What Would You Do?

What Would You Do? 

Human Dignity 08: "I am a professional," and "I have seen everything before."

You are a resident at a internal medicine physician office. You are shadowing the physician who is a good doctor and has built rapport with his patients. He has given you much latitude and autonomy with his patients so that you will get use to dealing with people (notice I said people and NOT patients) and become a good doctor. 

It is the end of your first week with him. You are done early for the last day. There will be 2 hours for you to keep busy after this last patient. At this point you are (pretty much) conducting the histories and exams and he is (more) shadowing you. 

He has backed you with every decision you have made about tests, changes in treatment plan, education, everything that you recommended. Your next patient is a 48 year old white male. His chart shows that he had a "bad healthcare experience" in his 20's. He has not seen a doctor since. His wife convinced him seven years ago to begin getting annual physicals. 

For the first 2 years, she thought he was going. That was until the day he was suppose to go, his buddy called to cancel their fishing trip that day. He cam clean, he was afraid to go and it was easier to lie about it than to go. His first two visits, she accompanied him in the exam room. She was in the waiting room, she trusts that he will go, it is just to "calm his nerves."   

He had been seen here for the last five years. He is physically fit, 36" waist, labs good, in good health (better than most men his age) and no history or genetic risk factors. His blood pressure is higher than it should be, but the "Good Doctor" attributes that to "white coat syndrome." A typical visit checks HEENT, BP, lungs, bowel sounds, weight, history, previous labs reviewed, new labs ordered. 

The "Good Doctor" suspects a "specific phobia" to healthcare providers and some lingering PTSD symptoms from his bad experience over 20 years ago. Counseling was recommended, a trial of fluoxetine (Prozac) was offered. He refused. He has no problems taking his shirt off in front of you both to have his heart and lungs checked. Socially he is healthy too. He says that he "hates going to the doctor," but between his wife and fishing he can deal with it. "Besides, she goes away with me for the weekend following my annual, and following my blood draw."

The attending has given him the talk that "he wouldn't be doing his job" if he did not give him a complete physical exam." The patient's response was "I would just walk out." It took two years after the bad experience for the nightmares to go away. I will not go through that again, especially over a false positive. He is open, honest, and understands his feelings on the matter and the consequences.

You go over what he should be getting checked, he strongly agrees. You recommend a tetanus booster and influenza vaccine, his attending adds them to the lab orders. You say you want to check some of these things, he casually agrees to fast (you think), and seemingly to placate you. You explain that you need some additional history. He talks openly and honestly about personal matters. Sex life is good, no urinary issues...

You are too comfortable in your role, and this is where things begin to go wrong. You take a gown out of the drawer, place it on the table and say "I am going to step out for five minutes, I need you to undress completely and put this on."  He has the look of a deer in the headlights. You say "Did you understand the instructions?" He nods and says yes. You and the attending step out. 

You and the attending come back in. He is sitting in the same place, fully clothed. He even put his shirt back on. You ask if there is a problem. He angrily states, "I should say there is a problem, you don't tell me, you ask me; that's first." He alludes to the event 20 years ago, it is no secret, it should be in his records, then about being naked, people seeing his junk, his body, and nothing to see. You did not bother going back in his chart to see what the event was, you try to look for it as he is ranting.

It goes from bad to worse...

You are annoyed at this point. He just wasted 10 minutes of your time when he complied. Why not just tell you no. You remind him that the practice partners have a new patient consent form that he signed five years ago, in which he agrees to an initial and ongoing "complete physical exams." You go back and forth trying to show him how compassionate you are and this is to keep him healthy (as you were taught). He keeps going back to "his stuff handing out." You instinctively say without thinking those dreaded words;  "Don't worry, I am a professional, and I have seen all this before." Up to this point, you did not notice that he was a technical writer specializing in contracts. (He wrote contracts for lawyers.)

He very calmly sits down, calls you out on the biggest, most obvious (one of many) mistakes you just made. He lectures you, not angrily, but like a "Jewish Uncle." You want to apologize, but that was "beaten out of you." As a physician, you NEVER apologize. You say some PC BS you were taught like "I will try to be more aware of your feelings." You go over everything that you want to check, finishing with the DRE. You wait for the conflict to start back up, but nothing. 

He says he has never had his penis examined, especially his urethral meatus, what ever that is. As for plaque, he brushes regularly, so why do you have to touch his penis? He jokingly compares the DRE to the performer "Doctor Dre." He is calm, professional, frank in candor, asking intelligent questions, and even made a joke. Your professionalism saved the day. 

He is still not grasping the concept of what you want to do or the reasons why. He inquires if he can just get a CAT scan without all that poking and prodding. He has a basic concept of the organs in the body and every now and then drops a hint that he is holding back the amount of knowledge he really has.

He does let you know about his past history with healthcare, his feelings, and how the experiences affected his life. He tells you that it is all in his charts, and counseling and anti-anxiety medication was recommended for him, but there was no reason for that. Now you validate his feelings, assure him that it is normal to feel that way, and you had fears and apprehensions when you first started dealing with the human body. You were able to overcome your apprehensions, he could too, you would walk him through it.

Again he apologizes for not comprehending. You can't understand how someone so intelligent can't grasp a simple concept like anatomy. You attribute that to your superior training as a physician. You explain the virtues of your profession of keeping people healthy, treating the sick, and educating the patient. You assure him that you are not like the provider that betray his trust, that was just "one bad apple" and most physicians are really good. You remember one of your professors holding a session about things that "you will never find in a book:" 

"If you have a noncompliant patient and he is debating your decision in a matter, pick an issue that the patient is blatantly at fault for, calmly and professionally switch to that subject. Once the patient has apologized for his transgression, reiterate it so he apologizes again. Then explain to him that this is never to happen again as you would to an adult child. Once the patient acknowledges this, the patient will be compliant. This will set the tone for the rest of the encounter. If the patient is not in a gown, have the patient don a gown even if it is not necessary. This will make the patient further submissive and easier to manage." 

He has continually apologized for not taking better care of himself, not learning about his body, or understanding your explanation. You have been using a picture on the wall, and usually you have a model of the male anatomy to educate the patient on where everything is, what, and how you check.  

Then he drops a bomb... In the interest of patient education, you can be the subject, "The Good Doctor" will demonstrate on you what will happen to him. He would feel very comfortable submitting to a full exam after seeing one done. It would also validate everything that you said about the GU part and that you were not hiding anything. 

You go into the mantra that this is not professional, blah... blah... blah... blah... blah... blah... blah... blah... blah...  He sits there silently listening. Then you say "We will just forego the complete exam." The whole time you have been waiting for "The Good Doctor" to jump in and undo this mess. He knows his patients better than you expected. He knew where this was going, and he let you "dig your own hole." The patient rebuts: 

"We are not finished here, you need to listen to me now... You never introduced yourself to me when you first came in here. I had to figure out who you were. You have all my information in the notes. I am open and honest how that experience has affected my life. I finally found a physician that I can trust. We work together. If you did not understand how this affected me you should have asked. You discounted my mental and emotional health and the consequences of you actions without explanation or maybe because you just don't care?" 

You want to jump in and say that is insulting, you do care, but after what just happened you listen. 

"I believe that you do care, or you wouldn't be doing this. You proceeded to disregard my feelings and made my mental anguish about you. If you want trust and respect, you need to give it. Then you order me to undress, not ask me. You did it as if you had a right to unfettered access to my body and person and I had no choice in the matter."  

"I have given you latitude ONLY because The Good Doctor" has allowed you to be here. Now you are tarnishing HIS reputation. Do you think that I do not know that I should be having complete physicals? I would like to, but it is not worth the worry, fear, and nightmares that it will bring."

"I know that it sounds silly to most people for a grown man to be afraid of the doctor,  more so to a physician, and it is easy to see why one may easily dismiss or question the validity of my feelings." 

"I can assure you that my feelings are very real. The physical feelings that follow are very real too; the sleeplessness, the fatigue, the chills from the worry. What compounds the problem is that your profession caused the problem and now refused to acknowledge it. I was ready to take a leap of faith, my trust was being restored and I wanted to see if you were willing to earn my trust back."  

"More than anybody I know how frightening and embarrassing it can be.  You extolled the virtues of your profession and preventative care, and I wanted to see if you believe what you say. Hence, I made that modest proposal. This will be a lesson that you never forget and make you a better physician. What this world needs is more good physicians, then you will have less people like me." 

"By refusing, you have told me that you you do not want to walk this path with me, you only want to tell me where to go. You give me the it's unprofessional excuse and blah... blah... blah... I know that. I don't want to see your ass anymore than you want to see mine. I would respect you more if you told me your real feeling on the matter. I know what they are because that is how I feel about it." 

"Finally, I feel lied to. You tell me it is not that bad, I will survive it, blah.. blah... blah..., then you avoid it like the plague. What are you not telling me, it is worse than you said, you are withholding information."   

"I can see your reasons are disingenuous. I know that "not professional" is valid reason, but it does not acknowledge my feelings again. Tell me you fear it as much as me, it is embarrassing, and you can hide behind "not professional. It is that attitude that made me the patient today. It is not just one pad physician, it is the whole system, and you are only proving that." 

What Would You Do?

You may think this absurd. I know that everybody will say no. But ask yourself HONESTLY, why you would say no. I'm sure that the real reason is that you have the same feelings as the patient. So if you expect the patient to "get over" their anxiety, why can't you?

You cannot use the excuse "how this affects the doctor-patient relationship." This is your patient right now YES, but the issues you point to are for long term doctor-patient relationships.

You may not believe it, but there are patients who will say this. There are two main reasons that they say this; first they want you to empathize with them. For some reason, you are not convincingly relaying your empathy (whether your empathy is real or fake). Second, there is research that shows people are more comfortable being exposed (naked) when there are other people exposed with them.