A lesson in misunderstanding.
Posted Feb 12, 2018
Last summer, I was at a friend’s house for dinner and started to feel cold. Those friends always overdo the air conditioning, so I put on a sweater. But the cold settled in to a chill that wouldn’t go away. By the time I got home I was staggering; it was like I’d been hit by a truck.
My fever rose, hitting 103. And as the days dragged on and the fever persisted, I started to feel like I might never get better. I tried to get up and do some work, but ended up on the floor, papers scattered around me. On day five, the fever still hadn’t broken and I noticed a strange rash on my belly. When I developed severe muscle pains, I gave in and went to a local urgent care office.
I’m a doctor: a neurologist. I take care of patients, including doctors, and I’ve been a patient many times. The special case of the doctor as patient has been written about before; the topic is not new. But I learned something new in that half hour as a patient that changed my way of thinking about how people understand each other, or fail to, and how that misunderstanding can get in the way of care—and not just care of doctors.
The urgent care suite was modern and clean, the staff polite, the wait time short. At first, my meeting with the doctor went well. He listened to my story attentively, nodding as I added details. But things started to go wrong once he realized I was a doctor too. He finished examining me and raised his eyebrows.
“You’ve got quite a bit of lymphadenopathy,” he said. This means swollen lymph nodes—that I knew. He pointed out one in particular that was quite swollen. My mind started turning—I’ve probably got some nasty virus, and my throat hurts, so no surprise. Plus, I often have prominent lymph nodes even when I’m not sick.
He took a throat culture; the rapid strep test, usually accurate, was negative. I’d been hoping for a quick diagnosis and treatment, but no.
“We could send additional blood tests if you’d like,” he said. If I’d like? Who likes blood tests?
“Do you think I need them?” I tried to communicate my confidence in his knowledge, which I truly believed to be better than mine about general medicine. “I’m just a neurologist,” I said, smiling. “What do you advise?”
“I’m happy to send them for you so you can be sure, if you prefer.” Sure of what? Prefer?
“Er, what were you thinking of sending?”
“We could send a blood count and Lyme disease tests, plus maybe liver function tests.” I hadn’t been bitten by a tick. Liver function? “Or you can get blood drawn later if you aren’t feeling better by next week.” I tried not to think about what illnesses would make me feel that bad for that long. Then I wondered what would happen if I didn’t get blood tests in time. In time to do what? In the end, I left without blood tests, feeling uneasy.
In the car, I put my hand up to feel my neck. That WAS a pretty big lymph node. I called the doctor.
“Doctor Winawer,” he said over the phone, “how can I help you?”
“This lymph node is pretty big.”
“Well, given your viral symptoms, it’s probably not lymphoma,” he said. Lymphoma? Cancer?
“OK, thank you,” I said weakly. It took me a while to calm down.
I started to feel better after a few days—it was just a nasty virus. But I began to think about what I’d learned from the experience.
There are specific challenges to doctoring doctors, and to being a doctor-patient.1, 2 Doctors may be assumed to know more than they actually do about their own health, or may be asked to determine the direction of their care when they are reluctant, or unable to do so. On the other hand, it may be difficult to incorporate a physicians’ potentially useful knowledge into therapeutic decision-making. When doctors become patients and decide to write about it, the stories told can be illuminating, providing important fuel to improve medical education and health care.3 This perspective is particularly helpful when the doctor-patient relationship fails—as mine did with that urgent care practitioner last summer.
I realized that the doctor assumed he understood what I needed, but he didn’t. He thought I’d want lab tests, or want to make my own decisions about testing, and didn’t seem to hear when I repeatedly asked him for help with the decision. And he thought nothing of mentioning lymphoma when I’d come to him expecting strep throat, frightening me, apparently without realizing it. Could these misunderstandings have been avoided?
The fundamental problem was that he saw me as a member of a group rather than as an individual, and that group happened to be physicians. Once he heard “Doctor” he stopped there, not bothering to find out more about who I was, what I knew and didn’t know, what I needed, and what I feared. Because he assumed I wouldn’t want to be treated “like a patient” he put me in the "doctor" category instead.
Treating me on the basis of group membership led him to make incorrect assumptions about how to take care of me. This is the definition of stereotyping—using a widely held oversimplified image to define someone, and in this case, to treat.
Stereotyping in patient care can have devastating effects. Studies demonstrate that racial stereotypes about the biological experience of pain persist in both lay and medical personnel, and that those stereotypes influence pain treatment. 4,5 Stereotypes can erode the benefits of the therapeutic relationship, impairing communication and acceptance of care, and can lead to persistent misdiagnoses, such as falsely labeling someone as HIV positive.6 Healthcare stereotyping can also lead to worse health outcomes: lower vaccination rates, increased depressive symptoms or hypertension, and importantly, it can make patients feel worse.7 Errors stem from incorrect assumptions, and stereotypes foster those errors, some with terrible consequences.
Fortunately, my brush with stereotyping resulted in just a few days of worry. But it also made me consider how I care for patients. I’ve made assumptions before, and I will probably make some again. But I hope now I’ll do so less often. Instead of assuming I understand what someone thinks, feels or needs, particularly because of a group they belong to, I must remind myself to ask. And once I ask, I’ll try hard to listen.
Kay et al. Doctors as patients: a systematic review of doctors' health access and the barriers they experience. British Journal of General Practice, July 2008 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441513/)
Tomlinson J. Lessons from “the other side”: teaching and learning from doctors’ illness narratives. British Medical Journal Careers, June 2 2014.
Hoffman KM et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences 2016 April, 113 (16) 4296-4301. https://doi.org/10.1073/pnas.1516047113 http://www.pnas.org/content/113/16/4296.full
Todd KH et al. Ethnicity and analgesic practice. Annals of Emergency Medicine 2000 Jan; 35(1):11-6. https://www.ncbi.nlm.nih.gov/pubmed/10613935
Ofri D. Stereotyping patients, and their ailments. New York Times June 20, 2011 http://www.nytimes.com/2011/06/21/health/views/21cases.html
Abdou CM et al. Heathcare Stereotype Threat in Older Adults in the Health and Retirement Study. American Journal of Preventive Medicine Feb 2016, Vol 50(2) 191-8. http://www.ajpmonline.org/article/S0749-3797(15)00425-0/abstract)