After graduating from college, I worked at an outpatient oncology facility. I was an administrative assistant, manning the phones, sorting the mail, hounding the doctors to sign insurance forms and complete refill requests—basic, unspectacular stuff. I inhabited the bottom of the workplace hierarchy, beneath the nurses and nursing aids, below the receptionists and medical assistants.
They say nurses and nursing assistants are a patient’s first point of contact; in reality, a patient’s first exchange with a health care facility is with the lowly serf who answers the phone. And this interaction is vastly definitive, for both the patient and the facility.
For a patient, this is a reflection of how she can expect to be received and catered to. For the facility, the patient’s behavior towards the person answering the phone is usually representative of the patient on her worst day, the day when her husband did not take out the trash, when her insurance company lost her claim form, or when the MetroAccess driver arrived three hours late and made her miss her appointment.
And then, she called to reschedule her chemotherapy appointment and the administrative assistant said there were no openings until April. And so, well past her breaking point, the patient let the assistant know that she was incompetent, illiterate and probably too dull-witted to hold a better job.
While physicians often complain about “difficult patients,” the ones who are noncompliant, those who miss follow-up appointments, or repeatedly engage in risky behavior, the truth is that patients are on their best behavior behind the closed doors of sterile clinics.
Perched on the exam table, they are amiable and appreciative, apologetic and unwavering in their commitment to positive change. It is only after they are emancipated from the exam room do they unveil their demands—for more medication, for a letter requesting their puppy be allowed on the aircraft, for a memo excusing them from jury duty.
Those riding the low-hanging rungs of the clinic often get the honor of refusing these requests, and receiving the patient’s revulsion: “Dr. Siegel would never say no to me!”
He just did.
Such moments expose the hypocrisy of clinical care: a patient-physician waltz, the duplicity of which approaches middle school proportions. In this case, the physician was right to make his patient feel that he was accessible to her and that she could approach him when she needed him. That, being said, he should have clarified how far he was willing to go for her, instead of pawning off the dirty work to his inferiors.
As physicians-in-training we are encouraged to be sympathetic, empathetic, compassionate, enthusiastic, accommodating, flexible and so on. What we are not taught is to be candid, frank and transparent.
I am not implying that honesty is not encouraged in medical school. It most definitely is, but the inherent message is, “Be honest, but more importantly, be gentle. When tenderness clashes with directness, choose to be tender.”
Therein lies the betrayal. We mislead patients into thinking that as physicians we are their champions, in and out of the clinic. No matter what the prognosis of the disease, we will ultimately save them from it. And while we are at it, we will also shield them from the evil airline personnel who deny dogs their rightful place on the airplane, from dreaded jury time, and most importantly, from the vile, inept idiots who staff the clinic’s phones.