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.

The Great Divide

Is there a Great Divide? Strange, perhaps, that the question has continued to haunt me all these years; but you see, if there is, it matters. As I’ve written about before, we each see the world through our own eyes and bring to that perception our own acculturated expectations, our own history, and yes, our own prejudices.

Philosophers have argued about this for centuries: do our sensations carry accurate information about the world, or are they so riven by internal conflicts and so rerouted along personally-determined neural pathways that they are uniquely what we make them? Representative only in that we have defined them as being such.

I do not want to mix up this thought with Plato’s; I’m not talking about his contention that we can only perceive ‘chairs’ -physical objects- but fail to identify the actual reality: ideal forms –chairness, if you will. I am not meaning to confuse the particular with the general.

Nor am I referring to the philosophical conundrum of Names. If I see a colour as red and yet you see that very same colour as blue in your brain, it may be interesting, but not particularly important: we’ve both learned to call it by the same name -a point not lost on Shakespeare, albeit in a changed analogy: ‘A rose by any other name would smell as sweet’… There’s no problem with this, largely because we assume the other person is seeing the same thing -she says she is, after all; why would I have reason to doubt it?

The world is sui generis in its apprehension, but does it necessarily follow that this can be attributed to things like differences in age, culture -even gender? Or is it merely that we inhabit different brains? And if so, is this gap bridgeable, or do we forever have to watch each other from opposite sides of the river?

I worry that even if we use a common vocabulary, and agree on definition and assignation, we’re not really out of the woods. Pain, for example: the pain of childbirth. It carries with it a melange of colours: the frustration of its temporal duration, the joy of anticipation, the determination that comes with motivation, but also the agony of contractions straining to overcome the body’s resistance to tissue stretch and damage, the hard-earned, unforgettable lesson and life-long experience that pain is a warning -a warning to stop what you’re doing and escape… Can I as an outsider, as a doctor, as a non-participant, ever truly understand the experience, let alone the meaning of what I see? And if not, where do I fit in? And when? To act without understanding is to risk acting inappropriately, insensitively: the Inadvertent Charity…

So, is there a Divide, and does it matter? If I respond to your pain -if I relieve it even though I can only guess at the depth of its effect on you, does it matter that I could never experience it? Because, as a male, I will never know what it’s like to have, say, irregular, heavy, or painful periods, does it really diminish the adequacy of my response, or change my ability to attend to your world? Does my inability to pass through the door, somehow detract from the action? Demean it?

Yes, I suppose I’ve passed middle age -left it behind the hill, perhaps- and no, I haven’t actually grown up with the same cultures, or traditions as those I see in my office; I am undoubtedly a product of my era, my generation. But how much does that separate me from those I see? Along with accreted knowledge, there is something that comes with age, comes with living in a room long enough to recognize and treasure the things in it. It’s something that used to be valued. Honored. Something that transcends gender, rises above mere culture and tradition. It is experience; it is acquaintance and comfort with difference; it is, I suppose, wisdom.

I will never be a woman; I will never be the same as anybody I see; I will only ever be a person reaching out…

A rather small Divide when you think about it.

Meanings

Can we ever understand each other? Know what is being asked of us? It’s not just a medical problem; it’s universal, I suspect. And it’s one that entails far more than simply comprehending the meaning of a word in both its denotative (definitional) as well as its connotative (secondary, or evocative) usage. It involves apprehending -truly appreciating – whatever is intended in the communication.

In a sense it is often a relational concept: we are linked in a sort of symbiosis and inherent in that is the empathetic interpretation of what is being conveyed. Friends potentially have this: Don’t listen to what I say; hear what I mean. We all hope for this, I think -especially when things are hard to express, when words fail, as it were. When we need the other person to grasp something we cannot adequately articulate, we are at a loss -or perhaps more accurately, at a disadvantage- in terms of receiving their help or advice. Words, large or small, can be impediments.

And this is particularly salient in medical encounters where both unfamiliarity with appropriate terminology as well, perhaps, as embarrassment, conspire to camouflage the reason for the visit. Where you say pain, but really mean cramp, or perhaps irregular -referring to your menses, for example- when you actually mean totally unpredictable, or maybe that you’ve even stopped trying to keep track of them… Where cancer could mean something you think your grandmother had -but nobody would talk about it with you- or that in fact it’s what you think you have but are afraid to verbalize it. Heavy is what your periods are not -even though you are anaemic- because they’ve always been like that, and so were your mother’s: They are normal, doctor

I realize this is not usually a major obstacle to doctor-patient relationships, because over time doctors learn to listen to what is not being said; the encounter is frequently more valuable than the words in it -no matter how descriptive. It is also why it is often so difficult to address problems over the phone.

Through the years, I have struck by the need not only to be a good listener, but a good and careful observer. There is as much meaning in silence as in conversation; as much information in examination as description. Words are susceptible to challenge, or misinterpretation; unimportant ones can be uttered with emphasis, significant ones mumbled sotto voce. Comfort level is privileged and not summonable at will. Words escape from the top of the tongue, or are inadvertently trapped behind the teeth; meaning is sometimes a prisoner to safety -be it cultural, or personal. And it can be as unpredictable as the weather; as fickle as a mood…

So then, how can we understand each other -especially in moments of crisis? How can we ensure that others know what we intend -what we need to convey? Is it as simple as choosing the right words, the right syntax? Is it a vocabulary issue, or something more complex? More profound? From the doctor point of view, I would argue for the latter; I think that the essence that underscores all communication, that underlies all meaning, is engagement: being present in the situation at hand; imbedded in the message -both obvious and covert, intended and accidental; alert to context; aware of the unspoken. Words, after all is said, are just drawings in sound; to understand, to really comprehend, we must listen with more than our ears, see with more than our eyes. To listen fully, we must hear.

It is not an arcane prescription, not something requiring years of training; it is what we all attempt when we truly care; it is what is missing when we do not… And absence of the effort is something Shakespeare noticed so many years ago (Henry IV part II):

It is the disease of not listening,
the malady of not marking,
that I am troubled withal.

Choice

What do you do if you just don’t like someone -or in the context of a doctor/patient relationship, what should you do? It’s a vexing question at the best of times, but perhaps even more so if you are a patient that has been referred to a specialist. Or you are that specialist…

The question assumes a different dynamic when it is viewed from the perspective of non-urgent healthcare -something with which I suspect we are all familiar. Not to be misunderstood: all healthcare is important. Health is not trivial, nor is the individual perception of it. Nuisances loom almost as large as burdens or hazards in many of our otherwise unthreatened lives. And the very concept of Health itself could likely use a more compelling definition. But that aside, the problem remains: having decided that something requires a diagnosis and hence a remedy, and having been informed that the help in question is only available outside the warm and reassuring nest of the family doctor, what if there is an unbridgeable gap? What if you feel that you simply cannot confide in the specialist? That he will not listen to you? That he will not take your condition or your suffering seriously? That you, in the final analysis, don’t like him?

There are many facets to this problem certainly, but in the end most of it boils down to trust, not to mention respect. On both sides.

In an emergency -an accident, say- the problem of trust is perhaps more secondary: if you’re bleeding, you need someone to stop the bleeding, attend to whatever injuries have been sustained -fix the problem as it were. Only in the recovery phase -the sober reflection phase- does trust re-enter. But that’s after the fact; analysis is usually suspended in the face of dire need. In other situations, things are in many ways more complex: there is time for choice -time, in other words for preference. Trust. Belief. Much in medicine depends on belief: belief that there is help, belief that you can be helped and of course, belief that the doctor is capable of helping you. Think of belief -trust- as being the Supreme Placebo. It is the underlying understanding that hope for recovery is justified. Some situations require less of it -an appendectomy will likely cure appendicitis whatever you think; some situations more: chronic pain, for example. Most conditions probably fall somewhere  between and within this spectrum, and the results of treatment therefore, as well. And treatment is usually a two-way street: an unwriteable contract between care-giver, and care-receiver. Both need to trust each other; both need to respect each other or it won’t work. There are just too many variables.

Let’s return to the original question, however. What if, after waiting for three months or more to see the specialist, you find you do not like him? Well, I suppose in our system, you could refuse to go back to him and request a second opinion. There may be a delay in finding another doctor, and there is always the chance you might not like her either, but at least there is a choice, an option… For you…

But what about the specialist? What should I do if a person has been waiting to see me for several months and I have trouble relating to her? Not because of her race, or creed or sexual orientation; and certainly not because she comes into the office poorly dressed, or seems preoccupied with something else… These things to me are irrelevant. A medical practice is like a UN membership: toleration and respect for differences is part of the relationship, part of the expectation. I do not need to become friends with those that have been sent to me, although I don’t preclude it. And while I hope that my diagnosis of their problem will be accepted or at least considered helpful, I don’t demand to have the final say in their ultimate treatment if they don’t wish it. But there is a core expectation on my part that is integral to my continuing role in their health: not necessarily that I should like the person, but rather that I must not dislike her -not what she stands for, not what she may profess to believe, nor even who, in fact, she is -but her!

There’s a difference, isn’t there? We don’t all get along, but if we do, things flow more smoothly. There can be a give and take of ideas, a path of mutual understanding: on my part, that I think I can help; on the patient’s part, that she agrees that I may very well be able to accomplish what she needs. It’s a mutual thing, and both must be present for the contractual obligations of the referral to be fulfilled.

Admittedly, if there is dislike on one side of the desk, it very likely extends to the other side as well. But that begs the question doesn’t it? The patient may be reluctant to ask for another opinion: there is often a discomfort in that; she may not know what to do or how to extricate herself from the situation. And it is difficult for me to suggest she see someone else as well -especially if it’s not evident that she feels similarly. But in her interest -and mine, to be sure- I feel it has to be done. Fortunately it is uncommon -rare, in fact. I can’t remember more than two or three occasions in all my years in practice where I felt it was essential for a successful outcome. But it is an important option, and one that I think the patient ultimately, if not immediately, understands and accepts. Deserves. A medical relationship should be a space -a room- that both agree to enter. It’s certainly a place where I live… Both of us should be comfortable in the same milieu.

As Jose Ortega y Gasset has written: I am I plus my surroundings and if I do not preserve the latter, I do not  preserve myself. Nor, I would add, the patient herself…