over in about 30 seconds. Our conversation continued for another 15 minutes after that, but nothing I said after the first half-minute mattered. He did not like me.
Being disliked by patients is a part of a doctor’s life. As hard as we try there are people we cannot please. Typically, it is because they want something we cannot give (such as antibiotics for a cold) or when we fail to meet expectations (such as running late or explaining things poorly). This was not the first time I had been disliked by a patient, but this happened quickly. It usually takes me longer to get on someone’s bad side.
He had not been to a doctor in many years, and probably would not have come this time if it had not been for the fact that his wife and some friends had been recently diagnosed with cancer. He was 49 years old, and he was worried that he had missed essential screening tests that were important for cancer detection.
“I know I am terrible for not coming in for physical exams,” he said.
In an effort to ease his guilt and calm his fears I said, “It’s not a big deal, physical exams are pretty useless. We almost never find anything.” I explained that in people who feel healthy, head to toe exams seldom uncover anything abnormal. I went on to explain that cancer screening starts at age 50 and that he had not missed anything.
He thought I was a fool and proceeded to tell my why. His friend was in his 30’s when he was diagnosed with prostate cancer. He believed that earlier screening would have saved his life. He told me of his wife’s breast cancer and how her doctor had missed the diagnosis. She should have been screened earlier as well. Based on their experiences he had a list of tests he wanted me to order.
I shared with him the reasoning behind cancer screening guidelines, how the harm of false positives was real and why we waited to screen until the benefits of screening outweighed potential harms. I went into specific detail about the screening guidelines for colon, prostate and breast cancer.
He interrupted me, saying, “So you are not going to give me what I want?” I replied that I would give him everything he needed. This answer was not good enough for him, and he started telling me of all the things he had read on the internet about detecting cancer. It was clear that he felt I needed to educated, and that he was just the person to do it.
I finally said, “Since it is clear that you think you know more about this than I do, I am not sure how I can respond.”
He said he didn’t think he knew more, but then proceeded to continue questioning my opinion. I finally said to him, “I do not think this is going to work. Maybe you should find a different doctor who you can trust.” He responded by telling me all of the ways he thought I did not know what I was talking about.
Exasperated, I said, “I have had hundreds of conversations with people about cancer and have said the exact same words that I have said to you. This is the first time it has blown up in my face. I am sitting here trying to figure out what the heck went wrong!” My implication that perhaps the problem was with him and not me did not register at all. I decided giving up was the better part of valor.
I said, “Let me buy you a cup of coffee and send you on your way.” I went and got a Starbucks gift card and handed it to him. “I wish you the best.”
I did not (and still don’t) feel good about the interaction. For days after I asked myself what I could have done differently. Absent a fit of clairvoyance, I did not see any way I could have prevented the conflict. The chip that he had on his shoulder when he came in was not visible to the naked eye.
As my attempts at self-blame proved pointless, I turned my reflections to his lack of trust in the medical profession. Since my comments and answers are shared by the vast majority of physicians, it was clear that his problem was not specifically with me. He did not trust any doctors.
I think his mistrust came from many places. The first is the elevation of self that has infected our society. For many, personal experience and google searches are perceived as the great elevator and the great equalizer. Instead of coming to my office seeking answers and asking informed questions, many patients now come certain in their knowledge and challenging mine.
It is easy to ridicule this mistrust but it is not unfounded. It is fed by doctors. There are some physicians who have gaps in their knowledge and who are not interested in investing the time required to fill those gaps. I have encountered these doctors both as a patient and as a primary care physician. I am not a specialist, but my basic knowledge of medicine combined with internet searches corrects specialist errors several times a year. As a patient, questioning my physicians has prevented unnecessary surgery, corrected erroneous diagnoses, and changed treatment plans.
I am not alone in my experiences. Also thanks to the internet, stories of medical errors and missed diagnoses are known to everyone. When combined with the mistrust brought by the advent of HMO medicine, the stories of price gouging by pharmaceutical companies and the loss of long term physician/patient relationships, blindly trusting physicians makes no sense.
Blind trust may be foolish, but not trusting at all is worse. Doctors cannot get through their days if they have to explain every single thing they do. Simple diagnoses and common recommendations cannot require detailed explanations. If they do, there will not be time to explain complicated conditions when they arise. Our experience and expertise needs to count for something.
My approach is simple. I have worked to develop a high level of self-awareness. I work hard to be expert in my field, but at the same time work to recognize the limits of my knowledge. I am willing to double check myself, and to answer all honest questions. For the occasional needy patient, I try to make time to calm their fears and go into greater detail. Fortunately for me, this approach meets the needs of the vast majority of patients. When it doesn’t, as it did with this patient, I reluctantly move on.
I take a similar approach as a patient. I seek out doctors I can trust. When in doubt, I ask honest and non-threatening questions. There are times when I do my own research, but I do not present it in an adversarial fashion. My relationships with my doctors are partnerships, and I try to work together with them. When we do work together, good care, and good relationships, happen.
Bart