Friday Reflection 56: Comments that Stuck
DD is an 86-year-old woman with hypertension and diabetes. On the day of her regularly scheduled primary care visit, there is a heavy snowstorm. Despite the weather, she convinces her husband to drive her to the doctor’s office. After digging out the car and driving down snow-covered Beacon Street, she arrives at her visit about 90 minutes late.
In a lifetime of possible memories, only some are accessible. I remember my 1st grade teacher, Ms. Kritz, handing out homework with “Let’s Go Mets” across the top – it was 1973. The rest of that year is a fog. I can visualize sitting by the lake early in my first year of summer camp, but I remember little else about that summer. Why do some experiences stick while others, more important ones, fade?
There are a few comments — made by mentors, co-residents, and patients — that have lingered and shaped my medical practice. The voices return to me, affecting my decisions and the advice I give patients. Some of the comments were meant to teach me something, some were not even meant for me. I am thankful for their lessons.
In my tweens and early teens, I often worked in our family’s grocery store. At first, I organized shelves, priced items, and made light deliveries to apartments close to the store. As I got older, I did larger deliveries to restaurants and provided customer service in the store. One day, early in my time waiting on customers, I served a woman who wanted a slice of cheese. I pulled a knife from the block, wiped it on my clean, starched white apron, and cut her a quarter pound of taleggio. I weighed, wrapped, and tied it, wrote the price on the paper, and handed it to her.
Without even motioning to accept the cheese, she said, loudly, “Did you wipe that knife on your apron before cutting my cheese with it?” I may have stammered something like, “Uh, maybe? The apron is clean. I was making sure the knife was clean.”
The image I hold in my mind is of her then storming out the door, leaving me standing, dumfounded, holding the wedge of cheese, the store silent. My uncle stepped up beside me and said, “What that person wants, we don’t have. Put the cheese in the back fridge, you can have it with lunch.”
I try to be the right doctor for every patient I see. My default bedside manner works with most patients. For the rest, I try to identify what is needed to serve them best. I usually do pretty well, but not always. There are some people for whom I am the wrong doctor. What they need or want, I can’t offer. Mostly, these people don’t make a follow-up appointment, no-show once, and then disappear. A few times, I have asked patients whether they thought they’d be better served by seeing one of my colleagues. Twice, I have told people I cannot care for them.
When I realize a patient has left my practice, I consider what I could have done better or differently, but I don’t blame myself. I am not the right doctor for everyone. My uncle told me that.
In 1997, my wife matched for a second residency in Chicago, and I took a week-long trip to interview for jobs on the third coast. Like when I’d interviewed for medical school, I was totally unprepared. On the flight to Midway, I decided that what I wanted was a job in academic medicine in which I could “care for the underserved.”
Early in the week, I visited a private practice in Evanston. It was an attractive, efficient, and well-respected practice. I remember being particularly impressed by the senior partner. She was an older, very sharp internist — a total professional with a no-nonsense demeanor. By the end of the day, I was sure that the only reason I would want to work there was to be mentored by her. Nothing else felt right.
During our final meeting, she asked what she could do to persuade me to join the practice. I told her that it didn’t really seem like the right place for me. When she pressed me, I said I wanted more clearly defined teaching responsibilities and I wanted to serve the underserved. Dismissively, she said something like, “You do know that everybody needs care, don’t you?”
The comment landed pretty hard, and I deserved it. Her words echo in my head to this day. Over the years, my practice has evolved into one in which at least three-quarters of my patients are as far from “underserved” as could be. It is a rare morning that my Epic in-basket doesn’t contain a few “Outside Events” of my patients seeing consultants at Northwestern, Mayo Clinic, Cleveland Clinic, Sloan Kettering, or wherever else the most fortunate feel they can find the best care. I think about her comment when I counsel trainees looking for jobs. There are few places in the US that couldn’t benefit from a well-trained, happy, primary care physician, regardless of the zip code’s median income.
I adored the patients I cared for in the primary care clinic during residency. Among them was a large cadre of Jewish immigrants, refugees really, from the USSR. They were older, had limited access to healthcare before moving to Brookline, and were willing to share their histories with me through our amazing medical interpreters.
On one cold, snowy December day, I had clinic the same afternoon that I was on call in the hospital. My schedule was to finish clinic, then go back to the hospital, finish my admissions, spend the night cross-covering patients, and work the next day. I was happy to notice that DD, one of my regular patients, a Russian lady in her mid-80s, had missed her appointment. This would make my afternoon a bit easier and let me get back to my admissions a little sooner.
As I left the clinic and headed back to the wards, the front desk paged me to let me know that DD had arrived, 90 minutes late for her 30-minute visit. I whined to the receptionist that I couldn’t possibly see her. Wisely, she said, “Well, if that’s your decision, you will have to come back and tell her yourself.”
The picture I have in my mind is of an elderly woman, covered in snow, wrapped in four layers of shawls. When I told her that she was late, I was busy, and that she would have to reschedule, she replied, with evident disbelief, “You’re not going to see me?”
She stopped me short. What in the world was I thinking? My next 24 hours were going to be terrible, whether I saw her or not. She had traipsed through the snow to see me, whom she considered her doctor – I might have been 26 at the time. Was I really going to refuse to see her?
Not only did I see her, but I have seen every patient who has come late since then.
Photo Credit: Saeed Karimi
“Not only did I see her, but I have seen every patient who has come late since then.”
Humility is the greatest lesson WE can learn.
I was a patient in a large ortho practice where the doctors were consistently running late, not 15-20 minutes late, we’re talking hours behind.
The last day I was there, a disabled elderly black lady was brought in by ambulance. She was late, not her fault, as the whole of the waiting room soon learned as the driver and a scheduler loudly discussed the woman with no concern for her privacy or dignity.
She was late because she was so large they had to get the ambulance to accommodate her size. It turned out she was not that late just 20 minutes but the scheduler kept insisting it was too late because the office had a schedule.
At that point it was already 40 minutes past my scheduled appointment. I sat there looking at that poor woman who was quietly crying being humiliated for a situation not in her control and I stood up and said she can have my appointment. The stunned scheduler told me to sit down that the woman was supposed to see another doctor. The man beside me asked if she was there to see his doctor and was told no. Any one of us in that waiting room would have given that woman our appointment but according to the scheduler their policies were inviolate, the woman was late and could not be seen as she was late. Most of us in the waiting room were waiting well beyond their inviolate patient late point for a doctor who had no such time constraints.
I mentioned the waiting room incident to the doctor when I finally saw him an hour later and he said he only saw patients he had nothing to do with the waiting room, other staff, policies or scheduling.
The next day I called the practice manager to discuss the incident as I still felt very uncomfortable about the way that patient had been treated. In that conversation the manager blithely admitted that they triple booked. My turn to be stunned two or three people for every appointment? Yes because of potential no shows I was told. They had to stick to their strict policies to keep things flowing.
I told her that it was obvious their priority was not patient care, certainly not patient privacy and that no matter how respected and highly touted the young doctor I saw there was, I would not be back. My time was important too and it would not be spent on a doctor who was consistently 1 1/2 hours behind schedule, not I now find out because he was giving his best to another patient but because he was playing catchup to all the patients booked for one appointment.
I also told her that the patient rights of the women denied care were violated by the very public discussion of her care in front of a waiting room filled with other patients and that if she sued they deserved it. Sadly I doubt there was any lawsuit and my leaving the practice made no difference to them.
It is now a huge practice statewide with beautiful new offices, PT facilities, surgical centers, very well known and highly respected.
I still wonder about that lady and how many other late patients they have turned away? Have there been any lessons learnt? As others I know who go there always complain about the wait, double and triple bookings apparently continue, but I bet discussions about patients are now done in private to avoid waiting room reactions.
If a doctor I see now is late I no longer sit and wait, I inquire how much longer and reschedule if I don’t want to wait longer. If it’s habitual I change doctors. My time is important and I want to use it well.