Universal Table

Monday was the day I performed procedures. I had eight cases scheduled at the hospital. Cathy had come for a colonoscopy as part of an evaluation of her anemia. She seemed a bit nervous as I greeted her, not making eye contact.  This was not the same smiling, talkative woman I remembered from the consultation at my office the previous week. I held her hand and reassured her about the procedure. By the time we were ready to start she appeared visibly more relaxed.

During her colonoscopy I found a polyp. This is a growth in the colon that might grow into a colon cancer. It needed to be removed but it was located adjacent to the appendix. This is a delicate part of the colon with a thin wall. Removing a polyp in this location carries a higher risk of causing a bowel perforation. After I had carefully removed the polyp and she had woken from sedation I explained to Cathy and her husband that a polyp had been removed but that I had concerns about her risk of complications. I  advised her not to eat any solid food for the rest of the day and to call me if she had any pain.

That evening she called. She said that at around 4 o'clock she developed a sudden pain in the lower right side of her abdomen, near where the appendix is located. My face went cold and my gut clenched. I thought "Oh no, she's perforated!"  This is the dread of every physician. Although we accept that there is the trade off of a small risk of complication from any procedure in order to help a patient, when something we've done results in harm to someone it is devastating.

I met Cathy at the hospital that evening. Initial x-rays did not show a perforation but she was quite tender by then and had developed a fever. I spoke with her at length, telling her I was still concerned that she might be developing a perforation and that I wanted to treat her with antibiotics and order further testing including a CAT scan. Many patients would be angry, even accusatory after such an event but Cathy was not and I was grateful for this. She and her family had many questions. I tried to answer them all as best as I could. When I left the hospital that night I was emotionally and physically exhausted but I didn't sleep well. I lay awake replaying the colonoscopy in my head, trying to think of what I might have done differently.

The next day brought good news. The CAT scan showed no perforation. Moreover, her fever was gone and her pain had improved. I shared the good report with her. Her face brightened and I saw the same bubbly, smiling person I remembered from our initial office visit. We talked about what had probably happened: that the cautery had weakened the wall of the colon without causing a complete perforation. After a lull in the conversation she looked away. When she looked back directly at me her smile had faded. "I need to tell you something" she said firmly. "When I first met you I did not like you."

I sat there speechless. This is not an easy thing to hear, especially in a profession where relationships are so important. In the silence that followed she waited and then continued. "When I came to see you in your office you seemed to be in a hurry. You spent only a few minutes talking to me and examining me, and after discussing the procedure you recommended you were out the door to see the next patient."

I looked at her, stunned. Had I really been that thoughtless?  Had I rushed her?  Had I ignored a worried look that might have alerted me to questions or fears that I hadn't let her express?

She went on. "But then you came to see me in the hospital. You sat by my bed and explained things to me. You took the time and I could see that you cared. That's when I started to like you."

I held back the tears. Yes, I did care. But I felt terrible about how I had treated her in my office.

That evening I thought about the day of her office visit. It had been a very busy day. Sick patients had to be added to an already full clinic schedule. These patients' problems took time to evaluate and I had gotten farther and farther behind. I was grateful that Cathy had such a simple problem. Anemia with relatively few symptoms was a bread and butter case. I could handle this in a short while and catch up on my other waiting patients. Cathy was right. I had rushed her through to get to the next patient. Now I thought of her sitting in my office after I'd left. What questions had gone unanswered?  What fears left unvoiced?  Issues that had become routine and rote to me were neither routine nor familiar to her. As I pondered our initial encounter from her perspective I began to wonder if in the midst of a busy practice I had somehow lost something.

I thought back to medical school and those first tentative contacts with "real patients". The science, the technology, the diseases fascinated me. But the interaction with people, the chance to help someone in pain, the privilege of sharing an intimacy necessitated by a patient's state of vulnerability and the opportunity to cherish and respect this responsibility, this is what made me love medicine. I have been profoundly lucky to have a job that can give as much as it asks of me.

But Cathy's comments were humbling. I wondered how often I had done this to others with "routine" problems. How many had felt as Cathy had but hadn't bothered to tell me?  I was struck by the courage it must have taken to say what she had said to me. How much easier would it have been just to have said nothing?

I went to see her the next day at the hospital. "You're doing well" I told her. "We can discharge you later today."  I paused. "About what you said to me yesterday - "  Her eyes dropped. I could tell she felt badly. "Thank you" I said. "You have given me a precious gift. You've helped me to remember why I chose to go into medicine. I'm grateful that you are the kind of person that you are and that you thought enough of me to tell me how I had treated you. It must not have been easy."

"No," she laughed, "it wasn't."

Clinics after that day were different. Patients with problems that I had seen a thousand times, I now saw through the eyes of someone for whom it was a new and possibly scary concern. I felt the newness of that special connection with patients that I remembered from medical school. Clinic was not a burden to complete, but a series of personal interactions I was privileged to be a part of. Of course, there are still good days and bad ones, easy days and days so busy my head spins. But now when I'm busy I take a deep breath before entering the next room and remember what Cathy taught me. And I love what I do all the more.

Thank you Cathy.

DISCUSSION QUESTIONS

In your experience of physicians, do you think the author is unusual in his ability to reflect on and respond to criticism by patients?

Have you ever tried to share a similar observation about effective communication with a physician, nurse, or therapist? What made you speak up? What happened in response?

If you are a healthcare professional, do you feel free to share with your colleagues observations about the style and content of their patient communication? Are you open to receiving the same kind of observations from them? Why or why not?