Caring for Patients, Not Judging Them
One of the many great things about being a general internist is the exposure to the wondrous diversity of humanity. I am a better person for having brief, but intense, visits with some 50 people every week. These people grew up all over the world and have worked in every imaginable field. I see people barely scraping by financially and people with unimaginable wealth. I care for 90-year-olds who look 60 and 60-year-olds who look 90. I see patients I could imagine being friends with and ones who, for lack of a better word, seem like jerks. I work hard to care equally for the people who, in another life, I’d have to dinner and those I’d steer clear from. This is why I was taken back by comments about a patient’s statement that I recently shared.
Twitter is not the real world. This is a common, and true, sentiment. Therefore, what goes on there seldom warrant discussion here. I share this only because the comments I discuss are important in the real world.
I first got on Twitter in 2011 when Vinay and I were beginning work on our Medical Reversal project. It seemed like a good place to share articles and, eventually, our book. On Twitter I found colleagues from around the world who thought about the same issue in medicine that I did. These e-colleagues shared articles that I would have missed. Tweeting critical appraisals helped me to remember the studies; I also received feedback on my appraisals. The site also gave me a place to share pithy observations — thus sparing my colleagues and family from my incessant, self-important, observations. Twitter also helped my career. It got my work read by people and made me more widely known than you average clinically active, pseudo-academic, bad-at-networking, general internist.1
Like all social media, I think Twitter (now X) has gotten worse. More nastiness, more divisiveness, harder to keep my feed “just about medicine”. I mostly go there to share posts from Sensible Medicine, The Clinical Excellence Podcast, and occasionally pithy observations. Mostly I am ignored, which is fine.
Recently, however a patient shared a comment about a doctor that I found thought-provoking. I told him I was on Twitter, asked if I could tweet it out anonymously, and I did.
I liked the comment because it’s such a good reminder that while we doctors are considering our patients, they are considering us with the same clinical eye. This is fair, normal, and should be expected.
I enjoy watching people’s professional appearance evolve as they go from student to resident to attending. Sure, some of the changes are just because people age and have more money to spend on clothes, but I also think it has to do with clinicians thinking about how we present ourselves to our patients. We think about what kind of doctor we want to be, what puts our patients at ease, what avoids distraction. For anyone who would argue with this, walk from a pediatrics clinic to an adult medicine clinic and consider the doctors’ ties or the adornments on white coats and stethoscopes.
My Twitter post garnered a lot of comments, quite a few resembled these three (all written by doctors).
It’s hard for me to overstate how wrongheaded I found these comments. I was especially bothered because they articulated a subtle change in attitude that I’ve sensed in the real world. I was trained to accept our patients for whom they are, perhaps to a fault. I was taught that the exam room should be a place that patients can be themselves, for better or for worse. I know that when many of us see a doctor, we are not the best versions of ourselves. We might be nervous, even scared; we might be uncomfortable with the odd power dynamic; we might be wearing a truly bizarre paper gown. I have tolerated people saying some pretty ugly things because my job is to care for them, not try to turn them into charming people free of biases.
Obviously, part of this is my fault. I shared this quote with certain expectations and without the context in which it was said. And, of course, people are ready to share grievances on social media that they would withhold in polite company.
I have a copy of the 1st edition of Principles of Internal Medicine, the one for which Tinsley Randolph Harrison was actually the editor-in-chief.2 The book begins its 1590 pages with a five page introduction titled, Approach to the Patient. The chapter ends:
The true physician has a Shakespearean breadth of interest in the wise and foolish, the proud and humble, the stoic and the whining rogue. He cares for people.
We have to remind ourselves that we are here to care for people, not judge them.
I may have just written my epitaph.
It’s a second printing from 1951, without a dust jacket, so it’s not even worth the paper it is printed on.
Dr. Cifu,
How you've inspired me today... As the owner of a small ALF (Assisted Living) Home, this is my life, and a frequent mantra. I find in my staff a tendency to mirror social media as it becomes more divisive and negative. Our residents are elderly, presently ranging from 77 to 91, and we've had them up to 99, as the 9th decade becomes more commonly survived and in my world, they're thriving. Our current diabetic came in with 34 units and 3 months later he was down to 12, and we kicked the oral meds a few weeks later... I love making that difference with hydration, sunlight, exercise, really great nutrition (we make healthy popsicles, 2-ingredient, 1-min peanut butter mousse) He's doing so well at 88, 2 years in! Except for the PCa, that is. But we don't focus there.
So the last ingredient is Meaningful Engagement. When elderly people dress up and go to the doctor, they often display attention-seeking behavior and the TV gives them ammo, what to ask about... I'm praying our aging population of docs don't all retire too soon, because many of them have common sense. And a heart, like our dear author.
I believe it's our job as caregivers, to, well... Care about these people. That is the hardest thing to find. Sure, everyone cares deeply until they get their preferred shift and enough hours. Then I start to hear suggestions to 'get a pill' for this or that one. There are those who work without speaking much to the people I love dearly. (why bother, they'll forget anyway) Well, in my 15 years I've seen they never forget you made them feel loved. I tell many of the same corny jokes and reflect on the beautiful moments, and we laugh together as a family. But the staff comes and goes and are dragged down and beaten up by the divisiveness of social media in between.
Last night one called and coughed up every negative thought that crossed her mind, while driving home from her shift. I realize our residents can be very different on any given day. I've been slapped many times but never by someone with their blood sugar on straight! They're not 'performatively nice individuals' - I'm indebted to Dr Braun Bates for that description. My view is from a different window in daily care.
Angel House is 'just' a house, converted with fire sprinklers. Some residents keep "their doctor" who sees the "performative" patient. I've said they see the 80-90-year-old with her lipstick and sweater, asking about the medicine she sees on TV. Why not? It seems having T2D is to dance in the streets with an instant family of obese people, when they take the magic shot and they can eat "anything they want"... We transport them to the 60's with tuna noodle casserole (healthier noodles & no-salt canned ingredients are no less tasty & comforting) They end up wanting real food in our house! (Life used to be so hard...) Music is huge in the meaningful engagement category!
I also remark, "I don't like any food enough to take a shot!" Still, a screen tells many people what to do and how to think today - exacerbated by the past 5 years of real-time isolation. And that doctor they ask about that advertised drug, has no idea she just put the cat in the fridge yesterday at home alone! But I'm not a doctor, just a real estate appraiser grown up from a bookworm - I love research and the internet has Lots of that to benefit my resident family.
One has to maintain a sense of humor, along with a sense of human.
Thank you so much for this thought-provoking and inspiring post.
It was a good and provocative tweet.
If those doctors commenting felt provoked, it possibly reveals their inability of dealing with the fact that our patients are persons with thoughts and not just files and medical cases.