0895-4356/90$3.00+ 0.00 Copyright 0 1990Pergamon Press plc
J Clin EpidemiolVol. 43, No. 8, pp. 845-847, 1990
Printed in Great Britain. All rights reserved
Second Thoughts THE TRAGEDY
OF MRS T.
JOSEPH HERMAN* Department of Family Medicine, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
(Received for publication 1 January 1990)
When a patient is angry with his doctor, it is fairly safe to assume that there has been a failing of tact on the latter’s part. Mrs T. has been under my care for 3 years and, recently, for a brief period, she nursed a grudge against me. Like most good grudges, it stemmed from several possible sources and an examination of them may elucidate aspects of the patient/ physician relationship that are not often discussed. Mrs T. was referred to hospital a few weeks ago for an episode of post-menopausal bleeding. Diagnostic curettage revealed cells that appeared malignant and a chest X-ray, later confirmed by computed tomogram, showed two small lesions suggestive of lung metastases. The oncologist thought that removal of the uterus was called for despite these findings and a total abdominal hysterectomy with salpingooophorectomy was duly performed. The operation was uneventful and produced no local evidence of spread beyond the uterine wall. The tissue diagnosis was sarcoma. The day before surgery I was unable to get free for a visit to the ward and asked my resident to drop by, find out how Mrs T. was feeling and how much of the bad news she knew. He reported back that she had been told everything, even about the suspicious lung spots, and was very angry with me for a seemingly unconnected reason that had to do with her last visit to the *All correspondence should be addressed to: Joseph Herman M.D., 42 Harav Uzziel Street, Bayit V’gan 96424, Jerusalem, Israel.
office. She had come in with her husband, a diabetic, for whom the appointment was made. After I had seen to his complaints, she requested that I examine her too. I replied, in what I thought was a polite tone, that if she would wait outside for a few minutes I was sure that it would be possible to fit her in between two scheduled patients. She sat down in the waiting area and, when the resident was free, went in to see him, giving no indication that she had been offended until he visited her a few weeks later in hospital. It is more than likely that my suggestion was made with barely concealed impatience and the background to our relationship must now be filled in. Both Mrs T. and her husband were of an inordinately pessimistic cast of mind. He took his diabetes, which was easily controlled and without evident complications, very hard while she always had difficulty recovering from minor inconveniences and disabilities, often asking to be excused from work when there seemed no further call for rest. Mrs T. was a saleslady and, a year before her present illness, had fallen on the job, twisting her knee. Emergency room X-rays and an orthopedic examination revealed nothing untoward beyond a swollen calf. She was unable to return to work for a prolonged period and I had the distinct impression that she was trying to parlay something that verged on being a non-event into a reason for seeking compensation. This was an unkind “diagnosis,” indicating that barriers of resentment were going up on both sides. I can only regret that it took the new and tragic circumstances under
845
846
Second Thoughts
which our relationship was proceeding to cause me to reflect on what was taking place between us. The factors predisposing to Mrs T.‘s grudge have now been presented. As is often the case, most of them’ can be attributed to her doctor’s obtuseness although there are some that require further examination. First, and most obvious, she may have believed herself to be the victim of a diagnostic delay. She was not at all an outsider regarding the health care system and had been seen both by her family doctor and a gynecologist on several occasions during the year preceding her illness. Neither had suggested the possibility of a uterine malignancy; the latter had diagnosed fibroids and the former had gone so far as to put off seeing her when she had wished to complain of a sense of fulness in the lower abdomen on the above-mentioned day. Thus, she could have interpreted this apparent procrastination as being responsible for her metastases. We go on a great deal about the curability of cancer at an “early” stage, disregarding the evidence that the disease may well be multi-focal at the outset and that cure may be more a matter of a felicitous “fit” between the patient’s surveillance system and the virulence of the process [l]. The public, then, is rightfully upset when we don’t “get there” in time, since we have aroused certain expectations in them. Furthermore, many people, given the prevailing atmosphere, are angry with themselves for being late, something that adds to their suffering afterwards. Second, in the general mind, not only those who toil in the towers of academe and are responsible for the truly sensational progress medicine makes now and then represent the profession. Primary care has been poetically called “the land outside the tower” [2] and those who work that land must share the blame for the fact that most cancers and collagen disorders are ultimately incurable. They must also accept responsibility for the 30% death rate still obtaining for bacterial meningitis [3] despite the gigantic armamentarium of antibiotics in their possession. I can see no reason why a woman with a uterine sarcoma and lung metastases should not be angry when, had she only been “fortuante” enough to be afflicted by chorioepithelioma involving the very same organs, she might have been cured. The exasperating selectivity of our skills can provide food for thought.
Third, just as there is an “innocent bystander” theory of hemolytic anemia [4], with the erythrocyte a victim of mistaken immunological identity, so my misdemeanor may have simply happened by. Mrs T. had heard two pieces of devastatingly bad news within the space of a day and had not been given time either to deny or to bargain [5]. Perhaps her “Why me?’ sense of outrage, rather than become an existential question, attached itself to a literal object. Certainly she was now aware that, on the day I asked her to wait outside, she already had cancer, and the enormity of the diagnosis must have contrasted overwhelmingly with the pettiness of my request. Fourth, Mrs T. may really have accepted my explanation of the workings of the appointment system and waited her turn without rancor (perhaps I was polite?), retroactively “using” the incident as a symbol for the real hurts she could not express, such as my self-righteous attitude towards her illness behavior on previous occasions and my failing to find out what lay behind it. Over the course of several visits to her bedside in hospital and two house calls paid after she was discharged, Mrs T.‘s attitude towards me grew unexpectedly conciliatory. Perhaps it represented the bargaining stage of her coming to terms with her disease, or was a concession to my persistent attempts to set matters right. Her own version of what caused her anger ran something as follows. She, her husband, their son, his wife and two children and the wife’s parents immigrated to Israel from Romania 64 years ago. She was then 53 and found adjusting to a new country with its strange climate, language and ways, very difficult. Whereas for nearly 30 years she had done secretarial work, a position to which she attached some status, in Israel her straitened economic circumstances had forced her to accept menial jobs that involved physical effort. She could not grasp the intricacies of the local bureaucracy and spoke with particular nostalgia of the health care system in Eastern Europe which she described as being very short on pharmaceuticals and equipment but long on respect for the patient. She felt that it had been a mistake to emigrate before being pensioned. Further in the background was her experience of the Holocaust when, at the age of 11, she was deported to a forced labor camp with her parents and three sisters. Hunger and disease were rife there and a sister succumbed to typhoid.
841
Second Thoughts
As she was seeing me out she burst into tears and begged me not to take her anger personally. I merely represented a mentality and a way of doing things she would never understand. A recent paper from Hungary speaks of macrosocial conflicts as being germane to family therapy [6]. Certainly the difficulties Mrs T. experienced in adjusting to life in Israel had as much to do with the differences in the political and social systems obtaining between her countries of origin and adoption as it did with the aforementioned problems of language, climate and livelihood. The macrosocial variability between nations rather than ethnic groups is too infrequently taken into account [6]. In the nature of things, and given the longitudinal dimension of primary care, there are two most likely scenarios for the termination of our relationship with patients of our own age: either they will take leave of us, with a regretful handshake on retirement or a tear at the graveside, or we will tend them in their last illnesses. The latter possibility should motivate us to curtail our impulses on busy days. Illness behavior, as perceived by us, is but one aspect of personality and often the least attractive. As such it cannot be equated with the whole patient but only with the way in which, flustered and frightened by how we come on, he presents himself. We are thus bound by Joshua ben Perahyah’s 2100-year-old injunction to “. . . judge all men favorably” [7]. It has been pointed out that certain difficulties in the patient/doctor relationship, usually surfacing when there seems to be no anatomic basis for the chief complaint, may reflect profoundly reductionistic health care delivery [8]. Although we tend, for our own convenience, to “nosologize” and attribute them to individual characteristics or behaviour learned in the family
of origin, they may better be thought of as patterned deportment at the interface of the patient and the health care system [8]. It is our duty to protect our patients even from themselves and the impression some of their traits make on us. If we are remiss, it is not difficult to imagine important consequences, not only for the sense of well-being but, possibly, also for health. At times, the patient feels constrained to make his physician the butt of anger. Under such circumstances the latter has an opportunity to use skilled and selective one-downmanship, allowing the former to vent a sense of outrage that may really represent a settling of old scores or a kind of Weltschmerz [9]. Since our practice is largely palliative and only peripherally related to the patient’s improvement in most instances [lo], we cannot afford to overlook even so humble a therapeutic option.
REFERENCES 1.
2. 3. 4. 5. 6.
I. 8. 9. 10.
Redding WH, Monaghan P, Imrie SF. Detection of micrometastases in patients with primary breast _ cancer. Lancet 1983; 2: -1271-1274. _ Gehlbach SH. Selection bias in clinical research: the land outside the tower. J Fam Pratt 1985; 20: 433-434. Tuomanen E. Partner drugs: a new outlook for bacterial meningitis. Ann Intern Med 1988; 109: 690-692. Miale JB. Laboratory Medicine: Hematology. St Louis: C.V. Mosby; 1972: 764. Kubler-Ross E. On Death and Dying. New York: MacMillan; 1970: 38. Furedi J, Kapusi G, Novak J. Macrosocial conflicts and the family: a Hungarian case study. Fam System Med 1989; 7: 30-41. Ethics of the Fathers. New York: Hebrew Publishing Company; 1962: 8. Bloch DA. Dr Biomedicine and Dr Psychosocial: the dual optic. Fam System Med 1988; 6: 131. Harkaway JE, Madsen WC. The case of chronic obesity. Fam System Med 1989; 7: 42-65. Gabbard GO. The role of compulsiveness in the normal physician. JAMA 1985; 254: 2926-2929.
J Clin EpidemiolVol. 43, No. 8, pp. 845-847, 1990
Printed in Great Britain. All rights reserved
Second Thoughts THE TRAGEDY
OF MRS T.
JOSEPH HERMAN* Department of Family Medicine, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
(Received for publication 1 January 1990)
When a patient is angry with his doctor, it is fairly safe to assume that there has been a failing of tact on the latter’s part. Mrs T. has been under my care for 3 years and, recently, for a brief period, she nursed a grudge against me. Like most good grudges, it stemmed from several possible sources and an examination of them may elucidate aspects of the patient/ physician relationship that are not often discussed. Mrs T. was referred to hospital a few weeks ago for an episode of post-menopausal bleeding. Diagnostic curettage revealed cells that appeared malignant and a chest X-ray, later confirmed by computed tomogram, showed two small lesions suggestive of lung metastases. The oncologist thought that removal of the uterus was called for despite these findings and a total abdominal hysterectomy with salpingooophorectomy was duly performed. The operation was uneventful and produced no local evidence of spread beyond the uterine wall. The tissue diagnosis was sarcoma. The day before surgery I was unable to get free for a visit to the ward and asked my resident to drop by, find out how Mrs T. was feeling and how much of the bad news she knew. He reported back that she had been told everything, even about the suspicious lung spots, and was very angry with me for a seemingly unconnected reason that had to do with her last visit to the *All correspondence should be addressed to: Joseph Herman M.D., 42 Harav Uzziel Street, Bayit V’gan 96424, Jerusalem, Israel.
office. She had come in with her husband, a diabetic, for whom the appointment was made. After I had seen to his complaints, she requested that I examine her too. I replied, in what I thought was a polite tone, that if she would wait outside for a few minutes I was sure that it would be possible to fit her in between two scheduled patients. She sat down in the waiting area and, when the resident was free, went in to see him, giving no indication that she had been offended until he visited her a few weeks later in hospital. It is more than likely that my suggestion was made with barely concealed impatience and the background to our relationship must now be filled in. Both Mrs T. and her husband were of an inordinately pessimistic cast of mind. He took his diabetes, which was easily controlled and without evident complications, very hard while she always had difficulty recovering from minor inconveniences and disabilities, often asking to be excused from work when there seemed no further call for rest. Mrs T. was a saleslady and, a year before her present illness, had fallen on the job, twisting her knee. Emergency room X-rays and an orthopedic examination revealed nothing untoward beyond a swollen calf. She was unable to return to work for a prolonged period and I had the distinct impression that she was trying to parlay something that verged on being a non-event into a reason for seeking compensation. This was an unkind “diagnosis,” indicating that barriers of resentment were going up on both sides. I can only regret that it took the new and tragic circumstances under
845
846
Second Thoughts
which our relationship was proceeding to cause me to reflect on what was taking place between us. The factors predisposing to Mrs T.‘s grudge have now been presented. As is often the case, most of them’ can be attributed to her doctor’s obtuseness although there are some that require further examination. First, and most obvious, she may have believed herself to be the victim of a diagnostic delay. She was not at all an outsider regarding the health care system and had been seen both by her family doctor and a gynecologist on several occasions during the year preceding her illness. Neither had suggested the possibility of a uterine malignancy; the latter had diagnosed fibroids and the former had gone so far as to put off seeing her when she had wished to complain of a sense of fulness in the lower abdomen on the above-mentioned day. Thus, she could have interpreted this apparent procrastination as being responsible for her metastases. We go on a great deal about the curability of cancer at an “early” stage, disregarding the evidence that the disease may well be multi-focal at the outset and that cure may be more a matter of a felicitous “fit” between the patient’s surveillance system and the virulence of the process [l]. The public, then, is rightfully upset when we don’t “get there” in time, since we have aroused certain expectations in them. Furthermore, many people, given the prevailing atmosphere, are angry with themselves for being late, something that adds to their suffering afterwards. Second, in the general mind, not only those who toil in the towers of academe and are responsible for the truly sensational progress medicine makes now and then represent the profession. Primary care has been poetically called “the land outside the tower” [2] and those who work that land must share the blame for the fact that most cancers and collagen disorders are ultimately incurable. They must also accept responsibility for the 30% death rate still obtaining for bacterial meningitis [3] despite the gigantic armamentarium of antibiotics in their possession. I can see no reason why a woman with a uterine sarcoma and lung metastases should not be angry when, had she only been “fortuante” enough to be afflicted by chorioepithelioma involving the very same organs, she might have been cured. The exasperating selectivity of our skills can provide food for thought.
Third, just as there is an “innocent bystander” theory of hemolytic anemia [4], with the erythrocyte a victim of mistaken immunological identity, so my misdemeanor may have simply happened by. Mrs T. had heard two pieces of devastatingly bad news within the space of a day and had not been given time either to deny or to bargain [5]. Perhaps her “Why me?’ sense of outrage, rather than become an existential question, attached itself to a literal object. Certainly she was now aware that, on the day I asked her to wait outside, she already had cancer, and the enormity of the diagnosis must have contrasted overwhelmingly with the pettiness of my request. Fourth, Mrs T. may really have accepted my explanation of the workings of the appointment system and waited her turn without rancor (perhaps I was polite?), retroactively “using” the incident as a symbol for the real hurts she could not express, such as my self-righteous attitude towards her illness behavior on previous occasions and my failing to find out what lay behind it. Over the course of several visits to her bedside in hospital and two house calls paid after she was discharged, Mrs T.‘s attitude towards me grew unexpectedly conciliatory. Perhaps it represented the bargaining stage of her coming to terms with her disease, or was a concession to my persistent attempts to set matters right. Her own version of what caused her anger ran something as follows. She, her husband, their son, his wife and two children and the wife’s parents immigrated to Israel from Romania 64 years ago. She was then 53 and found adjusting to a new country with its strange climate, language and ways, very difficult. Whereas for nearly 30 years she had done secretarial work, a position to which she attached some status, in Israel her straitened economic circumstances had forced her to accept menial jobs that involved physical effort. She could not grasp the intricacies of the local bureaucracy and spoke with particular nostalgia of the health care system in Eastern Europe which she described as being very short on pharmaceuticals and equipment but long on respect for the patient. She felt that it had been a mistake to emigrate before being pensioned. Further in the background was her experience of the Holocaust when, at the age of 11, she was deported to a forced labor camp with her parents and three sisters. Hunger and disease were rife there and a sister succumbed to typhoid.
841
Second Thoughts
As she was seeing me out she burst into tears and begged me not to take her anger personally. I merely represented a mentality and a way of doing things she would never understand. A recent paper from Hungary speaks of macrosocial conflicts as being germane to family therapy [6]. Certainly the difficulties Mrs T. experienced in adjusting to life in Israel had as much to do with the differences in the political and social systems obtaining between her countries of origin and adoption as it did with the aforementioned problems of language, climate and livelihood. The macrosocial variability between nations rather than ethnic groups is too infrequently taken into account [6]. In the nature of things, and given the longitudinal dimension of primary care, there are two most likely scenarios for the termination of our relationship with patients of our own age: either they will take leave of us, with a regretful handshake on retirement or a tear at the graveside, or we will tend them in their last illnesses. The latter possibility should motivate us to curtail our impulses on busy days. Illness behavior, as perceived by us, is but one aspect of personality and often the least attractive. As such it cannot be equated with the whole patient but only with the way in which, flustered and frightened by how we come on, he presents himself. We are thus bound by Joshua ben Perahyah’s 2100-year-old injunction to “. . . judge all men favorably” [7]. It has been pointed out that certain difficulties in the patient/doctor relationship, usually surfacing when there seems to be no anatomic basis for the chief complaint, may reflect profoundly reductionistic health care delivery [8]. Although we tend, for our own convenience, to “nosologize” and attribute them to individual characteristics or behaviour learned in the family
of origin, they may better be thought of as patterned deportment at the interface of the patient and the health care system [8]. It is our duty to protect our patients even from themselves and the impression some of their traits make on us. If we are remiss, it is not difficult to imagine important consequences, not only for the sense of well-being but, possibly, also for health. At times, the patient feels constrained to make his physician the butt of anger. Under such circumstances the latter has an opportunity to use skilled and selective one-downmanship, allowing the former to vent a sense of outrage that may really represent a settling of old scores or a kind of Weltschmerz [9]. Since our practice is largely palliative and only peripherally related to the patient’s improvement in most instances [lo], we cannot afford to overlook even so humble a therapeutic option.
REFERENCES 1.
2. 3. 4. 5. 6.
I. 8. 9. 10.
Redding WH, Monaghan P, Imrie SF. Detection of micrometastases in patients with primary breast _ cancer. Lancet 1983; 2: -1271-1274. _ Gehlbach SH. Selection bias in clinical research: the land outside the tower. J Fam Pratt 1985; 20: 433-434. Tuomanen E. Partner drugs: a new outlook for bacterial meningitis. Ann Intern Med 1988; 109: 690-692. Miale JB. Laboratory Medicine: Hematology. St Louis: C.V. Mosby; 1972: 764. Kubler-Ross E. On Death and Dying. New York: MacMillan; 1970: 38. Furedi J, Kapusi G, Novak J. Macrosocial conflicts and the family: a Hungarian case study. Fam System Med 1989; 7: 30-41. Ethics of the Fathers. New York: Hebrew Publishing Company; 1962: 8. Bloch DA. Dr Biomedicine and Dr Psychosocial: the dual optic. Fam System Med 1988; 6: 131. Harkaway JE, Madsen WC. The case of chronic obesity. Fam System Med 1989; 7: 42-65. Gabbard GO. The role of compulsiveness in the normal physician. JAMA 1985; 254: 2926-2929.
