Portal de Periódicos da CAPES

How to Survive Your Patients

2004; Lippincott Williams & Wilkins; Volume: 114; Issue: Supplement Linguagem: Inglês

10.1097/00006534-200410001-00048

1529-4242

Robert M. Goldwyn,

Empathy and Medical Education

Every doctor, even if not named Jekyll, has within him or her a Mr. or Ms. Hyde, one hopes not to the extreme of committing murder, as portrayed in Robert Louis Stevenson’s classic short story. We keep the less savory part of ourselves veiled or controlled. Most of us usually are “good boys” or “good girls.” In my instance, the “good boy, good doctor” aspect is reflected in The Patient and the Plastic Surgeon,1 whose content and tenets I still consider valid. What I offer here comes from the darker recesses of my brain. I hope my irreverence will not overly shock or offend serious readers. My secrets for survival have not come easily to me; they have been the result of random empiricism, miscalculation, and stress. My first tip-off to physician survival was an old joke to which at the time I had paid insufficient attention: the psychiatrist who, when asked how he tolerates listening to patients 12 hours a day, replies, “Who listens?” That story, now a cliché, later gave me an inkling into what doctors can do to maintain their emotional balance in the face of patient onslaught. Someone once observed, borrowing from Rudyard Kipling’s poem “If,” that “if you can keep your head when all about you are losing theirs, you will at least be taller.” Now, getting back to plastic surgery. The first stratagem is a variation of the psychiatrist’s poly—listen but not intently. As your face lift patient, for example, is immolating you with her flaming, angry eyes, think of something else: a favorite trout stream, a slice of key lime pie, a tennis match this afternoon; look at her directly but vacantly. Develop the see-through look. Consider her in the abstract—a representative of the human species, a species that is evolving but has not quite made it. If the patient does perceive that she is being regarded as a piece of living marble, she will become angrier, but finally, she will capitulate to the inevitable—the futility of it all. Your patient will think, “This doctor is not listening to me; he is not even seeing me, and in fact, he is not even on this planet.” She may detect a cosmic quality about you. As someone in his cabinet said after President Lincoln died, “Now he belongs to the ages,” so the patient will think that you belong to the universe. Your vision is so immense that before your unseeing eyes she is decreasing into nothingness. You, with this Olympian vacant stare, will loom a prophet, perhaps one of the greatest. What right, she will think, do I have to mention a mundane trifle such as a remaining crease on my face when this doctor, with his great mind, is pondering our world and worlds not yet known? Another stratagem is to adopt a historical perspective. Remember your last trip to Italy, when you took the family to Pompeii, where you observed that in a flash all human life stopped; people died in the midst of their activities; the hand that was paying the grocer became fixed in time, still clutching the coin that never reached the person on the other side of the counter, him also embedded in ash. Although I lack proof, I bet that when Mount Vesuvius erupted, some patient was complaining to some doctor about something that the physician did or did not do—but time has wiped away the complaint, the complainer, and the complainee. Drive by any cemetery. Who knows how many lie there who railed against their doctors, who may have even taken them to court? Now the plaintiff, defendant, attorneys, jury, and even the judge have been silenced forever. So when Mr. I. Wantmore complains that although you did improve his nose, your rhinoplasty did not go far enough and you failed to give him a sufficiently defined tip, you will be prepared. True, you never guaranteed the result, but he thought that with your reputation he would not have such a disappointing outcome. Before you allow your blood pressure to rise and get apoplexy, and before, heaven forbid, you apologize, take the historical approach both in your attitude and speech: “Mr. Wantmore, as I look at you, I am grievously troubled not just because you are unhappy with the result that I think is satisfactory. No, I am not unhappy with my evident failure to have pleased you, but I am disturbed by what I see in the future for you and for me [at this point, you take your handkerchief from your, pocket and pass it over your eyes]. I am older than you, and I have a vision of myself as a faltering old man, making his way with a cane, forgotten by his children, now caring for an invalid wife and you, though younger, beginning to decline, your physical strength ebbing, your mental grasp slipping, becoming forgetful, turning into a shadow on the streets. People will be looking through you and will not be paying attention to you as a human being when you have so courageously had to cope with cancer, your colon ripped apart by surgeons, who knows, perhaps you are being wracked by AIDS. God knows what can happen to us.” Now is the time to quote to the patient a saying of Victor Hugo, “We are all condemned but we do not know when the sentence will be carried out.” Then, you turn to the patient and say, “So when I hear your assessment of your nose, I am glad for the opportunity of focusing on the minor, the minimal. May God grant us time to try to rectify something of this sort, an almost nonexistent problem.” You suddenly change the subject, and jolt the patient back into reality: “How is your aged mother? How is your business during this awful recession? How are we all going to pay the increased taxes?” A few questions of this sort will make Mr. Wantmore want less. He will mumble a few words in farewell, slink from your office, and be grateful that he is still alive. When he goes to the lavatory, he will be thankful that his bodily functions have not yet gone kaput. The third strategy requires imagination, but it has never failed me. It is to imagine the patient in a setting different from your office. The blustering banker who is complaining that the scar on his cheek from your having excised a lentigo maligna becomes much less formidable, even ludicrous, if you imagine him in the morning in pajamas or leaving the shower. Such thoughts about someone of the opposite gender can prompt other fantasies, more disturbing, and not consonant with the teachings of Hippocrates, however. The key to translocating the patient is to place him or her in a ludicrous or embarrassing position. Imagine yourself returning to the store with newly purchased pants that were too long. The clerk semiapologizes and promises that the tailor will make amends, literally, but it will take 5 weeks. You are angry, and in the middle of your heated harangue, you suddenly have an image of yourself naked. Quickly, you tone down, perhaps even beg the clerk’s forgiveness for your intemperance. You might even tell the salesperson that waiting more than a month to have your pants shortened a foot is reasonable and that meanwhile you will employ Ilizarov technique to yourself—in order to meet the tailor half way. The fourth stratagem is reserved for the disgruntled, tenacious, unrelenting, venomous patient; I confess that that I have used it on only four occasions. I warn you that it is risky, but if successful, it is unequaled. It is to laugh at the patient while your mind transforms that individual into a fish, fowl, or animal. This is not translocation but transmutation. Thus, when Mrs. Nastee accuses you of incompetence and misrepresentation because the nasolabial folds, though lessened, are still there after her face lift, despite your having warned her of that possibility, think of her as a bulldog in heat. Then begin to laugh, first a chuckle, then a rising crescendo of glee, turning finally into demoniacal gales, like those you heard at the “Phantom of the Opera.” Mrs. Nastee will stare in disbelief and alarm; she will fear for her life in the presence of a surgeon who has obviously lost his mind; she has heard that all surgeons carry knives at all times. She will leap from her chair and overturn it as she flings herself from the office; she will stammer something incomprehensible to your secretary, who fakes a surprised expression, since she has witnessed this phenomenon before. Mrs. Nastee probably will never return, grateful that she has gone through the operation without your having slit her throat. Doubtless she will be scrutinizing the newspaper daily, hoping to see a picture of you in the arms of two hefty policemen, bringing you to the local insane asylum. The fifth tactic is what I have termed “the bolt from the blue”—the introduction of spectacular but threatening information at a critical time in the confrontation between you and the patient. When you sense that you are losing ground with a complaining, vicious patient, who unfortunately happens to be right—when you have that going-down-for-the-third-time feeling—press the buzzer under your desk. Your secretary, recognizing the signal, having been exquisitely trained as an accomplice, rushes into the room, visibly upset, and apologizes to the patient for her intrusion. She then whispers into your ear something that your patient will easily deduce to be of tremendous importance as you react with shock and bewilderment. You will then share the message with your patient. These communiqués can be anything you want. Good choices are “There is a serial killer loose in the building.” “Libya 2 minutes ago launched a nuclear missile.” “My wife has just run off with her podiatrist.” “My child [or grandchild] has been abducted by the Moonies.” “My brother-in-law, a prominent banker, has come out of the closet—literally—in 6-inch red heels and a purple bikini.” Obviously overwhelmed, you must excuse yourself. Any well-mannered patient, no matter how upset previously, will empathize with your pain and will leave the office. This will solve the problem for today. With luck either you or the patient may undergo spontaneous combustion. Before describing the sixth and final strategy for surviving your patients, a few words of caution about harassing techniques. These, usually recognized as such by patients, are characteristic of an amateur. A true professional is more subtle, more wily. Harassing techniques that I do not endorse range from being totally unavailable to being aggressively available. The latter refers to returning calls from dissatisfied patients at unwelcome hours, such as 2 a.m. or perhaps 11 p.m., when the patient is preparing to go to bed and may be contemplating a romantic interlude. One of my colleagues, in desperate situations, uses double talk to confuse the patient. While this may seem clever, the patient is likely to misinterpret the garbled words to his or her advantage. I wish to digress further to discuss the so-called sling stratagem and the tremor trick, both of which I strongly oppose even though others, whom I respect, tout them highly. The sling stratagem calls for putting your dominant arm in a sling immediately upon hearing that your next patient is the one who wants you to reoperate on her neck for the sixth time. After you endure Mrs. Percy Vere’s repeated complaints about her neck still not being “just right,” you note her eyeing with perplexity and alarm your presumably injured arm nestling healthy in its sling. Exuding amiability, you tell her that you would be delighted to try again, but obviously, because of your disability—just a fracture in three places, you say in an aside—you won’t be able to do the operation yourself, but you will be there in an advisory and assisting capacity. However, on your service, there is always a medical student. “They are a bright lot these days, you know. They’re enthusiastic as hell; they will jump at the chance to wield the knife.” Mrs. Percy Vere may decide to wait until you recover (“Just several months,” you sigh). This may solve the problem temporarily, but when I have tried this sling stratagem on two occasions, both patients, to my embarrassment, unexpectedly returned the next day to discover me miraculously cured. The tremor trick is more subtle, although it still falls short. This maneuver, as you have likely deduced, is quite simple: As you proceed to examine Mrs. Percy Vere’s oft-operated neck, you begin twitching your thumb and index finger while you jerk your arm and engage in mild athetoid movements. When your zigzagging hand finally gets to her chin, you seize the skin and pretend you cannot release your grasp. A few grunts of apology are helpful: “Sorry about this,” you mutter. “This damned condition is recent with me.” “Fortunately,” you explain, “it is only intermittent; sometimes I don’t have it at all when I operate, but other times it is a real problem.” You quickly change the subject: “My secretary tells me that someone canceled his operation for the day after tomorrow. Are you free then? We can slip you onto the schedule.” Mrs. Percy Vere thinks that the patient who canceled was no dope. Not wishing to hurt your feelings because of your disability, she brilliantly offers the old excuse of having to visit her sister, desperately ill in a hospital 200 miles away. Mrs. Percy Vere is an only child. Although you will get rid of her, as she spreads the word about your neurologic difficulty, she will get rid of your practice. That is why I do not recommend the tremor trick. Now for the sixth strategy for survival, which I must admit I have used only once. It is to pretend you have an acute physical illness, and, depending on the patient with whom you must deal, you must be ready to commit suicide—that is, pretend to do so. In response to the relentless complaints of a patient who may have decreased frontalis action after a forehead lift and who happens to be a plaintiff attorney, you should enact the following: Induce unilateral spasms of your mouth, roll your eyes upward, and slip with a gasp off the chair onto the floor. Engage in a protracted seizure to the point of urinating if the patient has not already left the office. A variation is to clutch your heart and moan while exclaiming that the pain is radiating down the inside of your left arm. This does have a hazard because the public is so well educated by the media that your patient is liable to ask when you had your last stress test and whether any inverted T waves were seen. If this should be her response, you must convince her that you are in the bona fide throes of a cardiac crisis. Start sobbing as you clutch your chest, and state your refusal to be a cardiac burden to your family. Drag one foot and lurch to the window, pretend to struggle to open it (it has been properly greased so that it yields easily in all seasons), and be prepared to throw yourself from the sill. At the same time, be aware of the patient’s reaction as you perceive her image reflected in the glass. If she is still sitting there, fascinated rather than fearful, and is still displaying the equanimity of an astronaut, there is no alternative—you have to jump (this assumes that your office is neither in the basement nor on the first floor). Ah, but you have prepared for this event; you surreptitiously attach your bungee which you have in readiness to a previously tested hook constructed for this purpose, and you leap. Any patient not unnerved by this behavior and who remains in your office is not the type to complain about any surgical mishap. In conclusion, I wish to make a few points that are probably obvious. We have all been brought up in the tradition of the care of the patient; namely, “the secret of the care of the patient is in caring for the patient,” an admonition with which Dr. Francis Peabody burdened generations of physicians.2 To this I say, the care of the physician is in not caring for the patient. Although very modest at heart, I consider my enunciation of this principle to be a momentous event in the history of medicine. I expect that soon we shall have a worldwide movement, called “Doctor Comes First.” I have no doubt that its ideas will sweep the world; my influence, and I state this humbly, may extend to other galaxies. For those of you wishing to become members of “Doctor Comes First,” the initiation fee, payable to me personally, of course, is a mere $100; the recording of the laughter technique on cassette or compact disc is an additional $75, and the bungee apparatus, with the easy to install hook (it has only a 5 percent failure rate), is but $44 more. The “Hippocrates Has Misled Us” or the “Physician, Save Thyself” bumper sticker is given gratis to each new member; both are available in 17 foreign languages. Acting today spares you from having to react tomorrow.