James Channing Shaw, MD
Cell 2 Soul. 2007 Summer; 3(2):a15
(Presented at Dermanities Day, February 1, 2007, Washington, D.C.)
Much of medical practice, indeed much of living, has considerable predictability. We take for granted the predictability of most life events, and we are lucky to be able to do so. In medicine, we are trained to handle most situations we encounter. We become expert in communication skills that afford us success in these interactions, whether with patients or colleagues. If we so choose, we learn how to approach specialized situations: the angry patient, or how to deliver bad news in a compassionate way.
Despite this predictability, unexpected situations occasionally happen. When the outcome is positive, it's no problem, but sometimes doing what we think is the right thing leads to a bad outcome. I used to think that bad outcomes could (and must) be rectified. I now accept that one must sometimes live with the discomfiture of an unresolved conflict; a misinterpretation; a false assumption. These are life's ironies; life's double negatives. That they threaten and besmirch our reputation, our integrity, is why they can be powerful.
Case 1: MALCOLM
Malcolm was 18 years old. He came to me for inflammatory facial acne. He had taken some of his older brother's minocycline with some success, but reported having had several absent spells during which he became unaware of his surroundings for several seconds. The problem had ceased when he stopped the minocycline, and had not recurred.
I started topical therapy and planned to add oral erythromycin cautiously if needed. Over the next 6 months I did prescribe erythromycin and Malcolm was doing well.
Conversation was not easy for Malcolm, but over time I learned more about his life and ambitions. He told me with pride that his older brother was a fighter pilot in the Air Force. Malcolm himself was in the preliminary stages of joining the Air Force, and hoped to become a pilot like his brother. Well into his treatment, Malcolm reported two more episodes of relative loss of consciousness. He thought that the episodes had occurred only after being fatigued, but admitted to having three minor automobile accidents in the last year. "I'm concerned about the cause of these spells," I said, "and I think you need to see a neurologist as soon as possible." I arranged for and immediate consultation.
The neurologist ordered an EEG that showed a seizure focus in the right hemisphere. He recommended an MRI to confirm the findings. Malcolm never had the MRI.
I saw Malcolm the following week and discussed the neurologist's findings and my concern about his plans to join the Air Force. At this point, however, his demeanor changed, and he was resistant to my recommendations to follow up with the neurologist and have further testing. He said that he had seen another neurologist who thought there was no problem. At the end of his visit, Malcolm told me that I was not authorized to contact the Air Force about him.
Within a week, Malcolm's mother called. She was furious. She screamed over the phone how I had destroyed her son's career (Malcolm had apparently withdrawn his Air Force application), that our diagnosis was wrong, that there was another neurologist involved, etc. No amount of reflection and legitimation of her sentiments could calm her. The next day, Malcolm hand-delivered a letter to the office. "Dear Doctor Shaw; You are not to release my medical records, repeat any conversations we have had or discuss with any other physician and/or persons any thing(sic) connected with me."
That was the last I heard of Malcolm. The Department of Motor Vehicles was contacted, but I don't know what became of him medically or aeronautically.
This incident may seem trivial for physicians who have been sued by their patients, but it illustrates one version of an 'unexpected outcome' that, for me, carried strong emotional impact for years.
Case 2: KEVIN
This case is about a patient who filed a formal complaint to the regulatory body under which I practice medicine. While a malpractice suit was ultimately averted, the story depicts the type of unexpected outcome that embroils physician with patient.
I brought Kevin to Wednesday patient rounds because he had an atypical scalp problem and was quite anxious about the condition. Kevin, age 40, had consulted me for burning frontal scalp and forehead, with some recent hair loss. I was the fourth dermatologist. The working differential diagnosis included a rosacea-like dermatosis, contact dermatitis from hair dye, cutaneous lupus, and androgenetic alopecia. Because of some scalp erythema, I did a biopsy which showed some interface change suggestive of possible early connective tissue disease. Like many dermatologists, I have found it helpful to bring anxious patients to 'rounds' for the positive effect that collaborative thinking seems to have on them. Kevin was willing to attend, and the group agreed with the diagnosis of probable rosacea and agreed with oral antibiotics which were started the following day, with follow up in one month.
Four months later, I received a long letter from Kevin. He had been stewing over what he thought was an unsatisfactory interaction during rounds, and probable esophagitis from the antibiotics. He complained about not being allowed to tell his full story during rounds, that body language of the doctors in the room suggested doubts about my treatment, and more. He requested to meet with me to discuss his concerns. The SARS epidemic in Toronto was at its height at the time, and our clinics were all closed, but I made arrangements for a special meeting. We met for a full hour of respectful discussion during which his controlled demeanor suggested to me that maybe the problem had blown over.
Five months after our meeting, I received the dreaded letter, the formal complaint, from the College of Physicians and Surgeons. He had viewed me as "arrogant, defensive, and evasive" in our meeting, and he was requesting formal review of the whole case, with possible sanctions against me. The mission of the College of Physicians and Surgeons is to protect the public, not doctors, and all complaints are investigated fully. I spent the next two months preparing documents for review and consulting malpractice advisors. Kevin met with my department head and human resource people from the hospital, to complain. Numerous reports were filed. Ultimately, after a year, the case closed in my favor.
While not exactly a nail-biting narrative, this story illustrates how intentions can backfire. We are taught that interactions with difficult patients should not be taken personally. Nevertheless, I carried some resentment about the process. The patient blames me. In return, I suppose I could blame one DSM IV designation or another. Either way, it remains unrectified, with bad feelings on both sides. More importantly, since that time, I have become reluctant to bring patients with challenging personalities to rounds. In my experience, considerable effort is required to 'get over it' and move on after an interaction like this one with Kevin.
Case 3: HOWARD
By now, you might be thinking that I attract bad outcomes. Quite to the contrary, it is because they happen so rarely that they have an impact. However, ironies can be positive, as the final case will illustrate. The outcome of this case brought me unexpected pleasure and satisfaction. The patient was Howard Backlund, whose real name I am proud to divulge. Mr. Backlund was an impeccably dressed man in his early 80s. I first met him at the end of a typically busy afternoon. He was somewhat stiff and slow in his interactions, and had a high-pitched whining voice. He was seeing me because of a tiny lesion near his nose and some spots on his forehead. I biopsied his nose and treated some very early actinic keratoses because he was worried about them. He asked to return in one or two months, and with some reservation, I agreed to see him at intervals that suited him, thereby adding another high-maintenance patient to my practice.
Two months later, the patient returned, was happy with the treatment and had new imperceptible lesions on his face. His plaintive tone had distanced me somewhat in our relationship, and we had not yet discussed his personal life. I explored more.
"What kind of work have you done during your life?" I asked.
Mr. Backlund responded excitedly. "Ohhh! I was an organist and a pianist! I still play the organ at my church! Yes!" Every one of his statements ended with an exclamation point.
"Very nice," I said. I decided to self-disclose that I, too, played the piano, jazz mostly. Self-disclosure with patients, like humor, must be used cautiously, since what pleases one patient may insult another. Fortunately, this time, it worked.
We had a wonderful discussion about the classical pianists in our city, who had a good touch, who didn't. Mr. Backlund had spent an entire year at the University working only on his touch, the control and force of his fingers on the piano keys. He was so thrilled with the life-long benefit of that specialized training, that he said to me, "You must be exposed to the method! It is something you can learn! It could benefit your playing tremendously!" He offered to teach me, at my home, on my piano, since he no longer owned one.
At that point in our visit I thought, who is this old guy? Do I want to get more involved with this quirky man? More importantly, is this crossing professional boundaries? What if it were a young woman who wanted to give me lessons on touch, in my own home? How would the Medical Board view that? How would my wife feel about it? Nevertheless, I finally decided to take him up on his offer, and before long, there he was, in my living room, assessing my touch on the keyboard and teaching his method of touch control. Suffice it to say that what he taught me was the most important piano lesson I ever had. What he did that day had a lasting effect and I have been grateful to him ever since. Our professional relationship was not harmed. By the simple act of exploring a patient's personal life for a moment, I had the good fortune of turning a somewhat strained professional interaction into a rich and rewarding one.
This case was different because it involved intentional interviewing techniques in an attempt to improve the relationship between patient and doctor. It also required some risk-taking on my part, namely self-disclosure, plus the interaction outside of the examination room. While thinking about Mr. Backlund for this presentation, I received an email from my former nurse, informing me of his death, and a eulogy to him in the local newspaper.