A while back, I wrote an essay responding to comments doctors made about patients. I discussed them from a patient’s point of view. I acknowledged that for many of the comments, it seemed like there was more to the story, or at least some subtext that was not explored; I simply addressed how these comments might be perceived, if they were said out-loud to the patient. My point was that these comments highlighted the communication gap that often exists between clinicians and patients. Clinicians often say that they can tell when patients are lying, and they wish patients would just be truthful. Meanwhile patients report that they couch their issues and concerns because they feel like they are being judged for every decision that they make. At the core of this is an unspoken tension that seems increasingly prevalent in all aspects of our life: that people are expected to always behave perfectly or suffer the consequences. In other words, humans are ridiculed for being human.
Before exploring this specific to clinicians and patients, I will lay out two core beliefs that may seem obvious when said aloud, but both often are casually ignored when looking at the real world. First, is that people are people (a tautology most associated with renowned philosopher, Depeche Mode.) Second, that human behavior has consequences, some intended and some unintended.
People are People
A trend I see across healthcare, politics, sports, social media, is that we hold some people to a higher standard than others. In some situations, like when there is a power imbalance, it is reasonable to expect some people to behave more professionally, or more thoughtfully, or with more intention, than we expect from everyone else. I expect a doctor to behave more professionally than a patient in the emergency department who was hit by a car while on their bicycle. I expect a politician to be more thoughtful and intentional on public policy than a drunk on a barstool holding forth on “what’s really wrong with the country today.”
There are two places, though, where this gets exaggerated. First, is when people push this expectation for professionalism to an expectation for perfection. I expect a sports referee to know the rulebook better than I do and I expect them to be attentive to all sorts of things that as a fan, I miss. But it is unreasonable for me to expect them to be perfect. Calls get missed, and judgement calls go against my team all the time and cursing them for imperfection demonstrates a distinct lack of self-awareness.
Second, is when people assume motivation for this lack of perfection. Clearly people do the things they do because they were bribed, they were covering for their idiocy, they are weaponizing incompetence. It seems rare that people point out a moment of humanness without people ascribing motivation for it. (Notice that I am trying to avoid words like mistake, accident1 or error, since these moments of humanness are often simply decisions people make.) It was not simply a lapse, an oversight or missed opportunity, it was clearly a purposeful decision. It is not surprising that if you expect perfection, when it doesn’t appear, it is clearly a sign of malevolence. To be clear, there are moments when an bad things were purposely done and an effort to deceive was intentional. But when the barista adds two pumps of vanilla to your latte instead of one, I don’t think it is because she is in league with ‘the cavity cartel.’ Or as my mother would often remind me, “Don’t ascribe to malice that which can easily be explained by stupidity.”
Human behavior has unintended consequences
People will often look for a reason for an action because these actions have consequences. Even if these consequences are not always clear, it can be easy to assume that they were intentional. Sometimes they are, but mostly these consequences are unintended. The ripples for a decision expand out in every direction. While we expect the unintended consequences from pharmaceuticals advertised on TV, we seem less tolerant of unintended consequences from other human beings. Part of this is human nature, as we want to identify the cause of the undesired effect. But in the search for simplicity, we often dismiss other factors or other intervening events. Sometimes it is about placing blame.2 Sometimes it is about simply categorizing, compartmentalizing, or creating clarity in a confusing situation. We do have a preoccupation with negative consequences, and this is because we are more willing to accept positive deviations from expectation without scrutiny.
As an example, listen to the conversation around the unexpected or untimely death of someone—celebrity or friend. People will ask pointed questions, like “was it drugs?” or make broad statements, like “we always told him that he needed to lose weight.” While sometimes these are meant to be as judgmental as they sound, mostly it is just people trying to make sense of a random senseless event. Afterall, if a random bad thing can just happen for no good reason, none of us are safe. If we can trace that bad effect to an understandable cause, we can avoid hardship with a simple intervention. The problem, though, is that the speaker might not mean to be snarky, they can often be interpreted as such.
Which brings me to where this intersects with healthcare. On one side, we need to be aware of others’ human behavior and on the other side, we need to check ourselves on our interpretation of that behavior. One side of this is primarily directed at clinicians and the other side is primarily directed at patients, but both elements have the tendency to generate more heat than light in any conversation.
To my brothers and sisters in clinical roles…
Doctors often have a reputation for speaking in unvarnished, even insulting ways. We even celebrate this personality in TV shows, like Hugh Laurie’s character Gregory House. We laugh and sit in judgement of people so stupid that they think contraceptive jelly is the stuff you buy at the grocery store in the condiment aisle, or people who think that they should use their asthma inhaler as a perfume atomizer. Lest you think that I am a humorless math nerd, I also find these portrayals very funny. I am simply calling out the fact that it is a short jump from rolling your eyes at the stupidity of a character on TV and rolling your eyes at an actual human being sitting in an emergency department exam room.
I have often heard doctors and nurses defend their direct and abrasive statements to patients using one or both of the following shields.
- “Hey, I am just stating facts.” At the very least, this is tone-deaf. You may stink at playing the piano. Your child may be ugly and untalented. That outfit may be hideous on you. But if I state these sentiments in a gruff way that seems designed to insult, I shouldn’t be surprised if I get punched or slapped.
- “You are being too sensitive.” It is true that people being obsessively concerned about how others feel is codependence, but that pendulum can also swing too far the other way as well. You are fat and ugly. Don’t blame me for calling out what everyone can see. Just know that if you act like you are trying to push other people’s buttons, they will likely be looking for ways to push yours as well.
This direct approach is popular because it can feel satisfying. After a long day of perceived idiots filing through the emergency department having done stupid things (or worse, stupid things they did just to get noticed on the internet), your self-control or tolerance can abruptly end. After all, you are just a human being. Just know that in doing so, you have shut down any further conversation with your patient. If you want your patient to be truthful and open up about their problems, you cannot ridicule them the moment that they do.
To my brothers and sisters as patients…
You should continue to treat your providers as experts. You should continue to expect them to behave as professionals. But please stop filtering everything they say through a prism of judgement. It can feel like a fine line between data-gathering and lifestyle-judgement as you are peppered with questions. Maybe the doctor is judging you. But perhaps, just perhaps, the feeling that they are judging you is simply a transference of you judging yourself. A doctor asking about your smoking and discussing cessation programs is not calling you ‘stupid’ or accusing you of having no willpower. OK, perhaps one time in a hundred it is, but I would wager that the other ninety-nine times, it is really you judging yourself about your decisions and willpower.
When the pandemic was in full-swing, one of the common questions asked during rooming was about the patient’s COVID vaccination status. If the answer was NO, the patient was often offered an opportunity to get the vaccination. Based upon the complaints I read, though, some patients saw this as a full-frontal assault on their body autonomy or their political beliefs and assumed that this information would skew diagnosis and prevent them from getting best-practice medicine. For those who think this is an isolated example, imagine a parent’s response when a clinician suggests an HIV or sexually-transmitted infection test for a teenage patient. Even when a provider is asking a simple question or offering a simple solution, it can get perceived as an indictment.
Not surprisingly, when one side is sick of pussyfooting around and the other side is looking for an opportunity to be offended, even well-meaning HUMANS behaving as HUMANS can get caught in the crossfire.
To my fellow humans…
As someone who taught political science for twenty years, please let me give you one piece of advice. When engaged in a conversation with someone that turns contentious (not pointing fingers here), you need to ask yourself one important question. Is it more important to be right or to have a fruitful conversation? I am not suggesting that you not engage with someone or be a doormat or to simply avoid a fight at Thanksgiving. I am suggesting that you look in the mirror and ask yourself what is important here, because you cannot both assert your rightness and have a fruitful conversation.
As a fan of movies, music, sports and books, I am more than happy to flex my I’M RIGHT energy. Heck, I do this daily with my friends in text and on-line. But most of my life is focused on creating useful solutions to impediments. In this arena, I will tell you that executing a conversational scorched-earth approach that only ends with complete capitulation to your sovereignty fails to appreciate anything that I just said in this essay.
Clinicians often choose “being right” for a host of reasons. Perhaps it is because they don’t want to confuse a patient with a lot of flowery language filled with caveats and compound run-on sentences. Perhaps they are focused on covering their butts from a legal perspective. Perhaps it is frustration that, after a long day, it feels like everyone they meet is an idiot. Perhaps they are hoping the direct approach will shock a patient into self-realization. All of this is fine. Just know that in choosing to be right, they have likely forfeited their ability to have a fruitful conversation. If their primary goal is really to convince me to change my behavior, then, my emotional response to being disrespected or judged or attacked is not helping their cause.
Patients also choose “being right” for emotional reasons. Patients often feel vulnerable. They see their inability to quit smoking, manage their diabetes or even bring their cholesterol down as a personal failing. They often don’t know anything about anything in medicine and need to rely on the clinician for everything. While you might imagine that this would bring an obsequiousness to the interaction, it often does not. People in trouble often behave more like cornered animals. Every question asked of them makes them feel dumber, so they will look for something that makes them feel smart and cling to that like a branch in a raging river.
What is funny is that this whole essay started as an exploration of the stupid things we do in healthcare that make trust and collaboration hard to create. A couple of thousand words later and that will have to be the subject of a different essay. For the moment, all of this reminds me of a Zen parable that illustrates how the smallest differences can create the greatest divides.
A man happened across a group of people surrounding a large hole. At the bottom of the hole, there was a young man. He was clearly cold, wet, scared and alone. He was ignoring everyone surrounding the pit who were calling down to him to “Give me your hand!” The man quieted the crowd, knelt and said, “Take my hand.” The young man immediately did and was pulled to safety. When asked how he did this, the man replied, “you saw this man had nothing and you still asked him to give something to you. I saw he had nothing and instead asked him to take something from me.”
Any variance in my retelling from the source material is evident of my humanness and not purposeful malice. So, as we confront broad problems in healthcare, or scary diagnoses delivered to our loved ones, please just say, “take my hand.”
1Don’t get me started on my annoyance when people use ‘accident’ when they really mean ‘mistake’ though I usually blame that on an inattention at school rather than some evil effort to deceive.
2There are Cubs fans who will blame the team’s performance in the 2003 National League Championship Series on an alleged fan interference. But they fail to own the fact that after the incident, the Cubs were still up 3-0 with two outs already logged in the eighth inning of a game that would send them to the World Series. The fact that the team failed to get four outs before the opponents could score four runs, and then completely blow Game 7 seems to me to be a better explanation for how that season ended.
PX Matters with Joseph Snipp 
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