Friday Reflection 52: The Three Worst Phone Calls of My Career

A rookie mistake, a veteran mistake, and a patient’s unforced error

When I was a kid, I went to summer camp. One evening, my bunkmates and I — I think we were eleven at the time — were discussing the work our parents did. One friend said that his dad talked on the phone for a living. We all laughed, and it became a story we still reference today. I think we found it amusing because, even if we had words for our parents’ jobs — doctor, writer, or restaurant owner — none of us really knew what they did.

There are weeks when I feel like my job is talking on the phone. I spend about 16 hours each week seeing patients in person. I spend about the same amount of time fielding calls and messages, following up on tests, and discussing results. Increasingly, this work is keyboard-based, but a significant portion of it still involves good old-fashioned phone calls.

Most phone calls are remarkable only for how forgettable they are. There are clinic visits and bedside discussions from decades ago that I can recall in almost perfect detail, but I can only remember a handful of phone conversations. Three of them I remember because of how bad they were.

A Rookie Mistake

TR was a 42-year-old man I’d been seeing for just a few months. He had one of those concerns that troubles patients far more than it worries doctors. His issue could have been headaches, insomnia, back pain, or any number of problems for which it is easier to exclude the sinister causes than it is to relieve the symptoms. Like many similar patients, he had already seen a few doctors for his concerns.

In the month that I had cared for him, I had already suggested a few therapies. I then received a voicemail from TR in which he informed me that my treatments had failed, alerted me that he was still suffering, wondered if I could think of anyone else he could see, and expected me to call him back urgently. After listening to the message, I felt annoyed, attacked, and insulted.

What should I have done? I should have deleted the message and written myself a reminder to call him the next day; this was not an emergency. Before returning the call, I should have worked out a plan, had treatment or referral options available, and researched his problem more thoroughly. This was a perfect opportunity to learn more about the management of a common problem.

What did I do? I called TR back immediately, still feeling pretty prickly. He felt poorly and blamed me for failing him. Exasperated, I said something to the effect that he could do a better job adhering to my recommendations, that there was little more I could do for him, and that maybe it was time to learn to live with his symptoms.

It’s little surprise that we never spoke again.

At least I learned something from the call. Today, if a call is not an emergency, I delay returning it until I can be prepared and at my best. I never tell patients that there is nothing I can do. Even if I don’t have a solution, I can always remain a caregiver and, sometimes, figure out who might have more to offer. In the years since my conversation with TR, I have learned so much more about managing his condition. I hope he found the person then, who did what I would do now.

A Veteran Mistake

For most doctors, our natural bedside manner suits most patients; let’s say 80-90% of them. Most people just want a doctor who is knowledgeable, empathic, and professional. For the other 10-20%, a doctor must play a role, reaching into her “bedside manner toolbox” if she is to succeed with the patient.

Not every doctor is right for every patient, but doctors can’t only see patients to whom they are naturally suited. For most of my patients, I can be my normal, doctor-self: empathic, respectful, collegial, conservative, and cheery, with a slightly off-color sense of humor. My hope is that, when necessary, I realize I am not naturally right for a patient and quickly pivot to a different bedside manner.¹ I care for patients with whom I find myself acting as an authoritarian, a paternalist, a liberal user of medical services, or someone willing to guide with only the gentlest of hands. I am fairly certain that I have become more adept at playing these roles over the course of my career.

HR was a 60-year-old woman I had seen for about five years. Our relationship was never comfortable, and she never seemed to trust me entirely. This situation was exacerbated early in our relationship when she was hospitalized. I felt that I had managed the illness leading up to the hospitalization appropriately, while she thought the diagnosis had been delayed. I believe that she continued to see me more because of my reputation than because of her satisfaction.

When she presented with another acute, though less serious illness, I played a role. Being a veteran by this point, I fell into a character that must have felt right to me. I remember being a bit of a needler with an edgy sense of humor. I think I felt that this worked to counteract the forcefulness with which she tried to guide her care (in what I considered an unwise direction). I was also probably defending myself against her doubt and mistrust. Even during our last clinic visit, as I played this role, I sensed that I was making a mistake.

I woke up the morning after that final visit and realized how poorly the visit had gone. I called her to apologize. To her credit, she accepted my apology, was clear with me about why I was the wrong doctor for her, and ended our relationship.

It was a memorable conversation I wish I could forget.

A patient’s unforced error

It reaffirms my generally rosy view of humanity that I am fond of almost all my patients. This does not mean that, under different circumstances, I’d be close friends with all of them. But, in the surreal setting that is the clinic, I appreciate every one of them. They are kind and generous, able to trust me, essentially a stranger, and ask for help. I am also continuously amazed at how we humans manage to deal with loss, disability, and terrible news.

There are a small number of my patients I know I would not like outside the clinic. As a doctor, this doesn’t matter to me. We all need care, and one of the things I love about my job is getting to work with people I’d otherwise avoid.

JR was a 77-year-old man struggling with a painful, though almost certainly temporary condition. I had offered what I could, and further care would need to come from consultants after diagnostic tests. There would be a wait for these tests and these appointments. To my mind, the waits were reasonable, and the delays would neither prolong JR’s suffering nor worsen his eventual outcome.

JR called me to discuss his case. The phone conversation turned into a lengthy rant about my staff's incompetence and the system's idiocy. JR went on to express remarkable self-importance and more than a touch of racism.

I was surprised; I had thought I knew JR well and wouldn't have expected him to hold these opinions, let alone express them to me. I did not imagine that this conversation would change our relationship. As mentioned above, I don’t need to like my patients.

Our relationship was, however, forever changed, not because of what I thought of him, but because of how he now felt about working with me. JR called a week later to apologize. He admitted he had been out of line on the call. In the years that followed, I sensed him being more circumspect with me. At some point, realizing that I had not heard from him in a while, I reviewed his records. I found that he had switched his care to another provider.

1. I am sure that sometimes I don’t pivot fast enough. This, no doubt, leads to some of the members of my ghost panel.

Photo Credit: Annie Spratt