Patient Interactions

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My favorite part of medicine is
interacting with patients. My second favorite part is fitting the puzzle
together, piecing all of the various bits of data from history, exam, labs and
the literature to form a coherent image. For some providers, I suppose, that is
the most exciting part. Dr. House comes to mind as an example of that disease
oriented provider. Others are all about the procedures. They just enjoy getting
hands on the patients, physically manipulating the diseased part, and providing
healing that way. I suppose that category would include most surgeons. I find,
however, that most patient encounters do not require much puzzling. Most are
actually quite straightforward. Hardly of my patient encounters
require procedures, although they are fun when they happen. However, every
patient encounter includes an encounter with another human being. Sometimes
these encounters are memorable, sometimes not. Sometimes they are fun, and
sometimes they are not. Sometimes there is good rapport, and sometimes it seems
that you are speaking totally different languages. Regardless, the encounter is
always an encounter with the ineffable other of a human being who is not
Tacoma is known for having a very high percentage of Asian
populations. In fact, South Tacoma Way, one of my favorite strips for Asian
cuisine, is informally called “South Korea Way.” Street signs are even labeled
in Korean. Being a Special Forces soldier, my training includes a foreign
language, which, in my case, is Korean. I would not say that I am fluent. I can
order food, exchange pleasantries, and maybe chat a little bit about C. S.
Lewis’ book “The Four Loves,” (I memorized a good deal of vocabulary for that
book when I was preparing for my Korean speaking and listening test). It is
not, however, to allow me to hold a conversation with ease with a native Korean
Several of my patients over the last
two weeks were older Korean ladies, wives of Korean war veterans. I usually
enjoy chatting with them a little, enough to say “Hello, how are you doing,
where does it hurt?” One patient, in particular, was a very sad looking Korean
lady who complained of fatigue, tiredness, pain, and heartburn. We talked with
her for quite some time trying to come up with a list of her complaints and
prioritize them, but she was a very listless and haphazard historian and she
complained of confusion. Finally I asked, in Korean, “Sunsengnim (term of
respect), do you get confused talking in Korean?” Her eyes widened and she
repeated my question back to me in more correct vocabulary. I asked about her
Korean friends, and she shook her head sadly.
“I not trusting Hanguk (Korean)
peoples, they not sharing feeling. They nod yes, yes, when talk but later they
like this behind you back,” she made a blabbing gesture with her hand. I asked
if she had any American friends and she said, “I no likey Miguk (Americans)
either. They just talking talking saying whatever come in they head. I not like
While the doctor typed his note we
chatted about this and that, and she slowly became more and more at ease. It
was more “konglish” than either Korean or English. I learned that she was very
lonely, and almost always sad. Her house had been broken into (she lived alone)
and she just felt nervous and unsafe. She gave me an impromptu lesson in Korean
language, history and folklore, and explained why the Korean number 4 “sa” is
considered unlucky. I very much doubt we were able to provide any lasting
relief for her symptoms, as I strongly suspect most of them had a behavioral or social health
basis. She was a sad, lonely old lady, and she needed a friend and a hug more
than she needed pain medications, but her fears and isolation kept her from
those, so pain medication was all she could understand. However, she seemed to
be put at ease by my broken attempts to speak and listen to her in her own
language, and there was even something like a half ghost of a smile on her face
when we shook hands goodbye.
Was that a good interaction? A positive
one? I would not classify it as such, objectively. We learned very little to
point our way to a treatment plan, and I do not have much hope that her
symptoms will ever be resolved strictly by medicine. However, the attempt to
reach out to her was just a little less negative than it otherwise would have
been, and I think therefore it was more than worth it.
Another Korean lady the same day came
in for coughing and post nasal drip, but she refused to believe that she had
allergies. She was very upset at not being able to see her regular doctor (who
was on maternity leave) and she denied ever having taken allergy medicine that
her doctor had prescribed her. “I throw that medicine away, because I not like
takey the pills!” It was hard not to laugh. She was about four feet tall and
about two inches in diameter and bound and determined that something was wrong
with her, because she could not stop coughing or sneezing, but it was NOT
allergies! Bless her heart!
No amount of cajoling in English or
Korean could convince her that, yes, in fact she very likely did have
allergies, and it was perfectly normal and treatable. We tried to get her to
promise at least to try the allergy medicine. When she would not we tried to
sneak it into her medicine list without telling her what it was for! We said,
“Oh, that’s to make you sniffles stop,” which was true, but she would have none
of it. “I not takey the pills.”
Finally when the visit was over she
stood up and said, “Thisa better working. You not makey me better I go to
Korean doctor!” I felt like saying, “Fine! Go to a Korean doctor! What sense
does it make to come to a western doctor and then refuse to take western
medicines?” She never got angry, she just laughed at us like we were too
ridiculous for believing that she was so weak that things like allergies and
pills could apply to her. She did, however, tell us most emphatically that
kimchi was going to keep us young and healthy and that I was going to live
longer than the doctor because I loved kimchi and he “only likey the pizza!” He
had never said that he didn’t like kimchi, he simply had never tried it, but in
her mind that lumped him in with all the other pizza eating Miguks!
I cannot get angry at patients like
that. I love their eccentricity, and I respect their autonomy. God bless them,
if they want to grow old and cantankerous and get their kicks out of making fun
of western medicine, more power to them. I hope I have enough spark left in me
when I am old to be grumpy and funny like that.
The patients I feel sorry for are like
the 60 year old man who came in for a regular checkup. In the course of the
interview he mentioned having a new feeling of shortness of breath whenever he
walked up hill. This prompted a deeper interview, a physical exam, an EKG, and
the end result was that he was going home with a bottle of nitro, a bottle of
baby aspirin, and a follow up appointment for an exercise stress test. As the
appointment progressed and the diagnosis took shape, I could see the growing
possibility reflected in his face and posture. His shoulders sank, more and
more, his face became more and more bewildered, distant, afraid. It was a
relief when the doctor finally said the word: “Heart disease.”
“We need to make sure you don’t have
heart disease.” Amazing how we all knew that was what we were talking about,
but we were reluctant to say it.
“Are you doing okay?” I asked.
He looked up at me. “I guess. It’s just
I have a lot going on at home. I have family troubles, and my dad is not doing
too well, and now this.”
“A hell of a thing,” I said.
“A hell of a thing” He agreed. His
dad’s brothers had died in their early sixties of heart attacks. His face fell
even further when he found that he could not work out until after the stress
test, because of the risk of having another incident. “I can’t go to the gym?”
His build spoke for itself. Despite his slight beer gut, his shoulders and arms
were thick and powerful. He had been lifting his entire life. Now he would have
to give it up, perhaps for a very long time, perhaps forever. Not only that,
but because Viagra reacts synergistically with nitroglycerin, and can cause a
catastrophic drop in blood pressure, he could not take Viagra until after the stress
test, when we would have a better plan.
He looked at the doctor. He looked at
me. “No weight lifting? And now you tell me no sex? Doc, what’s the point?”
At times like this you feel guilty
about the clock, ticking away, reminding us that his appointment was only
supposed to last twenty minutes, and that is long since up. How do you kick him
out the door so the next patient can come in and tell us all about his acne and
how it is affecting his social life?
I might be getting old, or maybe my
parents were just poor and backwards (poor they certainly were) but it never
would have occurred to them to take us to the doctor for acne, especially not
acne so mild as to be invisible under long, thick black hair. There were a
dozen or so cystic comadones around the hairline on his forehead, and another
dozen along his hairline in the back. This rates a trip to the doctor?
And yet, it is a big deal to him. It
never was to me, (I could have cared less for popularity at that age) and that
may make it difficult to relate. One hopes that he grows to be a little less
concerned about such things as he gets older and gains perspective, but he is
not older. He is a teenager. This is where he is, this is important, and in its
own way it is as devastating to him as a tumor would be to me. Why should I
allow my age and experience to deprive me of empathy for his lack of age and
experience? Would not that be shallow mindedness without even the excuse of
youth and ignorance? And how difficult is it to prescribe some erythromycin
face wash and an exfoliant? We sympathize with many, many older patients who
are just as silly, and with less excuse. Certainly in my life many, many older
and wiser people have put up with my ignorance and silliness. Shall I refuse to
do the same for him?
So I resisted the urge to write him a
script for “soap and water” or “a nice cup of man the heck up!” and provided
one for face wash instead. I wish him well at his next high school social
function. He was a nice kid, after all.
In reviewing these patient encounters I
find it very difficult to classify them as “positive” or “negative.” That is
more or less to be expected. Any encounter with another human being is
essentially an encounter with the unknown. We do not hear the other perfectly,
we do not communicate perfectly. The best I think we may expect of ourselves is
the continual effort to be present; beyond all filters, preconceptions,
contexts and languages, present for the other to be the other. Is it possible?
Probably not. It is a worthy effort, I think, for only thus is any real meeting
possible between humans. So, in any encounter, there is always more that could
have been achieved, or less that could have been said badly, or some aspect
that could have been improved. It is never perfect. The mistake, I think, is to
try to reduce it to a technique. Technique is a tool, body language, active
listening, participatory conversation techniques, or what have you. The
essence, however, is goodwill towards the other. It is goodwill that will
overcome all barriers, and hopefully shine through our clumsy, inept attempts
at using our various languages, to communicate with something essential in the
other person. On that level, perhaps we may even hope that some kind of real
healing might occur.

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