My patient seemed to be reconciled with her illness, even with the fact she might not go home. What she couldn’t get over was being thought of as ‘dumb’ ‘I yearned to argue then that her assessment was wrong, every single bit of it. That doctors existed to help patients, that no doctor actually thought a patient “dumb”.’ “Just because I have cancer they think I am dumb.” These were the last words a patient said to me and her lament has stayed with me ever since. Our conversation that morning had started ordinarily enough. She was in hospital with an infection that was proving more resolute than I’d thought. Every day I made a show of applying my stethoscope to her chest but I knew that she was slipping away. Her numbers looked worse and the once intermittently-used oxygen now stayed permanently by her side, the tubing plastered to her sweaty forehead. That day, I couldn’t bear to have the exchange that typically went, “What do you think, doctor?” “I’m afraid the infection is taking its time.” “I’d love to be home.” “I’d love to get you home.” “But I’m just too breathless to consider it.” “I know.” So that morning I said, “Tell me a little about yourself.” “You mean my cancer?” I cringed at the implication. “No, about the rest of you.” She smiled. She was the mother of five grown children and her husband’s successful business partner. She dabbled in art but her true love was cooking elaborate meals from which she would always save a little for the elderly neighbour who was doing it tough. Seeing him happy gave her a lift, she said. “It’s amazing, what you have accomplished,” I said, struck by how hard she had worked through many years of being unwell. Her reaction was even more striking. Tears streamed down her face, catching momentarily on the oxygen tubing. “You really mean that? Thank you.” Who thinks you are dumb? Why do they think that? How dare they? Maybe her children or husband were insensitive. Or maybe a friend or relative couldn’t be bothered anymore. Those who are viewed through the prism of their illness commonly encounter upsetting behaviour. These thoughts sped through my mind as I stood frozen at the very sight of her distress. Beside me, my resident shifted uncomfortably. I stared mutely at my patient. Any number of things could cause her anguish: the fact that she was gravely ill, that getting home was a dimming prospect, that the children would be motherless or the business might fall flat. But no, she seemed reconciled with all that. What she couldn’t get over was being thought of as dumb. The silence wasn’t long but the embarrassment threatened to swallow us. Taking our continued presence for interest, she wiped her tears, apologised and continued, “It’s the little things. They ask me questions but don’t wait for an answer. They think that when I speak slowly they can talk for me and over me. It’s like I am invisible. My brain is slower but I am not dumb.” No words were adequate. No apology, no explanation, certainly no disavowal. Up to then, I was hoping the culprit was a lone, outside offender but I should have known better. In the long history of her illness she had spent a lot of time in a lot of hospitals until, we, her doctors and nurses had become the insiders and those who loved her the outsiders. Her plain observations were an indictment of us, not them. I yearned to argue then that her assessment was wrong, every single bit of it. That doctors existed to help patients, that no doctor actually thought a patient “dumb”. And what an anachronistic, offensive term that was anyway. But all I could honestly say is that no doctor or nurse had ever said the word within my earshot. I couldn’t truthfully assert that the ruthless emphasis on absurd metrics hadn’t just about overtaken notions of genuine and meaningful care. A 2013 American College of Physician Executives study of 840 doctors found that two out of three doctors had witnessed doctors behaving badly towards patients or colleagues. Discrimination, inappropriate jokes and profanity all found a mention. A 2012 study published in the Journal of the American Medical Association stated that most US medical licensing authorities reported incidents of online professional violations by physicians, many of which resulted in serious disciplinary actions. With the rise of social media, doctors are facing constant reminders to not post disparaging remarks about patients online. The whole issue was catapulted into ignominy when the Annals of Internal Medicine last year published two accounts of specialists making lewd remarks about patients who were under anaesthetic. As a doctor, I am surely guilty of my fair share of rolled eyes, exasperated glances and impatient sighs. Just recently, my ire spilled over when an anaemic patient insisted that the story began 50 years ago when her obstetrician ignored her post-partum bleeding. “I never made that blood back, it’s all his fault.” “Your anaemia isn’t related to that,” I cut her off. “But I am still upset.” I should have understood that the real story wasn’t about the loss of blood but lack of validation. I should have listened a little more patiently. If I have doled out poor behaviour I have also received it. After surgery, my mother kept reporting more pain that her nurses deemed appropriate. A senior nurse announced that her basic problem was laziness: “She needs to help herself instead of depending on us all the time.” I was astounded by her ignorant conclusion that had filtered down to the other staff. Their attitude sapped my mother’s confidence and biased the doctors until an infection emerged as the cause of her pain. Had I not witnessed the exchange myself I would have found it hard to believe. In spite of the finest medical care, my patient died thinking the worst of herself. We couldn’t save her from her fate but we could certainly have combated the sense of shame and disempowerment illness engendered. We could have eased her suffering – if we had known what was causing it. My patient taught me that we don’t have to actually insult our patients by calling them dumb or lazy to make them feel bad. Where a power differential already exists, there are a hundred silent gestures, unintended slights and erroneous assumptions that can do the job and in this, each one of us is complicit. Good medicine means understanding the power of not just what we say to our patients but how we behave towards them. Ralph Waldo Emerson once said that life is short but there is always time for courtesy. It’s a message that may well have been scripted for the modern healthcare professional. Source
