Your patient is a 50-year-old woman with a large abscess on her back. She has never had this before, and she looks quite well. She starts to panic, however, when you tell her that you need to incise and drain it. Luckily, she brought a friend for moral support.
You notice the friend is carrying a copy of the Bible and reading it while you're getting your supplies. You casually mention, “I see you're reading the Good Book,” and the friend asks you, “Oh, are you a Christian?”
You are not. You're — if anything — somewhere in the agnostic/atheistic spectrum. You grew up occasionally going to church, but don't consider yourself a Christian anymore.
You reply, “ I was raised Presbyterian.”
The friend says, “See, Tanya, you've got a doctor who believes in God! You're in good hands!” You don't correct her. You just smile and stay silent.
The patient breathes a sigh of relief, appears visibly calmer, less anxious, less tense, and more relaxed as you perform the procedure. You get a good 10 mL of pus out of her abscess, and send her home.
Ethical? Unethical? Vote online at http://bit.ly/INRIr4.
What about something even more directly misleading, the “under-promise, over-deliver” strategy. You know, the labs and CT will be done in 90 minutes, but you tell the patient they'll be back in two and a half hours. The patient will be happy that they're done “early,” but isn't trust the cornerstone of the physician-patient relationship?
These little vignettes remind me of a question that I always ponder. What's more important: the intent or the outcome? The internal or the external? Do behaviors have to be genuine to matter? If a tree falls in the woods, but no one is around to hear it, does it make a sound? If the patient undergoing propofol sedation grimaces in pain during the cardioversion but doesn't remember it, does it matter?
You walk into a coffee shop. The barista smiles, and asks how your day is going. It seems genuine. You smile back. You feel good. (Let's be honest, he probably doesn't really care how your day is going, but he seems to.) And it has a positive effect on you. Isn't that the point?
You pat the patient on the shoulder. “I know how hard it can be to be sick. It can be really frustrating to have a runny nose for two days.” The patient thinks, “Wow, this doctor is really caring and empathetic.” But you're mostly focused on the guy with the GI bleed two rooms over who still looks terrible despite two units of blood, and you're dreading telling the gentleman in room six his headache is because the cancer has now spread to his brain. You can't help comparing these emergencies with the URI patient in front of you who seems much more upset about her runny nose than either of the other two. But your body language, tone, and sentiment say otherwise.
Is it wrong to give patients what they want? Validation? Reassurance? Encouragement? Acknowledgement? Attention? (And I mean, behaviorally. Not 100 Percocet 10/325, three refills.)
I don't think it is at all in some cases. The worried parent of a kid who has been up all night vomiting will feel much better with a little acknowledgement that she is doing a great job trying to keep Johnny hydrated than all the unnecessary blood tests and IV fluids in the world. (Okay, Zofran will help, too.)
But it certainly is wrong to do this in other cases. There's always the patient downplaying his symptoms, usually dragged in by his wife: “I'm sorry for wasting your time. I don't think anything's wrong; it's just that I couldn't speak and my left arm went limp for a few hours. That's all.” Those people want reassurance that you can't — and obviously shouldn't — give them.
Sometimes this can backfire, as with the patient you read completely wrong and end up upsetting. There are also patients with dysfunctional, deleterious behaviors that you don't want to encourage, like those acting out for attention and behaving in manipulative or borderline ways, and I find these patients need very strict boundaries and expectations set out from the beginning, not more attention.
But even patients with negative behaviors or emotions can often benefit from this approach: You walk into the room, and could cut the tension with a dull knife. The patient and his partner have their arms crossed, each giving the other the cold shoulder (alternatively, they are shooting eye daggers at each other). Someone's tapping his foot. Or rolling his eyes. Or audibly sighing when the other is talking. One approach is to ignore this huge outpouring of massive, very-direct-but-nonverbal communication, take your history, do your exam, and hightail it out of that room.
Another way, however, is to acknowledge the tension (which both probably want you to do because neither is acknowledging it), and get it out in the open. And we all know that often half of the reason for the ED visit is this frustration. So give them what they want: “Wow, maybe I'm totally reading you guys wrong here, but you both seem really tense and upset. What the heck is going on between you two?” (Warning: be anchored down. The floodgates will immediately open, but you'll actually get the real answers you wanted after a minute or two, not the vague, nonspecific, beat-around-the-bush stuff with which people usually start.)
I'd love to hear from people who use similar techniques — and from people who don't. If you do, when do you use it? Have you been burned? If you don't, what other techniques do you use to communicate effectively with the anxious, the worried well, and those with a secondary agenda or concerns?
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Vote in the Ethics Poll
Was it ethical to let the patient at the top of the story assume her doctor was a Christian? Vote in our poll at http://bit.ly/INRIr4. Results will be reported here in a few months.
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