My mother would often say that if you pick up one end of the stick, you pick up the other.1 I have always taken this to mean that how you treat others will determine how you will be treated. Yes, this is also dependent upon the vagaries of life. The other person may have a sour disposition or may be having a bad day. Of course, this proves the point, since when you encounter someone like this, it impacts how you approach them.2 They are also picking up both ends of the stick.
In the last essay, I explored how transactional thinking affects how providers can view patients which in turn can lead to suboptimal zero-sum encounters. But, as people may point out, provider behavior is also informed by patient behavior, which in turn informs additional patient behavior. Whether this becomes a vicious circle or a virtuous circle is dependent upon those behaviors. This essay, then, will examine how patient expectations about the size, dimension, and flexibility of that provider-sized hole in their space feeds the virtue or viciousness.
Before I begin, I want to make two points. First, much like with the essay on providers, it is easy to play the whataboutism game. Patient behaviors are fueled by provider behaviors just as provider behaviors are fueled by patient behaviors. As I have mentioned in the past, often patients can be forgiven if they are not fully present rational animals, given that they are suffering. But I also think that this can overstate that element of the relationship. I have often challenged clinicians when they have said, “I am here to save their ass, not kiss their ass,” by asking how many asses they have saved today. The reality is that, YES, asses get saved in a hospital all the time. The reality, though, is also that many, if not most, of the asses in a hospital—even in a hospital emergency room—are not in dire need of ass-saving so much as ass-addressing or ass-alteration.
As a patient, I have had a number of health challenges. I have been anxious and concerned about non-standard test results. These things have been quality-of-life-threatening or even potentially-life-threatening, but I was not on the razor’s edge of life and death. While my friends, family and physicians can factor this existential concern into my treatment of them during these health scares, I still need to own my treatment of them during these health scares. Please understand that I am NOT lecturing people to not be drama llamas. A patient’s panic might explain irrational behavior, but it does not excuse irrational behavior. People are not exempt from the one-end/other-end rule just because they don’t feel well. For a real-world example, consider how a friend or family member’s past behavior while they were sick informs how you approach them when they announce that they are currently sick.
This seems a reasonable statement. And yet, as I type this, even I cannot help but feel this this can be a harsh response to someone who is sick. Especially from health professionals. Especially since we have documented evidence of healthcare not treating patient concerns with sufficient amount of gravitas. Factoring in this information as one faces a doctor can feel legitimate. But it also is a clear indication of the vicious cycle I spoke of. If I am mistreated by my last three girlfriends or I think that all women in my target demographic are “all the same” or “only want one thing” so I decide to take it out on the next girlfriend, then anyone would rightly say that I am the asshole.3 We often use stereotypes as shorthand for understanding situations, but we should understand that these stereotypes also encourage us to prejudge people in new encounters. I am happy to grab a beer and discuss the accuracy of how lawyers, used car salesmen, and doctors are portrayed in common conversation, but for the moment, let us agree that part of the often-vicious cycle starts with preconceptions of what that relationship will be like. In this essay, then, I will review some of these stereotypes that patients have that can encourage them to engage with clinicians in a zero-sum or transactional way.
Doctors are all about money
I might simply dispute this stereotype by pointing out that all of us care about the money. Even those who say, “love what you do, and you never work a day in your life” expect to get paid. When I taught fulltime, I would say, “I would teach for free, but I’m still not paid enough to grade papers and exams.” I laugh when I hear those in alternative health spaces say this, since I know that they expect to get paid for the services that they provide.
What is more important, though, is how this sentiment affects how we view the provider. If you think that doctors are only in it for the money, that is the dictionary definition of a transactional relationship. This, then, can send you down the rabbit hole, where you think that healthcare is all about keeping you in some payment pipeline rather than fixing your problem. I have a lot of problems with healthcare and doctors but treating medicine like some multi-level marketing enterprise is simply swinging the pendulum too far the other way.
As I mentioned in the previous essay, doctors tend to be very incremental, either because it is a reasonable way to solve a problem, or because insurance companies prefer this approach.4 From a patient’s point of view, though, consider how this mindset affects how you evaluate their process and how it affects your commitment to this care journey.
Doctors just don’t listen
One complaint that I read often in patient comments and letters is that patients don’t feel heard. Like so many things, there are certainly examples of this. For example, plenty of studies have reported that physicians will interrupt patients as they are talking, in as little as eleven seconds. One of my biggest annoyances is getting interrupted because nothing tells me that you are not listening to me more than not even letting me reach the end of a sentence. This stereotype, though, often involves more than a simple interruption. When I have asked individual patients, PFACs, or focus groups what this phrase means, their answers tend to coalesce around a couple of descriptions.
“I am telling them what is wrong and they won’t listen”
When I worked as a statistician, I would often get emails from clients complaining about an error in the data. Early on, I might spend an inordinate amount of time trying to identify a reason for the problem only to discover that there was not a problem with the data, but in what the client was expecting from the data. I quickly learned that I needed to verify the claim before I could determine an explanation. People might get cranky with me because they would interpret my desire to see the problem as my not believing what they were telling me. In reality, I believed that they saw a problem, but their claim that the data “was wildly off” or “not tracking” or “not correlated with the key driver” or “doesn’t seem right” was insufficiently detailed or useful to identify a cause/effect. Often, what they saw was not a problem with the data, but a problem with their expectations of how data should behave. The solution, then, was not to fix something, but to explain why what they were seeing was normal.
In health care, doctors are often confronted with the same dilemma. Patients may leave out details that they don’t feel are important, or may be embarrassing, in their recitation of their problem. There are other things that can impact treatment that seem unrelated as well. For example, a friend of mine was confused about why, at a procedure where she was going to get steroid injections for back pain, she was asked to take a pregnancy test. (Any procedure, especially those with anesthetic, can pose problems.) Furthermore, she was confused why they couldn’t just ask, rather than perform the test. (For those that don’t know, TLC, Discovery, and Lifetime have a cottage industry of movies and shows of women who didn’t know that they were pregnant.) I have read quite a few letters from parents indignant that their pediatrician was testing their teenage children for sexually transmitted infections or asking about their sexual history. (Do I really need to explain this one?)
Doctors, especially specialists or doctors who are new to a chronic complaint, want to evaluate the situation for themselves. Even if they have read the health record and listened to the patient, there is no substitute for first-hand evaluation, especially when the symptoms are episodic or ill-defined. So, even if three other doctors did a visual inspection, this fourth doctor will still start there to form their own opinions. Ordering blood work may be to verify that the last blood work was not an anomaly, or they may be ordering different tests to be performed. None of this is a failure to listen. It is about due diligence. This can be especially challenging when problems can create symptoms that seem unrelated. For example, most of the knee or back pain I suffer from can be directly related to the quality of the shoes I wear. It is not unusual that a doctor may ask about seemingly unrelated things, not because they are not listening, but because they are looking for an unobvious cause.
“The only one to get it right was the one who listened to me”
Doctors get things wrong and doctors make mistakes. If doctors use the same basic process of incremental thinking, they may all arrive at the same conclusion. Dr. Theodore Woodward coined an adage in medicine that has certainly found life in other parts of society: “If you hear hoofbeats, think horses, not zebras.” Whether the doctor stops at this “horse explanation” rather than investigating cows, mules, or llamas says more about their attention and follow-through than anything else.
If they adamantly state, “Horse!” and won’t move off of that position, that is definitely a them-problem. If they say “horse” and you say, “Ugh! You are like everyone else! I am out of here!” that might be a you-problem. Listening is a two-way street. If you scream, “not horse, zebra!” you are making the same mistake that you accuse them of making. You also have disregarded all other ungulates in favor of what you have decided is the explanation. At this point, when they say, “Not likely zebras, but perhaps a deer or maybe an impala…” they are listening to you, even if they are not just buying your theory out of hand.
In this situation, we cannot ignore the power of confirmation bias. This is when we tend to recall/repeat stories the conform to a narrative. For example, we all like stories where we are proven right, especially when we are discounted by others, even experts. These make great stories. I still tell the story of how my diagnosis of scarlet fever was made by my first-grade teacher, even as it was disregarded by the school nurse and my parents.5 These reinforce the notion that expertise is overstated. What is lost in this narrative, though, is how often we thought we were right, even as the world thought we were wrong, only to find out that we were WRONG. Only through working through all cases can we really determine whether we are under-appreciated geniuses, or, just as a stopped clock is right twice a day, we have gotten lucky.6
In the end, I feel the need to stress the fact that there are exceptions to the rule. Some clinicians are so focused on their solutions or so dismissive of the words their patients say that they are a caricature. But this does not mean that all doctors who seem uncommitted to a patient’s version of events is evidence of ‘gaslighting’ any more than it means that any patient with an ill-defined or generalized set of complaints is a ‘drug seeker.’ Both impressions indicate that the person brings to this conversation a set of preconceived notions that are severely altering their ability to move past some transactional experience to a fruitful, if at times challenging, journey to wellness.
1I know that my mother was not the first to ever utter this phrase, but it is where I heard it, so while the citation may go elsewhere, the flowers will go to my mom.
2Just yesterday, I heard an in-network dermatologist complain that he was not getting referrals from the system. It turns out that he was getting referrals, but patients were not going to him because he was a jerk to his patients.
3To be clear, I am happily married and not working through girlfriends. It is hypothetical. This does not, however, disprove the fact that I might be an asshole.
4Yeah, I know that I tossed in a stereotype about insurance companies, as I write about avoiding stereotypes. Those things are as pernicious as they are ubiquitous.
5As with all stories I tell, my father may have an alternate version of the facts.
6When compounded with “Main Character Syndrome” it can lead to an aggressive disregard for competing viewpoints.
PX Matters with Joseph Snipp 
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