Taking arms against a sea of troubles


A quasi-existential question: what do you do if you are a doctor dealing with a patient you don’t like? More importantly, however, what if you are a patient, forced by necessity or circumstance to see a doctor you don’t like? This is a question that is often framed in terms of racial, socioeconomic or cultural biases, but it may be something even harder to define, impossible to predict: a  clash of personalities or communication expectations. It should come as no surprise that no matter who we are or what our roles require, we simply do not get along with everybody. None of us.

I realize this can present major problems in emergency situations where choice and time may be severely constrained; hospitals often cover these exigencies with policy statements -directives as to how to proceed. The classic example in my specialty is the issue of a patient in labour whose baby goes into distress and requires some form of timely emergency intervention. It is three in the morning and the obstetrician on call is a male; the patient -perhaps because of culture or previous experience- will accept only a female obstetrician. While every effort is expended to accede to her request, it is sometimes simply not possible. Under such exceptional circumstances and in the interests of the baby in distress, the hospital policy can direct and delegate the emergency care of the woman to the available personnel. Most parents ultimately accept this and are grateful to have a healthy and uncompromised infant from the experience. It’s not a perfect solution, obviously, but under the circumstances, it is an understandable compromise.

There are other situations however, where a middle ground is perhaps more difficult to define and sometimes even more awkward and embarrassing to accept. Let us say, for example, you are referred to a doctor by your GP for a non-life threatening but nonetheless serious and important condition. It is difficult to get an appointment with any specialist, but your doctor assures you the wait is both necessary and worthwhile and sends in a referral. You investigate the doctor online and realize your GP has made a good choice, so you wait the two or three months to see him. But it is apparent within the first few minutes that you don’t like him; you don’t get along; he isn’t what you expected -or wanted- in a specialist. Now what?

Now consider the other side of the equation. You are a doctor seeing patient after patient; most seem appreciative, or at least pretend to be, and this is a balm to your fatigue. And then you notice that the next person, a new patient, is sitting on the other side of the desk staring at you suspiciously, avoiding eye contact when you attempt it, answering questions reluctantly or incompletely. It is clear she doesn’t like you, and yet she has been referred for ongoing care and management.

Both parties are embarrassed, or at least constrained in their response to the situation. To be fair, for the doctor, it’s an easier thing to probe gently at the relationship and try to uncover why there is hostility. Is she merely anxious about her condition, or concerned about its management? Are there questions that need answering? Options that need exploring? Is she not feeling heard for some reason? Is there something that is bothering her that you might be able to address? These are ways that are not unique to medicine to be sure. But if you cannot establish a rapport, if you cannot narrow the gap, would it be wise to continue the consultation? Would either of you benefit? Would whatever treatment suggested even have a chance of success if she was unhappy with you providing it? And what if it didn’t? Would she accept your explanations? Would she seek legal redress?

Of course, the interaction is one of unequal distribution of power no matter how it is disguised. The patient (I dislike the word client) needs something from the doctor and has probably waited a long time for the opportunity; it is important for her not to antagonize. And yet she doesn’t like him. Doesn’t trust him… So how much should she tell him? The information he requests is deeply personal, and confiding in him is out of the question. Does she merely terminate the interview and walk out? What is her GP going to think? Will she have to wait an even longer time to see another specialist? And suppose she doesn’t like that one either…

The problem is a multi-headed Hydra admitting of no easy resolution for either party.  One solution for the doctor, once he has recognized the difficulty, might be to suggest a second opinion -another colleague that she might find more acceptable. But even that is fraught with difficulties if they are all as fully booked as himself and the condition is one that would benefit from a more immediate response.  For the patient, however, there is probably an even greater dilemma if the doctor does not recognize -or care- that there is a problem. How does she let him know that she is not comfortable with him if he seems unaware? Or insensitive..?

Personal interactions are complex; even when overt power is not a factor, influence and authority are often covertly present. We are creatures of strata: higher status in one thing, lower in another; a sorting out of levels is inherent in all communication, all encounters. Medicine seems to engender a dependency that it needn’t: sometimes even a simple statement of concern would initiate a search for a solution.  However, it may be difficult for some people to be assertive -neither aggressive nor overly passive- in negotiating a need that is not being addressed. We are not all capable of that -even doctors…

Recognizing that I do not have a Nobel Prize-winning solution to a problem that has bedeviled mankind since its inception, and understanding that casting about blindly in the dark shadows of mistrust is unlikely to resolve the issue either, I have forsaken the twisted road for the simplest way out of the labyrinth:  I suggest the patient bring a friend or a partner to the consultation -someone who is at least privy to the issues and whom she could trust to mediate on her behalf. She may choose to have him stay in the waiting room, but he is nevertheless close at hand and readily available if needed. The extra -and trusted- surveillance might serve to identify her discomfort and extricate her from her seemingly untenable position. It’s what friends are for: to knit the raveled sleeve of care… Or at least spot the ravel.

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