Most doctors develop a clinical persona that works with, let’s say, 90% of their patients. It includes some combination of kindness, patience, empathy, professionalism and their own, idiosyncratic personality.
Full disclosure: my now-retired GP has the patience of Job. He'd likely paint me as a journal junkie who is cheery & funny but ultimately resistant -- if not blatantly non-compliant. The poor guy actually begged me one time, to please-please-please get a nasty, invasive test. I did not, but he listened to my logic at a later date and looked at the journal printouts I brought to support my argument -- and he caved. That, in a nutshell, is the way our 'collaboration' went over 35 years. Infrequent office visits helped. I'll miss him.
As someone with autism spectrum traits I find I get misread a lot. Medical personnel are no exception. Given my limitations with conversation, (I don't read body language or social cues), I wonder how I can help the doctor/patient relationship go better.
I wish more doctors would be honest with their patients about their emotions and not try to be so professional all the time. Many times I have actually just put it out there to the doctors that I am feeling uncomfortable or that I feel they’re edgy with me. It brings an immediate reaction from them, mostly shock, but they do seem to soften up when I challenge them about their own emotional personas.
Excellent piece. It's really helpful to see how you have continuously reflected on this over time and your open discussion with the patient was brave and insightful.
I'd like to add a sociologist's perspective if I may. I think the lens of cultural values may be helpful as a lens through which to view some of these challenging communication mismatches. I've written a little about it here (https://muse.jhu.edu/article/701001/pdf), but my thoughts have developed since that piece was published.
One entry into this literature and how it affects clinical decision-making is through the world of antibiotics. There have been decades of Eurobarometer polls looking at various cultural values in Europe (a la Geert Hofstede). A number of researchers have taken these and looked for correlations between cultural values and antibiotic prescribing practices by clinicians, abx seeking behavior by patients or antimicrobial resistance. This runs very very deep: interestingly, antibiotic resistance sometimes tracks along the Protestant Catholic line (at least for pneumococcus, https://academic.oup.com/jac/article/50/suppl_3/27/2473461 see page 33, and another paper reviewing a few others that note the same thing https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-0691.2007.01724.x . This has been more recently backed up by a whole bunch of literature, mostly by Michael Borg who works out of Malta that finds the same association for other bacteria (https://scholar.google.com/citations?user=BTaO47sAAAAJ&hl=en), generally showing greater resistance in southern Europe and less resistance in northern European countries. The cultural values of power distance (deference to hierarchy), uncertainty avoidance and (sometimes) "masculinity" end up with pretty powerful correlations in much of this literature.
Of course cultural values are not absolute, and it's important not to stereotype. We must recognize (as we often do as clinicians) that population based measures do not necessarily always apply to the individual patient sitting in front of us. But I find these can still be useful as a guide, especially when we recognize that they are most helpful as *relative* not absolute indicators. In that case, what matters most is reflecting on where we are on the spectrum of these cultural values, and recognizing that patients that are very far from us (regardless of any stated cultural or ethnic origin) are likely to pose challenges for us in terms of both communication and shared clinical decision making. Though we often ignore it as medical professionals, the business literature recommends this process explicitly, probably most famously in Erin Meyer's book The Culture Map.
So when you mention your has medically-related anxiety and you worked to reassure him about his hip (and likely many other things), I'd like to reframe that and ask you a question. First, I tend not to use the term "anxious patient" because it seems pejorative. Who am I to say whether their anxiety is justified? I tend to look at patients who, to me, appear anxious as having a different level of uncertainty tolerance than I do. I am highly tolerant of uncertainty. Based on your writings, I'm guessing you are too, but I'll leave that reflection up to you. How do you navigate situations where patients appear, to you, to be anxious? Based on your mention that you have spent your career in medical education and love helping people understand medical issues, that is one approach to managing differences in uncertainty tolerance, but not the only one. Another approach is to offer certainty of process even when you cannot offer diagnostic or medical certainty: I sometimes say "I don't know what is going on, but I can assure you we will go through your chart with a fine-toothed comb and leave no stone unturned to make sure we're not missing anything." I can't say it always works, but it is another approach.
So the question: it sounds like you enjoy diverse patients who you noted may be "combative, mistrustful, suspicious and litigious," but may struggle when they're all combined. Would a cultural values framing help you think through some of these interactions and offer a wider range of solutions in how to navigate them?
Important points. In all our interactions with patients or anyone for that matter, there is that dance of our personality, biases, perception with those of another person, it's inevitable. We strive to be our best selves, to be nonjudgemental, objective, empathetic but none of us are blessed with 20/20 insight, who we are colors our interactions and we are all fallible.
I really enjoyed this piece. Thank you. This is not just sensible medicine but 'real' and honest medicine.
I am a chiropractor and I have experienced similar 'disconnectedness' many times too over 25 years/5000 patients. For me, a major factor in overcoming disconnectedness is #1: Just a lot of hands-on/touch (which often just seems to help melt away this type of tension) and #2: Just asking good patient-centered questions about their opinion regarding what is causing the symptoms and what they think ought to be done, etc. Cheers.
Sep 16, 2022·edited Sep 16, 2022Liked by Adam Cifu, MD
Adam,
This is excellent. Just the fact that you gave a physical exam (!) gets you a thousand extra bonus points from me.
Thank you for your willngness to self examine. Your conscious self-awareness allowed you to truly see what allowed you to become an even better physician for LB and no doubt countless others. The Mickey Mouse medicine I am accustomed to receiving in the system I get my doctering from is appalling. In the new practice I am with I have never yet to meet my physician. Each time I go I am met with a different nurse practitioner that they rotate. This makes it impossible to have an ongoing trusted relationship with anyone. And when I pointed this out and told them how important it was that I stick with one person they looked at me blankly and said "We don't do things that way here." I was aghast. And people are willing to put up with that. Whereas I've never been a Miss Go- Along. And of course if you complain more than once you get labeled as a "difficult patient" A difficult patient is anyone who doesn't go along with the program. The system is inhumane and I object. You bet I do. but because I'm walking a thin line of being dismissed from the practice if I show my anger and express my outrage this is happening and question why I have not been able to see my physician who seems to sit in an office behind a computer screen monitoring everything while the nurse practitioners and his PA do all the footwork. It's very strange and everything seems to be geared toward what the insurance will cover and what the insurance will say in their codes and this new " Epic" system and I find it quite insane and inhumane. This is better than the last one so I'm sticking with it for now. To my mind a doctor needs to see and hear and treat the whole person. In the current system most doctors treat lab tests they don't treat people. I notice you never heard the word cure anymore. doctors "treat" with surgery and drugs. Most don't know about you, they don't care about you, ( other than generically) ( how could they… they don't know you!) they don't ask about your family, how your life is going, they don't ask how your childhood was or how you're feeling about being you. And because they don't ask or know anything about you as a person, (they are treating lab tests not people and tuned into a computer screen instead of you), they fail to connect the dots. It's all about the connection. So far I have liked the nurse practitioners but feel invisible to them. and I am a VERY clear communicator. So this is a dilemma. Healing is all about the connection because that's where the trust begins to build. When a patient feels seen and heard she can trust. And when she can trust she can open up and say how it feels to be her and what her concerns are without having to be on the defensive. I find myself on the defensive alll the tine with medical people because I've been disappointed so many times. And I go in with that grudge assuming this will be yet another disappointment.
And it usually is. And I fully own that I may be projecting that from my childhood where I was not heard or seen. That's part of this picture of every human relationship because life is a mirror and like unto itself is drawn. But it's not the whole picture. The system is messed up. We have to do better.
I shouldn't have to feel disappointed in my physician. I should feel helped. Inshould feel hope. I should feel kindness. I should feel inspired that together we can get me well. I should feel cared for and cared about . And I should not feel alone in my quest for healing .. Every true physician should have the ability to see and hear through a clear lens and if it's not a clear lens do what you have done -- which is make the correction and switch lenses based on your own self-awareness .
True physicians today are rare. Thank you for being one of them.
Thank you for your desire to have things go better!
I appreciate reading the perspective from the physician’s point of view. As the patient, I know I am ultra respectful and communicate well. I often wonder what the doctor is thinking, especially if the situation is interesting. Recently I had a check-up that actually included a 45 minute visit with the doctor, we ended up chatting about life in general because I didn’t have any issues that needed attention; it was nice to relate on a personable level and establish a basic context.
Yup. Been there, done that. As a bedside nurse, I find that 13 hours with that kind of patient effects my ability to handle my other patients and I have to be very conscious in my interactions. It’s on those days that the hard patient inevitability loves me, but another one of my patients inevitability gets lost in the shuffle.
I really look forward to these - another great piece!
Full disclosure: my now-retired GP has the patience of Job. He'd likely paint me as a journal junkie who is cheery & funny but ultimately resistant -- if not blatantly non-compliant. The poor guy actually begged me one time, to please-please-please get a nasty, invasive test. I did not, but he listened to my logic at a later date and looked at the journal printouts I brought to support my argument -- and he caved. That, in a nutshell, is the way our 'collaboration' went over 35 years. Infrequent office visits helped. I'll miss him.
Frank and honest insights. Thank you.
As someone with autism spectrum traits I find I get misread a lot. Medical personnel are no exception. Given my limitations with conversation, (I don't read body language or social cues), I wonder how I can help the doctor/patient relationship go better.
I wish more doctors would be honest with their patients about their emotions and not try to be so professional all the time. Many times I have actually just put it out there to the doctors that I am feeling uncomfortable or that I feel they’re edgy with me. It brings an immediate reaction from them, mostly shock, but they do seem to soften up when I challenge them about their own emotional personas.
That strategy doesn't always work but when I t does I have had some marvelous breakthroughs with truly difficult patients...
It seems to hinge on timing and deep honesty
Excellent piece. It's really helpful to see how you have continuously reflected on this over time and your open discussion with the patient was brave and insightful.
I'd like to add a sociologist's perspective if I may. I think the lens of cultural values may be helpful as a lens through which to view some of these challenging communication mismatches. I've written a little about it here (https://muse.jhu.edu/article/701001/pdf), but my thoughts have developed since that piece was published.
One entry into this literature and how it affects clinical decision-making is through the world of antibiotics. There have been decades of Eurobarometer polls looking at various cultural values in Europe (a la Geert Hofstede). A number of researchers have taken these and looked for correlations between cultural values and antibiotic prescribing practices by clinicians, abx seeking behavior by patients or antimicrobial resistance. This runs very very deep: interestingly, antibiotic resistance sometimes tracks along the Protestant Catholic line (at least for pneumococcus, https://academic.oup.com/jac/article/50/suppl_3/27/2473461 see page 33, and another paper reviewing a few others that note the same thing https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-0691.2007.01724.x . This has been more recently backed up by a whole bunch of literature, mostly by Michael Borg who works out of Malta that finds the same association for other bacteria (https://scholar.google.com/citations?user=BTaO47sAAAAJ&hl=en), generally showing greater resistance in southern Europe and less resistance in northern European countries. The cultural values of power distance (deference to hierarchy), uncertainty avoidance and (sometimes) "masculinity" end up with pretty powerful correlations in much of this literature.
Of course cultural values are not absolute, and it's important not to stereotype. We must recognize (as we often do as clinicians) that population based measures do not necessarily always apply to the individual patient sitting in front of us. But I find these can still be useful as a guide, especially when we recognize that they are most helpful as *relative* not absolute indicators. In that case, what matters most is reflecting on where we are on the spectrum of these cultural values, and recognizing that patients that are very far from us (regardless of any stated cultural or ethnic origin) are likely to pose challenges for us in terms of both communication and shared clinical decision making. Though we often ignore it as medical professionals, the business literature recommends this process explicitly, probably most famously in Erin Meyer's book The Culture Map.
So when you mention your has medically-related anxiety and you worked to reassure him about his hip (and likely many other things), I'd like to reframe that and ask you a question. First, I tend not to use the term "anxious patient" because it seems pejorative. Who am I to say whether their anxiety is justified? I tend to look at patients who, to me, appear anxious as having a different level of uncertainty tolerance than I do. I am highly tolerant of uncertainty. Based on your writings, I'm guessing you are too, but I'll leave that reflection up to you. How do you navigate situations where patients appear, to you, to be anxious? Based on your mention that you have spent your career in medical education and love helping people understand medical issues, that is one approach to managing differences in uncertainty tolerance, but not the only one. Another approach is to offer certainty of process even when you cannot offer diagnostic or medical certainty: I sometimes say "I don't know what is going on, but I can assure you we will go through your chart with a fine-toothed comb and leave no stone unturned to make sure we're not missing anything." I can't say it always works, but it is another approach.
So the question: it sounds like you enjoy diverse patients who you noted may be "combative, mistrustful, suspicious and litigious," but may struggle when they're all combined. Would a cultural values framing help you think through some of these interactions and offer a wider range of solutions in how to navigate them?
I love these essays. thank you.
Important points. In all our interactions with patients or anyone for that matter, there is that dance of our personality, biases, perception with those of another person, it's inevitable. We strive to be our best selves, to be nonjudgemental, objective, empathetic but none of us are blessed with 20/20 insight, who we are colors our interactions and we are all fallible.
I really enjoyed this piece. Thank you. This is not just sensible medicine but 'real' and honest medicine.
I am a chiropractor and I have experienced similar 'disconnectedness' many times too over 25 years/5000 patients. For me, a major factor in overcoming disconnectedness is #1: Just a lot of hands-on/touch (which often just seems to help melt away this type of tension) and #2: Just asking good patient-centered questions about their opinion regarding what is causing the symptoms and what they think ought to be done, etc. Cheers.
Adam,
This is excellent. Just the fact that you gave a physical exam (!) gets you a thousand extra bonus points from me.
Thank you for your willngness to self examine. Your conscious self-awareness allowed you to truly see what allowed you to become an even better physician for LB and no doubt countless others. The Mickey Mouse medicine I am accustomed to receiving in the system I get my doctering from is appalling. In the new practice I am with I have never yet to meet my physician. Each time I go I am met with a different nurse practitioner that they rotate. This makes it impossible to have an ongoing trusted relationship with anyone. And when I pointed this out and told them how important it was that I stick with one person they looked at me blankly and said "We don't do things that way here." I was aghast. And people are willing to put up with that. Whereas I've never been a Miss Go- Along. And of course if you complain more than once you get labeled as a "difficult patient" A difficult patient is anyone who doesn't go along with the program. The system is inhumane and I object. You bet I do. but because I'm walking a thin line of being dismissed from the practice if I show my anger and express my outrage this is happening and question why I have not been able to see my physician who seems to sit in an office behind a computer screen monitoring everything while the nurse practitioners and his PA do all the footwork. It's very strange and everything seems to be geared toward what the insurance will cover and what the insurance will say in their codes and this new " Epic" system and I find it quite insane and inhumane. This is better than the last one so I'm sticking with it for now. To my mind a doctor needs to see and hear and treat the whole person. In the current system most doctors treat lab tests they don't treat people. I notice you never heard the word cure anymore. doctors "treat" with surgery and drugs. Most don't know about you, they don't care about you, ( other than generically) ( how could they… they don't know you!) they don't ask about your family, how your life is going, they don't ask how your childhood was or how you're feeling about being you. And because they don't ask or know anything about you as a person, (they are treating lab tests not people and tuned into a computer screen instead of you), they fail to connect the dots. It's all about the connection. So far I have liked the nurse practitioners but feel invisible to them. and I am a VERY clear communicator. So this is a dilemma. Healing is all about the connection because that's where the trust begins to build. When a patient feels seen and heard she can trust. And when she can trust she can open up and say how it feels to be her and what her concerns are without having to be on the defensive. I find myself on the defensive alll the tine with medical people because I've been disappointed so many times. And I go in with that grudge assuming this will be yet another disappointment.
And it usually is. And I fully own that I may be projecting that from my childhood where I was not heard or seen. That's part of this picture of every human relationship because life is a mirror and like unto itself is drawn. But it's not the whole picture. The system is messed up. We have to do better.
I shouldn't have to feel disappointed in my physician. I should feel helped. Inshould feel hope. I should feel kindness. I should feel inspired that together we can get me well. I should feel cared for and cared about . And I should not feel alone in my quest for healing .. Every true physician should have the ability to see and hear through a clear lens and if it's not a clear lens do what you have done -- which is make the correction and switch lenses based on your own self-awareness .
True physicians today are rare. Thank you for being one of them.
Thank you for your desire to have things go better!
Thanks, thoughtfully reminded me of the “problem patients” in my own practice.
I appreciate reading the perspective from the physician’s point of view. As the patient, I know I am ultra respectful and communicate well. I often wonder what the doctor is thinking, especially if the situation is interesting. Recently I had a check-up that actually included a 45 minute visit with the doctor, we ended up chatting about life in general because I didn’t have any issues that needed attention; it was nice to relate on a personable level and establish a basic context.
Adam where do I find the first four I would love to read them?
Do you have unresolved issues with your uncle?
Did you consider having a psych watch your interaction with LB?
Yup. Been there, done that. As a bedside nurse, I find that 13 hours with that kind of patient effects my ability to handle my other patients and I have to be very conscious in my interactions. It’s on those days that the hard patient inevitability loves me, but another one of my patients inevitability gets lost in the shuffle.