Monday, May 26, 2014

The Patient Is Always Right? The Christian Is Always Right?


Is the Patient Always Right? Is the Christian Always Right?

Abraham Lincoln is quoted as saying, “You can please some of the people some of the time, all of the people some of the time, some of the people all of the time, but you can never please all of the people all of the time.” 

A bit of a tongue twister, perhaps, but generally true, I think. Recognising the truth in a saying versus being happy about such when life circumstances fail to meet expectations is another tale though.

Many physicians are judged by their employers on patient satisfaction surveys. If Amazon and Travelocity can solicit customer feedback to encourage dependable, superior service by companies, can medical care organisations encourage quality patient care through similar type surveys?

The answer might not be so simple. As a primary care doctor, I cannot always deliver the news that patients want to hear. I cannot always provide the treatment that a patient desires. I am sometimes the worst obstacle in a patient’s perception to getting what he or she wants.

~o~

“Have you ever done your HIV test before?” I look into the eyes of a beautiful young Cameroonian university student who sits silently opposite me in the consult room while I read her test results. She lowers her eyes and stares unflinching at the table between us.

“Yes, doctor, last year,” she finally mumbles without looking up.

“And what were the results?” I tilt my head a bit to see her face better.

“Negative, doctor,” she answers flatly.

Pause. She knows I don’t have good news.

I know she knows I don’t have good news. Still, it is never easy informing someone that they have a socially shunned and essentially incurable disease.

This particular patient holds back her tears upon hearing the verdict. I wonder if she’ll go to church for prayers and get angry with God when she’s not healed of her HIV. I certainly haven’t given her the news that she was hoping for. I don’t get any hearty handshake of gratitude for diagnosing her HIV. Even if I deliver the report in the kindest and most culturally appropriate manner, she still isn’t likely to bring a big bunch of bananas to clinic tomorrow thanking me for my excellent medical acumen in diagnosing her illness. Perhaps one day she will feel thankful that someone diagnosed her early and made it possible for her to begin treatment and remain healthy.  I don’t know. What I do know is that I cannot always give patients the laboratory results they desire. I’m stuck with the truth.

~o~

“But, doctor!” the 35 year old woman across from me shifts unhappily in her chair.

“I’m sorry, there isn’t a medication that will make your fibroids fall out,” I explain for the fourth time. Madam X refuses to believe me.

“So what do I do now?” She stares expectantly.

“You have to have an operation to remove the fibroids if they are bothering you,” I restate as plainly as possible.

“But doctor, I’m afraid of surgery. Which medicine can I drink?”

“There isn’t any medication that will magically make your fibroids disappear,” I repeat. “If anyone says there is, they’re lying. I’m telling you the truth. The only way to get rid of fibroids is with surgery.”

“So, I have to have an operation?” She crosses her arms and straightens up in her chair, clearly sceptical.

“Yes.” I nod.

“But I just want to drink medicine, doctor. Can’t you prescribe medicine for my fibroids now?”

“There isn’t any medicine, only surgery.”

“So I have to have surgery?” she gives a small gasp to emphasise her point that surgery is a very surprising and unwanted treatment option.

“If your fibroids are bothering you, then you have the operation,” I reiterate.

“There’s no medicine that I can take to make them fall out?”

“I would tell you if there was,” I try to assure her.

She sighs and looks again at my diagram of a uterus containing multiple muscular benign tumours. She frowns. “There’s no other way except by operation?”

“Only if they’re bothering you.”

“Ok, doctor,” she plunks her mobile phone away in her purse in preparation to leave.

I write my advice in her medical booklet and slide the book over to her. She glances down at my writing. “So, you’ve written the medication I need to buy?”

“Which medicine?”

“The medicine for my fibroids.”

Clearly she is not satisfied with my advice and treatment options.

~o~

“But, doctor, I want to go home. I can’t stay here tonight. I have small children at home. There isn’t anyone to help with the children. I can’t stay.” The breastfeeding mother with her severely anaemic and very ill baby pleads with me to let her go home.

Her baby is very ill. He needs intravenous medications and likely a blood transfusion. “I can’t stay. Just write the medications.” She begs. “I will buy the medications and give them at home.”

“It’s not safe,” I try to explain. “He’s too sick to go home. He needs to be in the hospital and take intravenous drips. He can’t take those medications at home. He’s too sick.”

“I can’t, doctor,” the mother continues.

“I’m sorry. I wouldn’t keep him unless it was necessary. This is the best treatment for him.” The mother doesn’t appear to hear me though. Her face is contorted into anxiety for her ill infant and concern for the rest of her responsibilities at home.

“But doctor…” her plea trails off.

“I’m sorry,” I say with genuine sympathy. “It’s the only way. Perhaps you can call someone to help? A relative or a neighbour?”

She finally nods wearily. She is not happy but she is resigned. The white doctor failed to cure her baby with fast-acting potions so she could go home today. No bananas for me today from this unhappy mom.

(Of note: After two days, the baby was well and mother was happy. All things sorted themselves in the end much to mother’s joy and doctor’s relief.)

~o~

“What have you found today?” I inquire cheerfully from our sonographer. The technician has just finished scanning one of our patients that I saw earlier in the day, a thirty-year-old woman who has been trying to conceive for over a year. Last month she took a home pregnancy test and it was positive much to her and her husband’s joy. Today she came into the hospital for consultation because she noticed some traces of blood on her panties this morning.

The sonographer stapled the photographs in the patient’s medical booklet with a frown. “There’s the embryo,” she pointed a finger at a whitish peanut-shaped blob on the echo picture.

“Oh, good, so she’s still pregnant. She hasn’t lost the pregnancy,” I begin.

“There’s no foetal heartbeat,” the sonographer cuts me off.

“Oh,” I am not quite so cheerful now.

“There are times I’m glad I’m just the technician taking the pictures,” she continues. “I just tell them that the doctor will explain everything.”

“Ah, yes, there are those advantages,” I agree with a sigh. My enthusiasm has evaporated.

Madam G bursts into tears when I break the news to her. “I’m sorry. There’s nothing you could have done to prevent this though.” I don’t know if my empathy is much of a comfort or not.

She cries for a little while and then asks, “Why?”

“I don’t have a reason,” I shrug hopelessly. “Most of the time we never know why.” My shoulders slump. I wish I had better news for her. I wish I had more answers for her. Eventually she leaves. She’s not very happy. She’ll keep asking why until someone gives her a suitable reason. A curse. An evil demon. A vindictive relative…anything to give her a reason and a means to ensure it never happens again.

~o~

“You’re back,” I see my handwriting in the Madam T’s book. She is an elderly lady with a long history of COPD (chronic lung disease).

Madam T stares at me for a few moments and nods. “Yes, doctor,” she agrees.

“What is your problem today?”

“Doctor,” she pauses and hacks a telltale asthmatic cough, “when I take the medications, the problem cools. Then it comes back when the medicine is finished. I need a medicine to make the problem go away completely. Can you prescribe a stronger treatment?”

I shake my head slowly. “Remember, you have a disease that is chronic. That means you manage your symptoms. There isn’t a medication to make your problems go away completely. You can manage your lung problem but you can’t get rid of it completely.”

She frowns and then launches into a long discourse on all her symptoms. Cough. Wheezing. Insomnia. More cough. Back pain. Etc. The symptoms are the same as the last visit. “Doctor, maybe it’s my blood pressure?”

“Your blood pressure is a little high,” I agree. “I don’t think that is what is giving you the cough though.”

“It’s my blood pressure that is disturbing me, doctor,” she assures me. “Write me blood pressure medicine.”

Eventually she exits with prescriptions rather familiar to ones from her last visit. She’ll come back to learn more about her chronic problems with our health educator but for now, she is not convinced that her problems cannot be solved permanently with a stronger medicine – if only I would prescribe her the right drug. I wish I could.

~o~

Madam K is 9 months pregnant. Her due date is in three days. Her pelvis aches and she has intermittent contractions. She doesn’t sleep well and she has a slight headache. “Doctor,” she places a hand on the small of her back, “can’t you give me forced labour? I’m tired.”

“I know you’re tired. I’m sorry.” I give her a sympathetic pat on the shoulder. “But your baby is doing just fine inside. He’s not quite ready. It’s not good to force labour just yet. Babies don’t always read their due dates. Sometimes they’re late.”

“But I’m tired, doctor,” she shuffles around clearly uncomfortable.

“Patience. Just a little longer. It’s safer for you and your baby if labour comes naturally.”

She turns her face away unconvinced. “I have exams on Thursday. I have to have the baby now, doctor.”  She’s not happy with my advice.

Some of our antenatal patients persevere and go on to have their babies naturally. A few have become too impatient and turn to other clinics with less stringent rules on labour induction. Some women believe me when I explain the dangers associated with early forced labour; others prefer to go elsewhere and find another medical personnel who is more in line with their desire for an expedited delivery. Ethically I have to stick to what I believe is best for my patients. They don’t always agree though.

~o~

“Doctor,” the labouring woman with severe contractions grimaces in pain. “Give me caesarean section, please!”

“Soon you’ll put to birth and your pain will be over,” I reassure Madam BC.

“I can’t, doctor. Deliver me now… Owww…!” she moans as another contractions grips her waist. “Doctor, please,” she breathes heavily and leans against the doorpost. “I can’t.”

“Yes, you can. Soon it will be over. Think about your baby.”

Madam BC is not happy right now. If every woman who requested a caesarean at this stage in their labour received one, we’d have rates up to 90%. I can’t always comply with my patient’s most fervent wishes. I know that in a few hours, they’ll be happy again though. With a new infant suckling at their breast and the pains of labour fading rapidly into post-partum amnesia, Madam BC will be smiling and content again. For now, I endure her frustration and frowns knowing that things will get better given a bit more time. Patient requests can’t always be granted immediately.

~o~

I rather feel sorry for God at these times. As a physician, a healer, someone who went into medicine because they wanted to help people, giving bad news – news that is unsatisfying to the patient – dealing with unanswerable questions and heartfelt pleas of patients in pain that I cannot immediately alleviate --  it’s not so easy. It can’t be easy for God either.

How is it that humans so quickly become disillusioned by a God that fails to meet their heartfelt, prayerful demands choked heavenward with the sincerest of tears? When the pathology report from the biopsy comes back positive for carcinoma does God get a zero on His customer satisfaction survey?

‘…On a scale of 1 to 5 with 1 representing ‘not at all satisfied’ and 5 being ‘exceeded expectations’... does God earn a one that necessitates remedial classes in consumer satisfaction?

Is the ‘customer always right’ as the slogan goes? Should God pay closer attention to his loyal fans? Should God ascribe to the revised slogan, ‘the Christian is always right’?

Several recent studies have been published and garnered some discussion among the medical community in the U.S. at least regarding patient satisfaction surveys. Their titles are telling.

Patient Satisfaction Is Overrated.

Patient satisfaction: Hospitals are not like car dealerships

Is Placating Patients Putting Medicine in Peril?

You Can’t Yelp Your Doctor

How might these headlines look if one were to insert God as the physician?

Christian Satisfaction is Overrated
Christian Satisfaction: God is not running a used car dealership
Is Placating Christians Putting their spirituality in peril?
You Can’t Yelp Your God

Most people would agree that bad things happen to good people and good things happen to bad people. Even the Bible states that God rains down blessings on both the good and the evil inhabitants of earth.  And this all makes sense until those ‘bad things’ happen personally, making a negative dent in our own happiness. Theory is fine until it becomes reality. When tragedy strikes at a personal level, life suddenly seems unfair – unjust – terrible. The neighbour’s garden next door can suffer drought and destruction but one’s own Amaryllis must bloom brilliantly on one’s windowsill. Jeremiah even goes so far as to bring a case against the Lord. In Jeremiah 12:1.

‘You are always righteous, Lord, when I bring a case before you.
Yet I would speak with you about your justice:
Why does the way of the wicked prosper?
Why do all the faithless live at ease?”

~o~


Perhaps physicians and God can take heart in Mark Twain’s words: "Always do what is right. It will gratify half of mankind and astound the other."