Return to Transactional Communication: The Patient-Sized Hole

As anyone who has surfed social media knows, if you watch or read something, it gets logged somewhere and the algorithm decides to send you a lot more of the same thing.  This means that if you watch a couple of similar videos, you will get an opportunity to watch a hundred-thousand more.  There is certainly an essay about how this relates to healthcare, but I will save that for a moment.   Right now, I will simply point out that this reinforcing logic, when combined with my ADHD (undiagnosed, just assumed), can lead me down a deep rabbit hole on specific videos.¹ Lately I will admit to enjoying some schadenfreude, watching videos of people responding to delusional people posting their expectations for a potential significant other.²

What fascinates me is not the outsized expectations—I firmly believe that people should have standards and it is not my job to gatekeep what “reasonable” or “delulu” standards might be.  What fascinates me is that these standards are exclusively one-way.  For example, if you are a single parent and you express an expectation that a potential partner comes to the relationship with a significant income, well-toned physique, and the realization that they will always be treated as less important than that person’s child, have at it.  But what are you bringing to the table?  What sacrifices are you going to make to achieve this perfect partner?  These videos seem long on expectations, but short on concessions.  Now, again, one is well within their rights to have high standards and no consequences, so long as they also understand that no one may apply for that job posting.

My problem with these expectations is that there is no appreciation that a meaningful relationship is a journey.  A realistic relationship is full of twists and turns, highs and lows, dekes, and wrong turns.  These videos essentially demand a partner who has already experienced this journey and has come out the other side, perfect in every way, except that they have a partner-sized hole that they need to fill.³ For those who are confused about what this has to do with healthcare, please bear with me.  Although if you are still reading my essays this far down the path, you already understand patience.

In my past writing on transactional relationships, I focused on the fact that these sorts of strategies tend to devolve into an economic calculus, where service is seen as secondary to the black and white of care delivery and its cost.  Here, I am more interested in what unspoken expectations are made in this environment.  What demands are made (or assumed) and what behaviors might be expected in response.  If patients and providers enter relationships with clear expectations at the outset, they may be disappointed to find out that the other doesn’t fit perfectly in that patient-sized (or provider-sized) hole.  Or, worse, they may have to recognize that they have not even allowed for a hole for the other to occupy.  If the expectation is that this is all one-way, they may realize that there are no decent applicants for the position.  In this essay, I will focus on the assumptions providers make in defining the patient-sized hole that lead to unsatisfying transactional relationships.

People don’t care what you know until they know that you care

Many of the expectations that physicians have revolve around being subject matter experts.  Because their educational journey was long and hard and ended before they started practicing, they can feel like they are already the perfect mate.  They meet all of the preconditions to enter a healthcare relationship.  The problem is that, as perfect and well-rounded as they are, they often don’t have a patient-sized hole that they need to fill.

This is not to say that the patient is superfluous.  Of course, the patient is not superfluous when it comes to getting paid, and most doctors do enjoy helping patients get better.  I mean that, without a patient-sized hole in them, most of what they get is immediate and transactional.  They get paid.  They get to solve a problem.  They get the satisfaction of sending someone away better than when they arrived.  But they don’t seem connected.  They don’t feel like they get anything from the patient, and this distance can sometimes feel like patients only come to them when they need something.  (Of course, this is often because patients only come to them when they need something.)  The distance prevents connection.  I have said it before, but I like it when my doctor asks me how my dad is doing, how my dogs are, and how my guitar-playing is going.  I know that these are all in my chart and he has not remembered me from eleven months ago, but I don’t care.  On the other hand, my hematologist⁴ can see the same notes but doesn’t ask me about them. 

Without this hole, it can be easy to assume that everyone hangs on your every word or that your words are above reproach or challenge.  Doctors talk dismissively about “Dr. Google” which I can understand.  Without context, internet searches about symptoms or test-result terminology can lead to anxiety about what patients are experiencing.  Of course, patients search for answers on-line because it can be difficult to get clinic access in a timely manner.⁵ I can also be expensive to seek a professional opinion to something.  Providers may understand but not address these reasons for self-serve healthcare.

But another key reason why patients search on-line for answers also speaks to the broader disconnect in communication.  Patients often crave ownership or control over their situation.  Forty years ago, doctors complained that patients didn’t accept responsibility for their own health.  Be careful what you wish for, since a lot of this healthcare exploration is because patients want to understand what they can do or what they can expect with certain diagnoses.  This means, then, that these patients don’t fit in the behavioral box that providers have given them.  In other words, you cannot expect patients to be better informed about self-care and then still expect them to sit quietly in anticipation of your unchallenged opinion.

Failure does not always mean a lack of trying

I had an in-law who could not effectively manage his diabetes.  He was also an alcoholic.  You might be able to assemble this puzzle pretty quickly, but he did not.  When he was asked about his diet, he didn’t mention alcohol, because it didn’t seem relevant.  He completely understood why soda was a problem but didn’t think there was sugar in alcohol.  When the dots were connected and he was told to stop drinking, he still did not see a connection between this and diabetes.  They did not explain WHY this was important, so he thought he was just being judged about his drinking.  By the time that the importance had sunk in, he was wheelchair-bound and would be dead in less than a year.

You could say that he was an addict and willfully disregarding medical advice.  This assumption is likely part of the reason why it took so long to connect the dots for him.  He squeaked through high school.  So, he never took biology and never learned that alcohol broke down into sugar.  He worked for his family’s business, which didn’t have health insurance or health coaches.  He lived by the “work hard/play hard” mantra and no one suggested there was anything wrong with this mentality.  In fact, since he was the only one in the business who didn’t smoke, he thought he was ahead of the curve. 

So, he may not have wanted to stop drinking, but he also grew up in an environment that was not heavy in life lessons about the long-term costs of certain behaviors.  What surprised me was how often the assumption made by doctors, nurses, and care coordinators was that his drinking was a defiant choice.  No effort was made to connect with him about his addiction or provide resources.  He lived in Omaha, but transportation was still a challenge.  Strategizing how to get him to doctors’ appointments was one thing.  Figuring out how to get him to Alcoholics Anonymous meetings was even more of a challenge.  Or, it would have been, if he thought that going would help him.

None of this absolved him of his life choices and how he responded to curveballs.  He was rear-ended in an accident that was not his fault, during which he was sober.  This led to a need to seek help with the neck pain.  This revealed previously undiagnosed high blood pressure and diabetes.  This led to the loss of his CDL and the spiral was set.  Yes, he never missed an opportunity to miss an opportunity.  But there was also no patient-sized hole in any of the care he was receiving.  As the issues compounded, the provider addressed one, but all the others were deemed out-of-scope.  If there had been a patient-sized hole in any of these encounters, the course of care and his life might have changed.  Or maybe not.  No one’s winning percentage is 100%.  But the second we assume that failure is because someone didn’t even try or try hard enough; we have sentenced a large percentage of patients who have impulse control issues, behavioral health issues, or just good old fashioned social determinants of health issues, to suboptimal outcomes.  All while the road to hell is paved with a series of satisfactory transactional encounters.

Progress not perfection

Care providers will quickly point out that solutions won’t be immediate, and it takes time to calibrate for optimal outcomes.  Doctors will often start with a low-dose statin or SSRI and then increase over time to achieve the best balance between success and overmedication.  Where there can be confusion, though, is that the decision-making process itself is also a progress.  More common or less severe explanations for symptoms need to be ruled out before moving on to the bigger more ominous problems.  Again, by removing the patient from the equation, this can feel like a challenging, even fun, problem-solving exercise.

From a patient’s perspective, though, this can often feel less like progress and more like additional bites from the same apple.  There are certainly excellent reasons for proceeding thoughtfully.  Even though physical therapy is not likely to be sufficiently successful, attention to detail (and dictates from insurance) may require it.  If you are not sharing this information with a patient, it can feel like this is all transactional and not iterative and certainly not collaborative.  In a previous essay, I told the story of a friend of mine who had back pain that eventually required surgery.  He understood the need for each step and accepted the journey.  He was ultimately frustrated, though, with the fact that these steps seemed designed to play a game and seemed unconcerned with his physical pain. 

My mother thinks that these essays are too long for a doctor to read, but if you are a doctor reading this and are offended at my statements, I will leave you with two thoughts.  First, if my comments here fail to describe you, I will ask you to consider whether I am wrong, or if you are unique in your profession.  If you strive to always acknowledge the patient-sized hole in your care plans, then I am not describing you.  I don’t know you, so these words cannot be directed at you.  Simply understand that many of your peers do behave in this way.

Second, if you are feeling a bit mistreated and are thinking, “Well, OK, but patients don’t have a doctor-sized hole in their relationship with us, either!” I hear you.  I won’t call out the whataboutism and simply say that in the next essay, I will be discussing that side of the coin.  For the moment, please consider healing yourself.

¹I am always interested in seeing how the algorithm interprets my preferences.  Based upon my extremely diverse tastes in books and music, Amazon usually just throws up its digital hands and suggests the most random things based upon my buying history, like when it suggested that I might want a commercial-grade bubble tea maker.  Since I have never purchased bubbles, tea, bubble tea, or any commercial-grade appliance, I can only assume that Amazon’s algorithm was thinking, “shit, I don’t know, I am out of ideas.  How about this?”

²For those who don’t know what I am talking about, there are people posting about how they have been mistreated by past romantic partners and now have detailed lists of what someone needs to bring to the table to date them and other lists about what constitutes a deal-breaker, or ‘ick’ in the parlance of social media.  Essentially the message is that the speaker expects to be treated like a Queen or King at all times.  Their wants won’t be challenged and deviations won’t be tolerated.  I won’t give you links, because I don’t want to corrupt your social media feed.  Otherwise, IYKYK.

³It is also likely that the list maker will take the product of this journey for granted and will expect it to be the baseline for further improvement.  But is an observation for another time. 

⁴My parents who are avid readers of these essays may be surprised to discover that I have a hematologist.  So, I can probably expect a compassionate but sternly-worded email as soon as they read this…

⁵I definitely need an essay on patient perceptions as compared to clinical perceptions to concepts like timeliness when it comes to appointments, call-light response, or assistance with the bathroom.