One day, I realise that it has been months since I saw a patient whom I was closely involved with at the time of his cancer diagnosis. He was pale and shaken during our first consultation, his wife having retreated into a silent world of her own; it took several meetings to tame his fears, plan treatment and return a semblance of normality to his upended life. I felt relieved when our last meeting ended on a calm note and he expressed gratitude for my concern.
Remembering those conversations, I wonder why he has not returned to see me. Perhaps he switched doctors, clinic days, or healthcare networks, a common occurrence in a burdened public hospital where patients do not have a primary specialist and describe considerable stress navigating the healthcare maze. Or perhaps we forgot to send him an appointment and he fell through the cracks. The last patient who kept waiting to hear from us came to attention far too late and died shortly thereafter of disseminated cancer. Another woman who failed to attend was eventually discovered by a community nurse in a derelict caravan, starved, confused and incontinent. On my final visit with her in hospice she wept with joy at having a clean bed and a warm meal. I was consumed with guilt that we hadn’t searched for her more urgently.
Although healthcare professionals tend to focus on those in front of them, such cautionary tales routinely shape our daily concerns about our other patients. Therefore it is with apprehension that I look up my absent patient. Reading his notes I discover that his disease has recently advanced and another oncologist has prescribed chemotherapy. Knowing well how upset many patients feel at their perceived abandonment by their original oncologist when their illness becomes terminal, I immediately call him to express regret at his recurrence, and ask how he is doing. Somewhat cautiously, he replies he is okay. I wish him luck and hang up feeling relieved that he has not been lost to follow up. Our entire exchange must have taken a minute. The repercussions would reverberate much longer.
The next day an email lands in my inbox. In it, the patient curtly tells me to get lost. He alleges that my call upset his equanimity because the time for me to demonstrate my caring had lapsed. He accuses me of intruding on his privacy and signs off on an angry, even threatening note. It would be an understatement to say that I am blindsided by the vitriol.
I read and reread the accusation, not so much indignant at the diatribe than crushed by the awareness that I have somehow succeeded in distressing a dying patient. Overcome by feelings of humiliation, inadequacy and confusion, I wonder how I lost empathy, something I tell my residents is an integral part of being a doctor. Part of me is hurt that a patient I deeply care about would misinterpret my concern as something exploitative. Above all, self-blame roars inside my head.
In the ensuing weeks, on perpetual guard, I avoid checking on other concerns although my rational mind knows that most of my calls are appreciated and indeed, important because they rescue some patients in the nick of time. I double-check my motive, wonder if someone else can make the call, or tell myself that patients know where to find help. I soon realise that my fresh approach is a dereliction of duty but nevertheless, I am sobered by the battering my confidence takes from one vigorous incident of rejection.
Much is rightly said about doctors who harm their patients, but when it comes to discussing the ways in which patients can damage their doctors, there is mainly silence. Yet, nearly 70% of Australian doctors report written or verbal abuse by patients, and another 30% reporting physical aggression, with women and young trainees being at particular risk. If there is a failure of magnanimity, or even consideration, in human dealings, it is on the side of both doctors and patients.
Some health professionals suffer serious repercussions from these incidents, including the loss of life or work. For many more the accumulation of insults, derogatory comments, casual abuse and disrespect causes an insidious erosion of confidence and goodwill eventually leading to disengagement as a means of self-insulation.
Despite recognising a duty of care, any doctor or nurse will tell you that it is more difficult to repeatedly care for people if you think they will unexpectedly snub, abuse or assault you. The emergency rooms are one well-known place where professionals must always be on their guard to ward off nastiness. Many say that their experiences make them more guarded and clinical than they would like.
Anonymous posts about doctors are gaining strength in a consumer-driven society where people rate doctors like they rate restaurants. "Run away. Does not understand patients and kept me waiting", an unhappy patient posts about an oncologist. Below this, someone emphasizes his finer qualities, his empathy, diligence and ground-breaking research on a rare cancer. "He saved my son’s life when everyone else gave up", a mother writes poignantly.
But the praise does little to erase the reflexive hurt of someone who actually understands his patients better than most. This oncologist watched his young brother die of the same disease, untreatable at the time. He recognises better than most the intense suffering of patients and the existential distress of those left behind. "Nothing upsets me more than people saying I don’t get it", he observes quietly, regarding his brother’s framed photo that follows him everywhere. As I watch him go about his 16 hour day, I can’t help but wonder whether someday the unthinking criticism that he says he tries to ignore might be his undoing. It would be our common loss.
Doctors nearly always internalise insults that patients fling at them, and the insults are becoming more personal and pointed. Some doctors feel resigned; many have simply no idea how to respond while others are acutely conscious of not taking advantage of a power imbalance by being challenging or openly dissenting.
It is the rare and repeatedly distressed doctor who would reluctantly bring this problem to light and actively seek help in defraying the serious consequences of hurt feelings and frayed self-esteem. These needs are not just unmet, they are unspoken. Yet, why should doctors be any less sensitive to rejection than patients? These unmet needs contribute over time to the significantly higher rates of psychological distress and burnout faced by doctors.
Do no harm is a tenet instilled into every doctor from inception. A civil society rightly demands that unscrupulous and unprofessional doctors must be taken to task. But patients have a great responsibility to be sympathetic to the unique and complex pressures that doctors face, and not hasten to impugn their motives. Doctors are no more immune than their patients to the destructive power of words.
