Getting the medicine right, but failing in the art

When a patient leaves you for another physician, they simply cancel their appointments.  You might get a message that says they are moving on and, two months later, you get a follow up letter from the new doctor.

However, Sam was unusual. He came in to tell me that because of my mistakes, his wife was transferring her care. What made our confrontation remarkable was that Sam was wrong.

I had recommended that his wife undergo complex surgery, which I believe would not only extend her life, but greatly improve its quality.  After several long conferences, they sought a second opinion.  That doctor prescribed a radically different therapy, based instead on chemotherapy and radiation.  Apparently, that consultation was convincing because by the time Sam walked into the office, his wife was a week into radiation and had received the first cycle of intravenous treatment.

Sam wanted me to know how disappointed they were, that they “had expected more” from me.  He conveyed the anger of the time they had “wasted.”  Even though I had spent several hours in family meetings and had focused particularly hard on her medical issues, Sam and his wife believe that I never gave her case the attention it deserved.

The dilemma confronting me in that brief meeting with Sam was two-fold.  First, I firmly believe the care she is receiving is a mistake.  However, they are now fully committed to this course, and cannot change even if they wish.

On the other hand, in private practice my reputation is important.  Sam had taken the time to confront me in the office. How many people will he, his family and friends tell that I failed them?  Their complaints may go viral.  This could mean many patients whom I might never have the opportunity to assist. Having committed my life to fighting the dread disease in my community, this potential loss hurts.

So, what did I say?  The obvious.  I said nothing at all.  I listened to Sam’s words.  Thanked him, very much, for coming to speak with me and indicated that I understood the basis for their decision to change doctors and therapy.  I expressed my hopes that his wife would have a speedy recovery.  I offered that if any questions came up in the future, if I could help in any way, they should not hesitate to call.

Why not say more? Why not climb the bully pulpit and defend my honor?   What good would it do to convince Sam of the error?  If I succeeded in sowing confusion, would it bring comfort?  Coping with cancer, for a patient and family, is one of the most difficult things anyone must do, and adding more doubt could not possibly assist healing.  If things do not go well, what will be gained by giving Sam further guilt?

I failed Sam and his wife.  I presented them with “the truth,” but did not connect in a way that would have allowed her to follow that path.  I get an “A” in science, but an “F” in art.  Therefore, my reputation probably should take a bruise or two.  After all, while I was right, in the end, for Sam’s wife, what happened was wrong.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • DoubtfulGuest

    You sound like a very caring and conscientious doctor. I’d be curious to know how Sam responded to what you said? Good for you for leaving the door open to future communication. Also good for you for putting in the time to address their concerns, and for thinking about how to communicate better next time.

    I hope they will not go viral with their complaints. Please consider the possibility that a patient who takes the time to confront you actually cares about and respects you a great deal. What would be much better, of course, is if communication breakdowns could be resolved early —before rash decisions are made or feelings are hurt too badly. Some of us try to have open, respectful communication with our doctors but the doctors (or maybe it’s attorneys/insurance companies/administrators?) keep the barriers up.

  • Deceased MD

    I am confused. If so much time was spent with Sam then how come they seemed unaware of why you did not recommend chemo and radiation?

  • Ron Smith

    Hi, James.

    Been there and done that. Remember the lyric “If loving you is wrong, I don’t wanna’ be right?” Perception can everything to a patient, if they are self-deceiving.

    Your patient and spouse obviously had convinced themselves, because wishing for something different, that you must be wrong…bother the facts! They only demeaned you to justify their choice.

    I don’t confuse my warm feelings towards patients, with the idea that the patient is always right. My professional self-esteem as well as my staff morale will suffer if I believe everything a patient tells me at face value. Patient can and do lie!

    Wish them well and move on. There is no need to lose sleep or self-respect over that kind of nonsense.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • DoubtfulGuest

      Is the patient ever right? I agree Dr. Salwitz shouldn’t beat himself up, especially given how “Sam” talked to him without ever asking for clarification. Do you try to work out miscommunications with your patients, Dr. Smith? All kinds of stuff can go wrong that don’t involve self-deception or lying.

      • Ron Smith

        Hi, DoubtfulGuest,

        Yes, I always communicate with patients. But the issue here has nothing to do with good patient communications, just as James proved.

        Patients like this really want complete control of everything. They want what they want when they want it. More often it has to do with things like appointments, copay payments, i.e. office policy, than the actual medical decision-making.

        These patients took advantage of James. Someone else gave them the opinion that they wanted hear. They assaulted James’ medical judgment in order to justify themselves. James had to go and the only way they could salve their conscience was to accuse him of poor medical judgment.

        Hide and watch if the same doesn’t eventually happen to that new physician when he crosses their control line.

        Patients like these equate going to the doctor and paying their copay as a right to get any prescription for whatever medicine they want, and what the doctor says doesn’t matter. That’s why we are in the antibiotic mess we are with MRSA and other superbugs.

        Patients who demand control like this are high-risk. I’ve had this kind of thing happen before. I don’t allow these patients to stay in my practice and will respectfully give them a termination notice immediately if they pull this kind of stunt.

        No physician should cower to patients like these.

        Sincerely,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • DoubtfulGuest

          I think we agree on how Dr. Salwitz was treated by Sam. I was trying to ask how you respond if a patient appears upset or confused about your treatment plan. It sure sounds like Dr. Salwitz is reflecting on his end of communication? There may be nothing he could have done better. He surely put the time, effort, and compassion into it. Sometimes people are just not on the same page, for any number of reasons.

          Chances are high that Sam is an asshole. Many patients don’t process what you say, but they’re not assholes. I was chewed out by a doctor because I misheard instructions about the timing of labs to be drawn. I have a hearing loss and some cognitive problems, caused by my inborn error of metabolism that was not yet diagnosed back then. I felt bad for making the mistake and I tried to explain, but she was sure I was messing with her mind or had a sense of entitlement, heard what I wanted to hear, etc.

          Later, we talked things over and ended up on good terms even though I see different doctors (a team of specialists). She’s a great doctor, she was just tired and pressed for time as you all are. It’s just an example of how easy it is for communication to fall apart for other reasons than you describe.

          • rbthe4th2

            Oh I’ve been called a few things, had some real nasty tones in the voice, got up and walked out on. You name it, I’ve experienced it. Docs are under a lot of pressure. I understand that. I am too.
            Can any of the docs here tell me how this doc(s) did me, their patient, their profession, their personal reputation, any good, by not dropping the ego or barrier or whatever personal issue they had and investigating what the issue was and what the patient was trying to tell you? We’re talking one set of bloodwork tests, the other would be a test or two in another month or two. Some teaching. The patient would end up healthier (and out of everyones’ offices) quicker, less or maybe no physical permanent damage from the effects of no treatment.
            On top of that, I now help the competition in the area. ALL of them.

  • David Gelber MD

    Why is the second opinion always correct? Of course it’s not, but for some reason patients almost always believe this. Patients will shop around until they find a doctor who agrees with what a family member has told them, particularly if the family member has some medical knowledge, EMT, medical assistant or merely watches Grey’s Anatomy.

  • ErnieG

    Don’t sweat it. You can’t save everyone. You did your best. Sometimes people only hear what they want to hear. Regarding your first part of the dilemma (your feeling they are making a mistake)– it is their mistake to make. You showed them what you believe to be a better course…”you can lead a horse to water, etc.. As far as your second dilemma, there is not much you can do. Perhaps I would send a card to the couple thanking them for the opportunity to help them and wish them the best, etc. Life is tough, and we as docs have the privilege to see life in all its guts and glory,

  • Sherene

    You handled the situation well. Although the comment below me says Sam was an a**hole, he was in an extremely stressful situation and was frustrated. Also, who knows what the other doc told him to make him so convinced. I think it is really great that you offered to be there if they need any further advice.

  • rbthe4th2

    Here here! I’ve had doctors call me an ‘a hole’ because I presented evidence and they couldn’t or wouldn’t refute me. I had one issue with a 2nd, 3rd and an ER docs opinion I had one disease that the first didn’t. I put this information to the first doc and asked them to fix the problem. They got nasty with me on it, because my insurance wanted to know what was going on. Had they been willing to consider the first doc wrong and listened to me and NOT called me an ‘a hole’ then things would have been different. Instead, I suffered for months, and never got apologized to, because of this doctor.
    Consider also, I tell people never to go to that doctor, and a few others, and WHY. Not one person, who knows the full story, is willing to say what that doc did was right.
    Especially after trying to work it out with them. It was the doc who said if you don’t like me, just go elsewhere. I’ve seen it a couple of times: they think they know what they’re doing and end up harming the patient because they know it all, and the fact remains, they don’t. Not always a good idea to practice out of your expertise.
    Randy

    • DoubtfulGuest

      Wow. They actually CALLED you that? Classy!

      Mine just got real mad at me and implied it. One said I must have “secondary gain” and was doomed to float from one doctor’s office to the next, “claiming” weird symptoms, until he put a stop to it. There were no inconsistent findings, no proof of faking. It was just challenging to put it all together. Then, I found a team of docs who took me seriously, and 10 or 12 pieces of biochemical data all show the same problem. The icing on the cake is it’s usually progressive and doesn’t have a great prognosis. The treatments I’m on now can slow it down some. Evidence based medicine for the win…

      • rbthe4th2

        Same here – score one for EBM, at least I hope I’m still alive then. I still equate the 25-33% misdiagnosis, missed diagnosis, delayed diagnosis, percentages, to this very problem. Not being willing to list differential dx’s, listen to the patient, interpret blood work results in light of the patients’ symptoms, and be willing to go from there.

  • DoubtfulGuest

    Yes! All the best to you, Deborah.