Story time for patients who won't listen

Our Family Medicine OB group keeps in touch with each other over WhatsApp. This is where we sort out our inevitable On Call issues, ask questions, share the latest gossip, and commiserate with each other. There’s another, allegedly, even more secure app where we tell each other about what we euphemistically call “Patients of Note” i.e. the patients who are giving us nightmares. This is where we discuss the patients with complications, the psychosocial disasters we want our colleagues to be aware of, like “Admit as Jane Doe, make sure to not disclose that the patient is in hospital. Her ex-husband just got out of jail and is looking for her,” and other issues common in our “low risk” practice. Read: Hospital food: the good, the bad and the ugly This time there was a flurry of posts about the patient of one of my colleagues. This young woman was pregnant for the first time and her fetus was falling off the growth curve, having gone from the 65th percentile to the 5th over the past two months. Her doctor had long discussions with her about why she needed an induction, but with the advice of her mother she had refused, saying that she had been born small and this was likely just normal for her. She was booked for induction, came in and decided to leave “because the baby was OK.” She agreed to come back in two days for a non-stress test which was equivocal, and had another long discussion with another colleague who again recommended induction. She refused, but agreed to come back the next day, for a formal Biophysical Profile. I know my colleagues, they are both very competent and good communicators, yet somehow they could not penetrate her belief system. When I was on call the next day, I’d been prompted by my colleagues’ increasingly frantic posts that I had to get this baby out. My resident that day was a lovely young woman, who was doing an elective with us with the view of applying to our Fellowship. She was keen. We did the non-stress test again and it was again, equivocal. While we waited for OB to get out of a C-Section, we chatted with the patient and her mother. A few things became apparent. First we could see that the patient had been frequenting the worst of the Obstetrics Internet, where doctors were portrayed as evil, money grubbing, soul denying fiends. Second, that she was floating down that river in Egypt. Her denial was so potent that she told me that my two colleagues had not recommended an induction for her. All she had heard was the caveat, “of course we won’t force you.” Read: The Bubbie business I then gave her a little lecture on placental pathophysiology, and how we could tell the difference between constitutional smallness and Intrauterine Growth Retardation. I told her that I knew that she loved her baby and wanted to do her best for her. I applied a combination of compassion, guilt and gentle coercion. I made her tell me what I had just told her. I enlisted her mother into the good grandma club. I called her doctor and had her tell the patient that she had, in fact, recommended induction. When the Biophysical showed that the fluid levels were dropping, I told her that I would not force her to be induced, but if she were my daughter I would be forcing her. I pulled out all the tricks in my bag and we got the show on the road. “That was a Master Class in communication skills,” said my resident. “It was really patient-centred, and clear. You explained what needed to be done so well, you didn’t let her not understand. The patient could really see that you cared about her and her baby.” I pride myself on my communication skills. I was one of the authors of the CanMeds communication competencies. It’s a lot of what I teach. Yet so often, students and residents will comment on how “nice” I am. They seem to conflate explaining the physiology to patients, understanding their ideas of what’s happening and making sure that they understand what and why they need to do something, as some kind of intrinsic kindness which is an optional added extra. They think it is a nice trait to have, rather than some of the central skills of every physician. This makes me very grumpy. These are not gifts from the good goddess of medicine. These are skills, to be learned and practiced and applied. You can be the most brilliant diagnostician in the world and be able to make the most up-to-date and elegant plans, but if you cannot get the patient on your team, you are doomed to failure. The easy way out of this is to blame the patient for being at fault somehow. Yet most patients want help. That is why they come in. But as Michael Balint said in The Doctor the Patient and his Illness in 1957, “True healing can only happen when the doctor and the patient agree on the pathophysiology.” The next day the baby was born. The tracing was scary at the end. There was a vacuum delivery and the baby needed resuscitation, but ultimately all was well. I guess the induction happened just in time. Read: Chocolate cake: a medical metaphor

Story time for patients who won't listen

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Perle Feldman

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