Please and Thank you

Please and thank you –isn’t that what we were all taught? Perhaps it was my prairie upbringing, but it seemed the norm when I was growing up. There was no asking why –no need to, in fact- we all just did it. Indeed its absence was noticed and noticeable –like maybe wearing a suit without a shirt. Nothing dangerous, nothing threatening, but just not done, all the same. Maybe in another culture or in a different era, it might have been passed off as an eccentricity, or perhaps mental illness –but not in my youth. And not now either, I had assumed. Polite is polite. Period.

But mores and folkways are fickle creatures, it seems -pragmatic at best, capricious at worst. At times, they seem rooted in tradition and ancestral wisdom, but increasingly, they smack expediency, fashion –borrowed from somewhere else like a hat for an occasion. And as with trends on social media, they are ephemeral –tales told by an idiot full of sound and fury, signifying nothing…

Or am I being too critical? Too unwilling to accept change? Too… old?


Judith was an angry person –or maybe I just met her on an awkward day. But she held her body stiffly, as if any movement might reveal a secret. She had an accent I couldn’t place, but her demeanour didn’t really invite my inquiring about it -another secret she needed to conceal, I suppose. The referral note said only that she had pain but had refused to let her doctor examine her. Judith wouldn’t let me examine her either; she was certain it was caused by an ovarian cyst and she just wanted to talk about it.

I could see her peeking at my computer screen with suspicious eyes. The way I’ve had to configure my temporary desk to accommodate both the ability to access the monitor as well as well as the patient’s face, lends a certain intimacy to the little makeshift office. No longer can I afford to write a note to myself that the patient I’ve been asked to see seems unduly anxious or irritable; I dare not suggest that she is being evasive in her answers to my questions; I cannot even intimate that she doesn’t appear to trust me. All is open to scrutiny during a renovation.

And that’s fine. She can have access to her chart; I have nothing to hide. But as well as her answers to my questions, what I write are merely impressions, conjectures: colours. The subsequent consultation letter to her referring doctor is a collation of these -a considered appraisal of what I have observed and heard. The initial chart is a first draft of things that will later become an opinion. An assessment.

But Judith was persistent. Like someone reading my book over my shoulder on a bus, I have to admit I did feel some boundary issues. I toyed with the idea of turning the screen so she could read it more easily, but my long-held prairie rules of decorum prevented me. Instead, I contented myself with an obviously self-conscious stare at her face. She paid no attention to my discomfort except to wrinkle her face at what I had just written.

I was filling out the reasons for ordering a pelvic ultrasound –outlining what questions I hoped could be answered, and what, specifically, I hoped they would address: The patient has complained of right lower quadrant pain for several months. She may have a right ovarian cyst. Please assess ovaries and characterize cyst if present. Thanks. It seemed a perfectly straightforward request, but I could see Judith shaking her head.

“You’ve got to be more forceful in your request, doctor,” she said, her face tight with concern. “I told you I have a cyst so why don’t you just say so?”

Her response took me by surprise. “I was just outlining my suspicions for them to confirm or refute on the ultrasound…”

Her eyebrows stayed lashed to her hairline. She was shaking her head again, but whether in disapproval or disbelief I couldn’t tell. “And why do they have to know about the pain? That seems to be a breach of patient confidentiality, don’t you think?”

I sighed quietly. “It’s not a breach of confidentiality, Judith, it’s a medical document outlining the questions I want answered, and so it has to have pertinent details about the condition. If it is an ovarian cyst, not all cysts cause pain and not all pain is caused by cysts. I need to know the details of what they see.”

You’d think that would have appeased her but I could tell she was still troubled by what she saw. “And why do Canadians insist on using ‘please and thank you’ all the time? It’s just a request for an ultrasound…”

I sat back in my squeaky chair and smiled. “What would you write, Judith?”

She thought about it for a moment, obviously caught off guard. “Well… How about: I’d like you to describe the cyst on her right ovary.”

“ ‘I’d like you to..?’ Isn’t that just a longer way of saying ‘please’?”

Her eyes narrowed and I could almost hear the gears grinding in her head. “Then… why not just: Assess the pelvis?

I squeaked my chair again. “Seems to me that’s just a command to do something without explaining why. The more information they have, the more they are able to tailor their study.”

A little smile fought for the stage on her face. She was getting into this. “Okay, so: Cyst suspected in pelvis. Confirmation and characterization required.”

I nodded, then turned back to the screen to amend it. “I can accept that, Judith,” I said, as I typed her words onto the requisition. “But I can’t say I agree with it.” I looked up at her. “It seems  too impersonal and uncaring, somehow.”

Her face softened with bewilderment and I could feel her eyes searching my face for an answer. “What do you mean?” she asked after sifting through my words for clues.

I shrugged, not at all sure I could explain. “I guess it’s sort of like the Golden Rule: If a person is standing in a doorway talking to a friend and I want to get past, I could say ‘Get out of my way!’ or I could smile and say something like ‘Would you mind if I squeezed through?’ Experience tells me I’m likely to get more cooperation with the second way. Maybe even a smile…” My chair squeaked again. “I like smiles, even if I’m not there to see them.”

Suddenly her whole body relaxed and a laugh lit the room like the sun coming out from behind a cloud. She reached out in the tiny room and touched my arm. “When I said I didn’t want to see a male gynaecologist, my family doctor said you were different…” She sat back in her chair looking the most relaxed I’d seen her. “Put the ‘Please and Thank you’ back in the form if you want. I think I’d like to see the smile on the technician’s face when she reads it, too.”

The prairie in me sighed. I suppose she meant well- meant it as a compliment… Thought she had gained a unique perspective on a world she had never trusted and maybe never thanked. And yet I don’t think she really understood. What I considered thoughtful, she saw as weak. Not polite. And it bothered me. Am I really so different in being accommodating and respectful when I request a service from someone? Is the concept now so unusual that it draws attention to itself? Attention to me? Thank you, but I cannot let myself believe that. Please let me be right…

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