There are a few things that I figured out which was never taught in any of my medical training as a pediatrician. If the patient is getting better, or not very ill to begin with, but the parents are getting angrier, it is because they have mistaken my reassurances for dismissal. When I made that realization, I started calling that confusion out and explain that I am not in fact dismissive but trying my best to mollify. This seems to help.
The other is that if families have a terrible diagnosis, and they use you as a punching bag, just take the punches. Their kid is dying of relapsed ALL or lupus or brain tumor or what have you. Once a family expected me to lie and tell their kid something less devastating than what they have. I simply kept silent. Family called me into a different room, lit into me, and told me my silence killed all their hope.
I can feel unfairly accused of being a bringer of despair and still be compassionate about their situation.
I have taught since 1988: "Be the doctor the patient needs you to be." I learned this lesson the hard way, at age 38. I had gotten very wrapped up in AIDS care - at this time, the only available antivirals were AZT and ddI. I spent many long sessions with young men living in the shadow of death, going over and over (and over) one drug, two drugs, switch drugs, how often, etc, etc.
I had a new patient who found out she was HIV+ when her baby died of AIDS. I had seen her a couple of times. ddC was in the pipeline. I tried a number of times to start a conversation about how to proceed.
Not being a complete idiot, I had the sense to see she was getting annoyed, then aggravated, then angry. Having been taught interviewing by the great Franz Reichsmann, I made a move: "I can see you are upset. Can we talk about it?"
There was one of those little trays in the room, with the metal insert to hold syringes and sutures. Her hand in a fist slammed it, sending the insert clattering across the room.
"Goddamn it! You are supposed to be the doctor! IF you don't know what to do, what chance do I have!"
Point taken. Patient 100, doctor zero.
Always be the doctor the patient needs you to be. That's why you are there.
Last year I had a child I saw from birth. Overall Ok, weak muscle tone but the family thought improving. Aspirated and cyanotic a day out of the hospital. Admitted, parents had my personal number so lots of calls, talked to the admitting MD, reassured parents all was being done properly.
Saw me for a 1 month check (mom declined earlier follow up), limp child, got her a visit with Neurology literally the same day as we finished the visit. During the 1 week hospital visit no one thought Neurology was an issue. Prader Willi.
And the next week the mother fired me because I didn't care enough about her child.
By far my greatest communication mistakes have been the ones that I never knew happened. I get lots of feedback from patients who complain about poor communication by other physicians and I also get lots of feedback from patients who like the way I relate ( I discount those highly unless there is a specific behavior I can identify). However it is rare that I get feedback from patients who were put off by what I said. These are gifts because I have an opportunity to both apologize and learn. The best I get do it into try to be aware of my own emotional vitality signs before I have a patient encounter which is one of the things you point out
One problem is older patients and young Dr.'s. My mother was fired by one of her Dr's as a patient. The new Dr. was closer to my mother's age and they go along better. The young Dr. went back to doing "research". I suspect older patients want to chat a bit, which is hard to do now with visits so regulated and timed. Not really the Dr.'s fault. Where I worked sometimes if you wanted information about a project you had to ease into it. Talk about model trains with one person and then ask for what you want and so on. It's life. Due to various medical conditions I've interacted with a lot of Dr.'s. Most were very very good. A few were not and one or two were outright loons. One thing a Dr. has to learn is to walk away if it's not a good fit. A patient has to learn that also.
I thought I was expected know everything and return every phone call on the same day.
Which, of course, is impossible.
At our age the patients are accustomed to talking to a Human on the phone. The generations following may not have that expectation. They will still use the phone, just not for speaking.
I'm a forensic psychiatrist, working in state prisons with highly manipulative, often aggressive and offensive felons. I will never forget the day years ago I picked up "Principles & Practices of Group Psychotherapy" by Irvin Yalom, MD of Stanford University & read his list of "healing factors." At the very top was "the instillation of hope." I was literally shocked at his discussion and it changed my attitude & determined that no one would leave my presence without the message that change was possible, and that life could be different. Have I conducted research as to the efficacy of this effect. Nope. But I have relied upon Dr. Yalom's insistence of its power. I have much more confidence as a clinician; I have astonishingly fewer arguments; and I have better compliance from patients on discharge to community mental health resources pursuant to conditions of parole. Is this simply longterm bias and confounding on my part? Perhaps there are elements - I continue to have my share of ineffective interactions - but I maintain Yalom is a genius!
I pictured each of those scenarios and the patients I had worked with popped in. When doing addictions treatment was the real, gritty, muddy end of the field, I had a style as an amateur AND as a veteran that didn’t fit everyone. Think less Adam and more Gordon Ramsay. Since a large portion came from the streets they wouldn’t trust a nice guy, even though I was. Sometimes.
This reflections are inspiring Adam. The rookie mistake is the reason I believe involvement in research is necessary to be a better physician. It would be interesting to know your ability to interpret P-values when the rookie mistake occurred?
In clinical medicine, the nature of the hustle and fast pace makes it almost impossible to say: “I dont know, let me take a few days to find out”. It was with this mindset I embarked on a PhD. You can imagine the pure chaos, putting ethical approvals hurriedly. It obviously confused the committee got rejected.
I really love these reflection posts. Your memory for these life moments is remarkable, and your humble introspection is inspiring! I would love to develop this in my own practice.
I have met, in my 68 years, so many doctors--as patient and caregiver--and at least half betray no shred of concern about bedside manner or gaining/retaining the good will of the patient. The other half seem to be making an effort, but even in this group I can't picture any of them thoughtfully reviewing a phone call years later. Your patients are very lucky.
Humility is a gift from God. Sometimes we do it willingly, and sometimes we eat the whole pie unwillingly. Either way, the lesson is the same and sometimes necessary. ❤️
As much as we'd like to be born with all the answers, that's simply not how it works. I've concluded that perhaps the best we can do as we move through life is to learn from our experiences and use them to continually do better. Take the lesson, leave the baggage.
There are a few things that I figured out which was never taught in any of my medical training as a pediatrician. If the patient is getting better, or not very ill to begin with, but the parents are getting angrier, it is because they have mistaken my reassurances for dismissal. When I made that realization, I started calling that confusion out and explain that I am not in fact dismissive but trying my best to mollify. This seems to help.
The other is that if families have a terrible diagnosis, and they use you as a punching bag, just take the punches. Their kid is dying of relapsed ALL or lupus or brain tumor or what have you. Once a family expected me to lie and tell their kid something less devastating than what they have. I simply kept silent. Family called me into a different room, lit into me, and told me my silence killed all their hope.
I can feel unfairly accused of being a bringer of despair and still be compassionate about their situation.
I have taught since 1988: "Be the doctor the patient needs you to be." I learned this lesson the hard way, at age 38. I had gotten very wrapped up in AIDS care - at this time, the only available antivirals were AZT and ddI. I spent many long sessions with young men living in the shadow of death, going over and over (and over) one drug, two drugs, switch drugs, how often, etc, etc.
I had a new patient who found out she was HIV+ when her baby died of AIDS. I had seen her a couple of times. ddC was in the pipeline. I tried a number of times to start a conversation about how to proceed.
Not being a complete idiot, I had the sense to see she was getting annoyed, then aggravated, then angry. Having been taught interviewing by the great Franz Reichsmann, I made a move: "I can see you are upset. Can we talk about it?"
There was one of those little trays in the room, with the metal insert to hold syringes and sutures. Her hand in a fist slammed it, sending the insert clattering across the room.
"Goddamn it! You are supposed to be the doctor! IF you don't know what to do, what chance do I have!"
Point taken. Patient 100, doctor zero.
Always be the doctor the patient needs you to be. That's why you are there.
Last year I had a child I saw from birth. Overall Ok, weak muscle tone but the family thought improving. Aspirated and cyanotic a day out of the hospital. Admitted, parents had my personal number so lots of calls, talked to the admitting MD, reassured parents all was being done properly.
Saw me for a 1 month check (mom declined earlier follow up), limp child, got her a visit with Neurology literally the same day as we finished the visit. During the 1 week hospital visit no one thought Neurology was an issue. Prader Willi.
And the next week the mother fired me because I didn't care enough about her child.
Adam
By far my greatest communication mistakes have been the ones that I never knew happened. I get lots of feedback from patients who complain about poor communication by other physicians and I also get lots of feedback from patients who like the way I relate ( I discount those highly unless there is a specific behavior I can identify). However it is rare that I get feedback from patients who were put off by what I said. These are gifts because I have an opportunity to both apologize and learn. The best I get do it into try to be aware of my own emotional vitality signs before I have a patient encounter which is one of the things you point out
One problem is older patients and young Dr.'s. My mother was fired by one of her Dr's as a patient. The new Dr. was closer to my mother's age and they go along better. The young Dr. went back to doing "research". I suspect older patients want to chat a bit, which is hard to do now with visits so regulated and timed. Not really the Dr.'s fault. Where I worked sometimes if you wanted information about a project you had to ease into it. Talk about model trains with one person and then ask for what you want and so on. It's life. Due to various medical conditions I've interacted with a lot of Dr.'s. Most were very very good. A few were not and one or two were outright loons. One thing a Dr. has to learn is to walk away if it's not a good fit. A patient has to learn that also.
I really enjoy your retrospectives.
I thought I was expected know everything and return every phone call on the same day.
Which, of course, is impossible.
At our age the patients are accustomed to talking to a Human on the phone. The generations following may not have that expectation. They will still use the phone, just not for speaking.
I'm a forensic psychiatrist, working in state prisons with highly manipulative, often aggressive and offensive felons. I will never forget the day years ago I picked up "Principles & Practices of Group Psychotherapy" by Irvin Yalom, MD of Stanford University & read his list of "healing factors." At the very top was "the instillation of hope." I was literally shocked at his discussion and it changed my attitude & determined that no one would leave my presence without the message that change was possible, and that life could be different. Have I conducted research as to the efficacy of this effect. Nope. But I have relied upon Dr. Yalom's insistence of its power. I have much more confidence as a clinician; I have astonishingly fewer arguments; and I have better compliance from patients on discharge to community mental health resources pursuant to conditions of parole. Is this simply longterm bias and confounding on my part? Perhaps there are elements - I continue to have my share of ineffective interactions - but I maintain Yalom is a genius!
I pictured each of those scenarios and the patients I had worked with popped in. When doing addictions treatment was the real, gritty, muddy end of the field, I had a style as an amateur AND as a veteran that didn’t fit everyone. Think less Adam and more Gordon Ramsay. Since a large portion came from the streets they wouldn’t trust a nice guy, even though I was. Sometimes.
This reflections are inspiring Adam. The rookie mistake is the reason I believe involvement in research is necessary to be a better physician. It would be interesting to know your ability to interpret P-values when the rookie mistake occurred?
In clinical medicine, the nature of the hustle and fast pace makes it almost impossible to say: “I dont know, let me take a few days to find out”. It was with this mindset I embarked on a PhD. You can imagine the pure chaos, putting ethical approvals hurriedly. It obviously confused the committee got rejected.
I mastered p-values well before my practice of medicine was even passable! Nothing better than confusing admissions committees. It should be a goal.
Marvelous! I agree.
I really love these reflection posts. Your memory for these life moments is remarkable, and your humble introspection is inspiring! I would love to develop this in my own practice.
I have met, in my 68 years, so many doctors--as patient and caregiver--and at least half betray no shred of concern about bedside manner or gaining/retaining the good will of the patient. The other half seem to be making an effort, but even in this group I can't picture any of them thoughtfully reviewing a phone call years later. Your patients are very lucky.
Humility is a gift from God. Sometimes we do it willingly, and sometimes we eat the whole pie unwillingly. Either way, the lesson is the same and sometimes necessary. ❤️
As much as we'd like to be born with all the answers, that's simply not how it works. I've concluded that perhaps the best we can do as we move through life is to learn from our experiences and use them to continually do better. Take the lesson, leave the baggage.