One of the obligations of a medical or surgical specialist is to communicate with the referring primary care provider. This can take many forms: a phone call, texting via smartphone, email, messages sent via EMR, and dictated letters. The format is pretty standard no matter what medium is chosen. You thank the referring doc for the consult request, you give some brief background info about the patient in question, and then you articulate an assessment and plan. Then you thank the doc again. Multiple times if necessary. Because your livelihood depends on whether or not that doctor decides to continue to send patients your way.
My practice is to freely text physicians I know well about their patients. It’s instantaneous, it’s informal, it breeds a certain collegial connectivity that is good for business. I also like free-form written emails via our internal encrypted system. In addition, our outpatient EMR auto-creates “referral letters” to primary doctors. These get sent to the doctor’s inbox as soon as I click “sign” on my office notes. These notes are really something. Not exactly an unearthed archive of F. Scott Fitzgerald corresponding with Hemingway, these babies. Some computer algorithm takes your office note, chops it up into relevant blocks of transferable data and information, splices in seemingly human-sounding phrases and sentences, and then synthesizes it all back together to make it look like an actual letter. I sometimes try to type in a block of text toward the end in an attempt to personalize things but that usually just gets buried under an avalanche of x-ray reports, review of system minutiae, exam findings, and various instances of tortured computer-generated syntax.
Prior to EMR, texting, and instantaneous communication, most specialists had no other option but to dictate referral letters to their feeders. And for some reason it evolved that the referral letter had to be composed in this faux-formalized, knock-off Henry Jamesian diction and syntax, as if American doctors were a bunch of 18th-century coutiers.
As an example, busy primary care docs would have to open up and read mangled prose poems from the local ENT surgeon or cardiologist like:
Dearest Dr. Smith,
It was my great pleasure to meet with your lovely, well-manicured, modernly festooned, entirely enjoyable patient Mrs. Corey today. As you know, she is a fabulous and engaging woman who has been suffering from rhinitis for two score and four years. I found her to be highly charming and eminently intelligent during my manipulations of her pharynx. I have diagnosed her with “——” and have prescribed “——” inhalers and nasal drops to be used as per instructions, She will follow up with me in 2 weeks for another evaluation.
Dr. Smith, if there is anything at all I can do to aid in your quest for professional perfection, please, from the bottom of my soul and heart, I would be honored if you were to call upon me at your leisure, as a knight errant at your disposal. From the core of my being I express you my sincere gratitude that you have entrusted me with the care of Mrs. Corey, a delightful human woman. I promise you, on the graves of my children, that I will do everything in my power, save those interventions dependent on supernatural forces, to provide the sort of care that you and your family, and Mrs. Corey’s family and neighbors and people standing near Mrs. Corey at airports or malls or wherever and, especially, Mrs. Corey herself, most incontrovertibly deserve.
My humble regards and everlasting faith,
I mean who wants to read that, let alone have to compose such garbage? I got a letter one time from a hematologist regarding a patient I had sent him regarding thrombocytopenia and the guy was an acquaintance of mine, we’d chat about the Cavs or Browns or whatever when crossing paths in the hall, but if you read his letter you’d think we had never met except in a castle hundreds of years ago outside Agincourt. I was like, Josh, why you write like that, man? And the next time I saw him at a nursing station he was perfectly normal and vernacularly modern and authentic.
And that’s what I just hated about it all. The phoniness and overt obsequiousness. The expectation that one had to lower oneself into the gutter of sycophantic servility in order to demonstrate proper respect and ensure a steady stream of future referrals. My favorite modern writer, David Foster Wallace, wrote about the corrosive effects of prostituting one’s very integrity for financial gain in his masterful long form non-fiction piece “A Supposedly Fun Thing I’ll Never Do Again” about his week-long excursion aboard a luxury cruise ship. Specifically he writes about his dismay upon finding an advertorial disguised as an essay by the American writer Frank Conroy (a writer he theretofore respected) tucked within a promotional pamphlet of a major Caribbean cruise line. Allow me to quote from that at length here:
In the case of Frank Conroy’s “essay,” Celebrity Cruises is trying to position an ad in such a way that we come to it with the lowered guard and leading chin we reserve for coming to an essay, for something that is art (or that is at least trying to be art). An ad that pretends to be art is — at absolute best — like somebody who smiles at you only because he wants something from you. This is dishonest, but what’s insidious is the cumulative effect that such dishonesty has on us: since it offers a perfect simulacrum of goodwill without goodwill’s real substance, it messes with our heads and eventually starts upping our defenses even in cases of genuine smiles and real art and true goodwill. It makes us feel confused and lonely and impotent and angry and scared. It causes despair.
This gets at something essential and unique to the overall American experience. It transcends cruise lines or phony doctor-doctor communiques. Everything we perceive or are exposed to has to be taken with giant grain of salt. We live in the age of consumption, the age of commerce. All the seemingly insignificant facets of life have been marketed in such a way to maximize the selling of a product whether that product is a phone or a car or a Bose wireless stereo system or sunglasses or a sweat- wicking workout shirt or a retirement strategy or a vacuum cleaner or even an actual person. It has seeped into the fabric of all aspects of American life — even something as intimate and private and ostensibly authentic as the doctor-patient relationship.
Doctors must advertise and market themselves and push a “brand” into the public consciousness. We see giant billboards advertising “world class care” for your loved ones. (Who doesn’t want that?) Plastic surgeons hint at the possibility of having a body like one of the various lanky 6-foot models gracing the pages of their print ads. And it’s more than overt mass media advertising. Specialists send holiday gifts to referring providers, thanking them for a spot at the trough. Ordinarily surly surgeons, while charting at a nurses station, who have nothing in common with the very busy foreign-born internal medicine doctor somehow suddenly become all joyful plasticized smiles, ostentatiously interested in his wife and children and political developments in the foreign-born doctor’s country of birth. “Great seeing you!” he says, and it’s all bullshit. As a general surgeon, I am constantly deluged with warnings from robotic instrumentation companies about how I risk “losing market share” to competitors if I do not incorporate robotic surgery into my practice to a wider extent.
We now judge rate physicians based on their patient satisfaction scores. Low scores get you a phone call from the hospital CMO. Seminars are held to help low scoring doctors improve their ratings. This actually happens. There are strategies for “connecting” with patients. Doctors learn how to smile better. They are encouraged to ask personal questions and to act amicably interested in the replies vis a vis head tilts and appropriate conversational interjections: “Oh I see … that’s interesting .. you are a fascinating person Mr. Blanks.”
On rounds, they are taught to sit on a chair bedside with the chair angled in such a way that is simultaneously intimate and yet unobtrusive. These skills are acquired and implemented. The scores are then re-tabulated after three months. Physicians who continue to score low, in this age of employed practice paradigms, are at risk of losing their jobs.
The sad and depressing part is that once you realize everything is being marketed and sold to you, even the things that are seemingly more relationship-based and professionally-driven, you start to develop cynical doubts about the authenticity of encounters that ought to be real and honest and devoid of any commercial entanglements. It seeps into the air we breathe like a poisonous ether, and you find yourself harboring a nagging cynicism about anything anyone is saying to you.
This is the world we have created by deifying the entrepreneur, the disruptive innovator, the capitalist, the Masters of the Universe, the advertising exec. I mean, when I go to a car dealership, I expect to be served a load of B.S from an oily, disingenuous snake trying to get me to fall for the rust protection plan. I’m almost disappointed if I don’t get a salesman so cartoonishly slick and craven. But I don’t want my doctor or dentist or counselor or whatever being nice and caring and empathetic toward me because it is in their best interest, remuneratively speaking, to do so. That would ruin everything for me. I can’t imagine opening up myself in a state of vulnerability to another human who I felt was feigning interest and compassion in order to avoid getting a poor patient satisfaction evaluation from me or because they were worried about their cumulative scores on Healthgrades. If I had to worry about deciding whether or not a health care provider truly gave a damn about me or was just acting out a role in a simulacrum of “professional conduct” I would probably never be able to make an appointment.
What’s worse is that this corrosive cynicism doesn’t just poison one’s relations with peers or professionals you seek for advice or help; it also, over time, can boomerang back, hari-kiri style, and pierce your own veneer of self-regard. You start asking yourself, how do I know I am truly sitting here listening to this patient with a full heart, selflessly striving to understand what ails him? How can I be certain of my motivations? How do I know I am making my rounds, doing my surgeries because I am generally a decent person who wants to “help people” or if, in reality, I just like being perceived as a decent person, a pillar of society, a caring professional by others? Am I just exhausting all my energy cultivating and maintaining this persona rather than living a genuine life?
Then you start questioning everything. The doctor you smile to and say hello to in the hall while on morning rounds — did you just do that because she might be a potential source of referral revenue and you want her to remember that you are friendly and smile nice when passing her in the halls? Did that conversation you just had in the doctor’s lounge with the family practice chief about the Cavs’ chances this year — was that all a theatrical performance to demonstrate that you too like sports and have something in common with him and perhaps he will remember that the next time he sees a patient with a hernia? It’s a deep dark bottomless rabbit role to tumble down and, believe me, it gets tiresome and soul-annihilating after about 5 seconds of free falling. It bleeds into all routine encounters, medical or otherwise.
One of the hospital cleaning ladies with her mop and bucket smiles and wishes me a good day and I wonder if she really means it or if maybe she is only doing it because she thinks that I will remember her and recommend her to some supervisor for a higher position or, even worse, if a directive had been sent to the janitorial staff imploring them to be more friendly and outgoing with patients and other employees in order to foster a culture of hospital amiability? At least in the first case she would have been doing it out of her own agency. It’s awful. And then you come home, and your little kids come running to you, you just want to collapse in a chair and hold them and cry.
The really terrible thing about all this nonsense is I really, truly am grateful that other doctors trust my judgment and surgical skills enough to send their patients to me. I want to be able to truly, humbly thank them for their faith in me. But how to do it without seeming coy or naive or, worse, as a cynical shill for more referrals? To express such sentiments in writing would just arouse suspicion and contempt. It’s all been ruined.
I can’t imagine doing anything else for a living. I’m lucky as hell. At least I know that I can sometimes impact people’s lives. I can’t imagine having to wake up every morning and try to sell or market cell phone plans or life insurance or a used Audi or some similar product that I didn’t truly believe in. I feel blessed. I have only my best efforts and prior clinical experiences and technical expertise to offer. And if it’s all a fraud or a sham or some ornate marketing scheme, then there will be consequences. Patients will get hurt. Real lives are at stake. It should be easier for me not to get too bogged down in self-recrimination and despair.
And so I approach the patient/physician encounter as a sanctuary from the rapacious, counterfeit, profit-driven world that I have to navigate through every day. I really am curious about these people who come into my exam rooms. I am interested in their seemingly trifling anecdotes and back stories. I love when they ramble on about some trip planned to Montana or the vegetable garden they had last summer or whatever. I am there as a privileged guest, invited inside, if but for a short while, when they are vulnerable and hurting and completely open and trusting. I have been allowed behind the curtain, and I don’t want to betray them, I don’t want to let them down. I want them to like me and trust me and believe in me. I need this to be true, and it doesn’t have anything to do with high HCAHPS scores or patient satisfaction metrics.
We’ve defiled most of the remaining holy grounds in America through a combination of cynical detachment, professionalized irony and the crass commodification of certain venues where it ought to have place. Anything can be marketized and sold. Even human intimacy and connection, love and compassion.
Or we can always choose not to.
Jeffrey Parks is a general surgeon who blogs at his self-titled site, Jeffrey Parks, MD.