The patient strikes back

I’ve always been rather outspoken, so over the years, I have had a number of run-ins with my doctors. I’ve been asked to write about them – documenting ‘difficult’ conversations. This post is an account of how to tell your doctor to go to hell. It’s a post about my struggle to keep afloat when in the doctor’s surgery.

Before I start I want to say two things. First, however outspoken I might be, challenging a doctor during a consultation is always difficult. Sometimes very difficult. However well you know the doctor, however friendly they are, the moment the consultation starts, the conversation changes. To be honest, I’ve always been fascinated by it. The change of frame, from ‘chat’ to ‘consultation’ (then back to ‘chat’) inevitably results in very different talk. All of a sudden, the power relations, barely visible at first, are re-constructed with full strength the moment we start talking about ‘my symptoms’. This is also why it’s so difficult to challenge.

The second point is about the medic’s reaction. I’ve never been told off by a challenge, probably because that would make me challenge considerably more, but you can see a range of reactions, from mild amusement to strong irritations. Interestingly, I am yet to see a reflection. But maybe I’m just unlucky or, of course, maybe what I say is not worth reflecting on.

Now, I want to be very clear that I am not offering ‘a guide’. What you do when talking to a doctor depends on too many things, from who you are and how you are perceived, all the way to whether you think that challenging is in your best interest. I can and I want to speak only for myself. I am also fairly certain that conversational analysts have already looked at this. So, what I am writing about is my own experience. During one conversation I thought that I would end up in a zero-tolerance unit, to be honest (see below).

1. The most direct challenge I can remember is me thumping my finger on the GP’s desk, my voice raised, saying ‘No, you WILL do it!’. It was a conversation about my son and I was quite convinced (on taking advice) that an appointment in half a year’s time was just idiotic and I wanted an appointment ‘now’. Surprisingly, the appointment was offered two weeks later. After leaving the surgery, however, I thought I was in trouble. No, not because I thought I was wrong, but because I thought I crossed the power barrier too forcefully.

2. I remember the last time said to my GP: Don’t pathologise me. It was when he asked why I was looking for an illness in myself. I was livid. He was so certain that he promised me I was OK. I wasn’t. In fact, I’m still unwell.

For me the ‘don’t’ imperatives are very difficult. Not only are they impolite, they also challenge the doctor quite directly. It’s difficult also because never goes down well. I suppose my GP got used it. Mind you, I tried so many times to get him to stop asking me about my ‘symptoms’ that I just gave up. It’s still fun doing it to other doctors. The blank expression when they hear “I don’t have symptoms” is always a source of joy. Some of them understand immediately what I am talking about and I hear about taking shortcuts, some get aggressive. I suppose it’s even funnier then.

  • One of my favourite examples is the following exchange, obviously, it’s the way I remember it only:
  • Doctor: So, can you tell me about your symptoms, please?
  • Me: Can you please stop thinking of me in terms of ICD?
  • Doctor (visibly shocked): How do you know about the ICD?
  • Me: Why can’t I?
  • Doctor: I don’t know, patients don’t know such things.
  • Me: How about not making such assumptions?

I’m afraid I wasn’t particularly shocked that the doctor assumed I could not possibly have any access to the wonders and secrets of medical knowledge. How could I possibly. Aren’t I, after all, just a patient? In fact, I sometimes wonder about how many medics allow the possibility that their patients can be more knowledgeable, let alone cleverer than they are. What would I find out, if I could know the most sincere answer possible….I’m sorry to say that I think I’d be horrified by the number of physicians who think I am just plain stupid…Maybe that’s why it’s worth shocking you, doctor?

Still, my point about the statement about symptoms is that it only implies things. Challenge by implication is more useful. At least you’re not on a collision course immediately.

3. “Have you learnt to speak like that at ‘Patronising 101’? I asked this question a number of times. It never goes down well. No, there is never an answer, yes, there is always a palpable change in the atmosphere. This is the most extreme case of questions like “Is it a waiting room?”, which I asked some time ago, after one nurse after another was entering the doctor’s surgery completely ignoring the fact that there was a consultation.

To be honest, I like such questions. For on the surface questions ask and what you really want to say is only implied, much like in the notorious question: “Have you stopped beating your spouse?”

4. Finally, a funny example. Polish dentists often use ‘we’ when they direct their patients. So, they say: ‘We’re opening’, implying that I should open my mouth. I always say: ‘You go first, doctor’.  No, they never get it. Still, humour is useful. It renders my challenge more palatable, less threatening. Just like when you ask your questions smiling or laughing.

 

As I write about ways in which I can remember myself challenging the doctors I do realise that I construct my patient-doctor interactions as a fight. No, it’s not deliberate; it’s inevitable (if someone could see Heinrich Böll in this sentence, I’d be delighted). To a considerable extent it is a struggle in which I want to keep being myself, not reduced to a nitwit who is spoken to slooooowly, after all, to make matters worse, I still have a Polish accent, even worse, it was much heavier. So, yes, also doctors were recipients of: ‘Just because I have an accent doesn’t mean I am stupid’. The challenge allows me to hold the doctor’s encroachment on me, to set parameters in our conversation, to say that I won’t let them take liberties.

But there is one more reason. Many, many years ago, I was sitting in a doctor’s surgery with what I thought was a significant problem and I was just dismissed. The medic didn’t bother with anything, just sent me going. He was the all-powerful man in the castle, I was a minion not to be even engaged with. I was unable to oppose. I don’t know why, but I was just crushed by his power. I wouldn’t say I was traumatised by it, but the discomfort with the situation was so strong that I promised myself never to feel it again. Was I successful? Yes, in the sense that I never felt like that, no, in the sense that the power relationship between me, the patient, and the doctor is impossible to overcome by a patient. It can be done by the doctor, but I’m afraid hell will sooner freeze over.

And here we come to the final point – communication skills. You see, I think that all that I described above has nothing to do with ‘communication skills’ and it’s all to do with power. Yes, you can teach medics to say appropriate things, be nice, say “Hello my name is…”.  In contrast, I would like them to be able to understand that when I sit down in front them, I don’t become a boy, an idiot who can be talked down to. Understand it, live it, accept it. Yes, let me just say it, I would like them to respect me, not because I am a professor and I can write a good complaint. No, only because I am a fellow human being.

 

4 Comments
  1. Dariusz Galasinski

    Accepting what you say, Jonathon, let me point out that anger doesn’t need to lead to a complaint. In order to complain I would need to assume that there is something wrong with the particular person I talked to. And I don’t. I actually think that the question about me looking for my illness, however misguided it was, was in fact aimed at helping me. And the insensitivity behind it was systemic.

    Just like another GP telling me: This is the treatment. When I challenged her, commenitng on the certainty with which she spoke, she barely blinked. She wasn’t uncaring, she just didn’t understand.

    What can I complain about? His and her training? It’s like hitting a wall and it is the wall that’s the problem, not the person who invited you to walk into it. They don’t even see the wall.

  2. I deal with most of the complaints at my practice and at least as frequently listen to my patients’ complaints about poor care elsewhere. While there are many reasons to be angered by the manner in which a consultation is conducted, I have noticed that there is often little or no relationship between the degree of anger expressed by patients and the doctor’s behaviour. Most of our angriest complaints arise in cases where the anger is a reflection of underlying issues, and the consultation happens to be where frustrations are expressed.
    Whenever there is a complaint about a doctor’s conduct, I help the doctor reflect on their own assumptions, behaviour, language, power etc. We’re left trying to imagine what assumptions, prior and ongoing experiences underlie the patients’ response. Challenging discussions about prior assumptions, power and prejudice are increasingly part of the formal and informal medical curricula and in my experience, the younger generations of doctors are much more sophisticated in their dialogue with patients than the older ones.

  3. Dariusz Galasinski

    Thank you for your comment, particularly, for point 1. To be completely honest, you’re not the first person who says that what I write is not constructive enough, too aggressive. My response, as ever, is: Why must I be constructive and polite, if, for example, three nurses walk into my doctor’s surgery, without knocking, when I discuss the possibility of having cancer with him? There is nothing constructive to be said, if he and the hospital do not understand how unacceptable it is. Or perhaps: what’s so constructive in being told that I am looking for an illness? When I walk out of a doctor’s surgery furious with how I was talked to, there is nothing constructive in me to be shared.

    I do realise that my posts might be seen as painful reading, I’ve been told this. And it would be better to be nicer, to appreciate, to thank. I’m afraid this is not how I feel.

    What can be done with it? Especially that I think you are right when you say it’s endemic. It’s not about telling Dr A and DR B to change how they talk to their patients, there is still the whole alphabet to go, many times over. But I’m always game for more conversations about how to get there.

  4. Some thoughts from a (retired) GP and (active) medical educator:

    1. I used to find your blogs too provocative and non-constructive but have gradually come to appreciate them as representing an essential voice of patient protest and sometimes anger that we need to hear.

    2. I share your perception that paternalism and patronisation towards patients isn’t an accidental or occasional problem in consultations, it is endemic.

    3. Although I have spent much of my career trying to impart what you call “consultation skills” (although I use other terms) I agree these are insufficient and can be/often are appropriated to become part of the problem rather than of the solution

    4. I also don’t believe that the problems can be solved by different structural/financial relationships eg going private. They are deeply rooted in a lack of training and insight into the power relations inherent in expertise, especially where the body and mortality are concerned (although often compounded by injustices due to social class, economic
    status etc.)

    5. What I am particularly interested in is educational approaches to ameliorate this, ie how to offer forms of training at every level that will truly humanise moral recognition of patients whether or not people “get it” in terms of the right questions to ask, the right language to use etc. I have no doubt this will need to involve patients (including/especially “stroppy” ones like yourself) and look forward to further conversations about this.

Leave a Reply

Your email address will not be published.

Loading ...