The Medical Student

She was not old for a medical student I suppose, although her face spoke of experience far beyond her years. But how do you measure age in a profession that cherishes the wisdom and equanimity that so often accompany Time’s passage? No, she was not old, but nor did she possess the naïveté that so often colours the awkward period of youth; she was, in a way, just Maria: confident, inquisitive, but neither gullible nor easily swayed from an opinion once she had weighed the evidence.

Short, with straight brown hair to match, she was dressed in what I would call an unobtrusive fashion –not meant to draw attention to herself but to enable her to emerge from the shadows with dignity should it be required. Only the short white coat so indicative of her student status and which I suggested she remove before seeing patients, would have marked her as out of place in an office that otherwise spoke of the ordinary. I’ve always felt that patients would be more accepting of the student’s presence if they were perceived as being part of the process of consultation with a specialist, not an artifice. Not an appendage. Not an add-on.

Maria sat politely against the wall, legs crossed and a smile tattooed on her lips as she listened to the first of my patients describe how she had finally decided she needed another checkup and a pap smear. For some reason, her family doctor had not felt comfortable in acceding to her request. Maria studied her so intensely it made me nervous.

“What are you using for contraception?” I asked as part of the history.

Janet, who looked  forty or so, but was really 28, just shrugged. She was comfortable with the question; she was comfortable with men who asked them. “I try to get them to use condoms, but…” Maria’s eyes opened wide at this, but she refrained from saying anything. I could see it was an effort for her, though.

As I progressed through the history, it became obvious that Janet was struggling with many issues, but I was impressed that she was trying to solve them bit by bit. Life was not easy for her but she was obviously trying to take control of what little she could. I was just one stage in that process…

After I had examined her, done the pap smear and cultures for infection, and given her the form for the lab to take some blood to rule out other conditions to which her lifestyle had made her unduly susceptible, I sat her down in the office again to discuss her needs.

A broad smile creased her face and her eyes narrowed almost seductively. “Is this where you try to convince me to stop the drugs, and follow the straight and narrow, doc?” There was a fatalism in her tone; she’d heard it all before –many times. Too many times. “…‘Cause you know it’s not gonna happen. I’m just trying to keep myself alive until I decide to change. If I decide. Nobody understands…” Her expression didn’t waiver, but I could tell she was on the brink of tears as she reached for the faded coat she’d draped over the chair. “And there’s nothing you can do until I decide, you know.”

And she was right –all I could do was support her until she was ready. We lived on separate sides of a river that was so wide in most places that it couldn’t be bridged. I felt like reaching across the desk and touching her hand to show her I understood, but I stopped myself. However well-intentioned my gesture, it might be misinterpreted –it was a prologue for most of the men she had encountered… So I just smiled in a lame attempt at encouraging her. “If you ever need to talk, Janet…” I said as she stood up before we could discuss anything further. I don’t even know why I said that -it seemed so utterly inadequate to her needs. I told myself I was only a gynaecologist and that she would require far more than I could ever hope to offer. But I still felt humbled and my specialist arrogance melted away as she left the room.

But just as she was about to leave, she turned and smiled briefly at me. Not seductively –not even out of politeness- but there was gratitude in that smile. Maybe she was just happy that I hadn’t tried to change her like her GP, or that I was willing to wait for her -treat her like an adult capable of making her own decisions. I fancied I could see some hope in her eyes before they hardened to face the world outside.

I’d intended to engage Maria in the conversation with Janet but it all happened so quickly I didn’t get a chance.

Maria stared at me as Janet disappeared through the door. She seemed angry. “So what are you going to do now?” It was not said with kindness. It was not said out of curiosity; she had embedded an accusation in it. A condemnation. The tone was polite, but the insinuation was contempt. I was reminded of that speech by Macbeth: ‘Curses, not loud but deep, mouth-honour, breath which the poor heart would fain deny and dare not…

“Janet has to want to change,” I said. It was a weak reply, but I already felt depressed.

“And until then..?” She said it sweetly enough, but I could hear the anger in her voice.

I sighed and looked at her. “What would you do, Maria?”

I sensed she wanted to throw up her hands and pace around the room, but I could see she was trying to control herself. “Well, talk to her social worker, for one thing…”

“And tell her what, exactly? That Janet took a small first step to help herself? That she seems to be developing a little bit of insight? That I, for one, see the glimmerings of hope that she will change?”

Maria’s eyebrows shot up. “Change?” –she almost spit the word at me. “How can you say that? We’ve been facilitating her, not trying to help her!”

I took a deep breath and relaxed my face. Maria was not as mature as I had thought. “We’ve been listening to her, Maria.” I smiled to diffuse her eyes. “How often do you think somebody has actually listened to her before? Not tried to change her, warn her, or use her?” I softened my expression even more. “The initial step in any change is actually hearing what the other person has to say. Hearing what she thinks and why. Listening; not judging. Not continually interfering, continually trying to impose our idea of the world on her.”

Maria’s whole demeanour tensed with the injustice of it all. “But we didn’t even get a chance to listen! She walked out of here before…”

“Before I had a chance to advise her? Tell her what she should do?” I shook my head slowly.

“But…”

“But sometimes we have to be patient, Maria. Advise when asked; help when needed.” I shrugged to indicate how hard that was. “She may never change –never want to change. We need to try to understand that… Understand her.”

I don’t think Maria understood; I don’t think she felt her own opinion was acknowledged either. I could tell that in her eyes, I had failed as a doctor. Failed as a person. I had committed with her the same sin that I had committed with Janet: not acting on what I had heard.

Maybe she’s right; maybe one’s own principles should be subsumed in those generally held by a society. And yet… And yet I can’t help thinking of Shakespeare again -this time, Polonius in Hamlet: This above all: to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man… –or woman, in this case

If age has taught me anything, it is that we live in our own worlds for a reason… I think we must sit with the door open. And if Janet wanders back..? Well, I will be here.

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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.

Health care is one thing,  access to health care is another. There are many barriers to its acquisition: in some countries it is money, in others,availability of services. But for most non life-threatening health care needs, an underlying problem in all I would suspect, is fear. Not so much fear for safety as a feeling of unease: is what I have serious, will the doctor think I’m wasting his time, will he actually listen to me? So much of who we are -who we think we are- is bound up in our relationships and encounters with others. The medical visit is no different.

Illness, however serious, is still an article of clothing we wear. No matter how much of us it covers, no matter how it weighs us down, it is still we who wear it, we who peek out through the folds. It is important therefore that we meet with acceptance and respect when we finally bare ourselves enough to seek advice.

Cultural safety is one aspect of it. We are less likely to seek help if we feel that our views -cultural or otherwise- will meet with derision or condescension. I’ve always felt that my own specialty -certainly  the obstetrics side of it- is very much like the United Nations. It’s hard to miss the obvious; there’s a common theme that runs through my day; no matter the culture, the background, the social stratum, we all want the same things: our families to be happy, healthy and safe. We want that for ourselves as well. I would think it would be difficult to be prejudiced and a good obstetrician at the same time. I often learn more from my patients than they ever learn from me.

But along with the grateful acceptance of our superficial differences, I think there are other things that make the medical encounter more comfortable, less stressful. The waiting room for example. A picture on the wall, a plant in the corner, or even a carpet on the floor may seem trivial and unnecessary -I suppose they are- but they go a long way to helping the person seeking help feel less like they are about to visit a stethoscope and more that there may be a human in the other room. I realize that the physical constraints of an office impose many limits on the ability to make it look more appealing, but if you lived in that space -and most doctors do for the majority of the week- would you leave it bare and tasteless? Does it really have to look like a holding area, a resting place in a mall? A waiting room says a lot about who the patient is about to see. It can alter expectations.

If ambience is important in a waiting room, it is even more critical in the office. That is where secrets are told, trust is engendered, rapport is established. For new patients especially, what they see is what they judge. They haven’t met you yet, and they are both nervous and fearful. Putting them at their ease is part of establishing a meaningful contact, part of teasing a story out of them, part of actually helping them. It is not the Emergency Department where symptoms speak louder than words, and the diagnosis is often enabled by a wordless glance or an expressionless examination of a person lying on a bed. I’m certainly not suggesting than compassion and rapport are not important under those circumstances because they always are, but merely that the severity of symptoms and the urgency of need is often different in an office.  The approach is usually slower, more gradual -more dependent on mutual understanding and trust. The doctor is more able to explore the issues that surround the need for the visit, as much as the concern itself. He is, in short, more able to talk to the patient, understand her, listen to her -according her the respect and dignity she expects and needs from a health care encounter. It is never easy to confide in a stranger, let alone trust him with personal and often embarrassing problems. But a non-threatening environment may help to ease the transition in an otherwise awkward and frightening meeting.

I realize that considering the venue where health care is administered may seem trivial, but for some it may prove to be the difference between feeling comfortable with seeking help, and deciding to wait until it is truly an emergency. That comfort level takes time. It has to be earned and friends need to be consulted about their experiences. Many important things depend on the word of mouth: reputation, trustworthiness, honesty… and maybe health care utilization.

Health care is…