Today's post is from Danielle Ofri, writer and practicing internist at New York City's Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. This post originally appeared at her Medicine in Translation blog at Psychology Today.
"Angelina Gomez," the medical assistant hollers out to the crowded waiting room. As always, I cringe when I hear this. It sounds so harsh, so cattle-like. I know that the assistant is actually a gentle and caring person, and I understand that he uses a loud voice so that he can be heard over the general din of a large waiting room.
Nevertheless it feels horrible to me, so demeaning, like we're in the DMV instead of a medical clinic. I want the environment to be more humane, more civilized, and so when I go out to call a patient, I use a much softer voice, with a tone that I hope conveys more respect.
Of course, no one can hear me. Heads turn, ears strain, faces contort as people try to figure out who I am calling. The medical assistant usually gets the right person on the first try. I, on the other hand, end up pacing up and down the waiting room repeating the name. Am I making the environment any better?
There is so much wrong about medicine today. The list is endless and contains so many high-profile items like lack of universal coverage, inequitable distribution of resources, higher reimbursement for procedures than for primary care. But sometimes it's the tiniest details that seem to affect us the most strongly, and certainly these are the only ones we can possibly control.
I've been in other clinics where an overhead announcement is used to call the patients. It certainly offers clarity and volume, and achieves the goal of locating the patients. But it feels even more factory-like to me.
I often try to figure out what a patient will look like, based on their age, sex, and name. There's a tinge of guilt because I suppose there's undoubtedly an amount of stereotype involved, but it does allow me to direct my calls to the reasonably appropriate demographic.
There are other small things that can contribute grains of humanity to the doctor-patient encounter, such as how we address patients. Our entire society has shifted toward familiarity and use of first names. Nevertheless, a conscious effort to use patients' proper names and titles respectful titles is worthwhile. It conveys that the medical profession is here at the patient's service, not the other way around.
In my particular clinic, much of the care is conducted in Spanish. I am by no means fluent, and my mistakes are legion. (They are often the primary sources of humor in otherwise serious encounters). I've tried my best to learn the more formal usages in Spanish--usted vs tu, for example. I get constant ribbing on this from bilingual staff members who insist that I sound archaic, but I persist because I think it contributes a modicum of respect in an environment where patients often feel powerless.
Lastly, how doctors dress and comport themselves has a distinct impact on the environment. Obviously, the most nattily dressed physician who doesn't know her medicine is worthless, but whenever I see interns dressed overly casually, or in old scrubs, or in clothes better suited to a club, I try to point out the incongruity. I feel a little silly since I am no fashion maven, but it's important for doctors-in-training to understand how their appearance contributes to the sense of respect their patients glean from them.
I often buttress this conversation with a mention of an older gentleman I took care of in the hospital a few years back. Mr. B--as I'll call him--was found in his squalid apartment, having fallen in the bathroom, unable to get up. He had the look of someone who was homeless, or nearly so--disheveled, unkempt, emaciated--and I could sense the interns and students unconsciously recoiling from him.
But he was an intelligent man, and we found ourselves in long--often long-winded--conversations. He had many opinions about the medical profession, and I finally asked him what would be the one thing he'd want to teach the upcoming generation of doctors. "Respect," he said. "Respect for the patients in the little things." He told me that he felt the doctors were giving him good medical care, but he sensed their mild disparagement toward him. "And half of them don't even look like doctors," he added, "running around in ratty clothes and sneakers."
Up until that point, I hadn't thought much about how we doctors dressed, but he had a good point. Unfortunately there was a complication in his care-a respiratory arrest in the CT scanner suite thanks to a sedative dose that was too high. He recovered from that, but his case was presented at the monthly departmental conference. After the medical issues regarding cautious sedation of the elderly were reviewed, I stood up and said that this patient had a message for the medical staff. I recounted his observations about how the doctors dressed and treated him, reminding us that patients do notice and do care.
(Mr. B eventually taught us another lesson-about assumptions based on appearance. I saw him several months later, after he had spent time doing intensive physical rehabilitation. He wore a smart blue blazer over a white-button shirt, walking confidently with an elegant silver-tipped cane. His hair was neatly trimmed, and his smile was beaming. The condition we'd seen him in was a temporary one, not a defining one.)
Many of us want to solve the big issues in medicine right now. Unfortunately, we can't do a whole lot on most of these fronts. But there are a host of small things we can do right now that can improve the environment of medicine. If readers have other suggestions of small do-able things, please post them.
I'd love to see doctors begin to ask more questions which give the patient a chance to talk about their intuition of what's wrong, and really listen. I once self-diagnosed an issue using my own guess, followed Medline, and found I was exactly right, when my esteemed endocrinologist had dismissed my hypothesis without checking the literature. Could have saved several hundred dollars in tests, and I would have thought better of the doctor, too.
Posted by: Nancy Gift | November 20, 2009 at 02:38 PM
Sorry, your call for "small things" got me going anyway.
The problems with state of the art health care are numerous and profound.
To begin at the beginning, they include: 1) the abuse of parapsychology, also known as the soul, misdiagnosed as schizophrenic delusion; n.b. the priority of mental health; 2) no insurance covering post traumatic stress disorder, regardless of the trauma(s); 3) unnecessary procedures, posted here at "...mammogram" among them.
To its credit, the art, the profession admitted in the late 90s it had been mismeasuring blood pressure for decades, resulting in false diagnoses of mild hypertension, with attending prescriptions for treatment.
So, it isn't just the litte things we should be concerned about: there are big things too!
(Demand the editors of the DSM and ICD revise their texts at schizophrenia.)
Posted by: Arthur Toegemann | November 28, 2009 at 09:18 AM