Tuesday, December 28, 2004

The Nice Doctor

“I think it puts an interesting question to the audience: Would you rather have an unkind person who is right, or a kind person who is wrong?” Hugh Laurie, on playing a brilliant but asocial doctor on House.

I was asked this question, indirectly, by one of my doctors. The specialists who first diagnosed me with lymphoma referred me to my oncologist. After I met with the oncologist, the ENT who had referred me said that Dr. Schnur was a good doctor. I said he was nice.

The ENT showed a flash of irritation and suggested that good was more important than nice.

I know that, of course. The Reed-Sternberg cells that identify my malignancy don't give a rat's ass about Dr. Schnur's bedside manner. They won't politely roll belly up because he is caring and compassionate. Nor will the chemo drug bleomycin chemically alter in potency, like water to wine, in the presence of a nice doctor. And I want my clincian to be brilliant, thank you. I want him to be the guy that the son of the Sheik of Oman is referred to when he comes to the U.S. to be treated for lymphoma. (Not that the Sheik of Oman's son has lymphoma, or even exists, as far as I know, but Cleveland Clinic, where my doctor practices, gets it's share of wealthy Arab princes coming for medical treatment.)

So why, when Dr. Abelson said my oncologist was good, did I respond that he was nice?

Well, I've thought about it. And I appreciate Dr. Abelson's flash of irritation. Four years of med school, residency, specialization, boards, constant work of keeping up with the literature on top of long hours of practice, all to be the best, most informed, physician that he can be and patients worry about nice. But unfortunately, I say to you, Dr. Abelson, as a patient I have to take that on faith.

When a patient sees a doctor, we really can't judge how good the doctor is. I mean, I have some clues; the Cleveland Clinic has their pick when it comes to hiring, and I was referred to Dr. Schnur by another physician. I can get a second opinion. I can even pay a fee to an online service which will tell me where the doctor was educated, what boards the doctor passed, and whether the doctor has been subjected to disciplinary action. But I can't tell if the doctor is good.

Thanks to the legal climate of malpractice, there is an aspect of doctor patient care which is adversarial. There are things doctors can't say, and things they are forced to say in carefully circumscribed language. So some of the relationship between doctor and patient is in code. And I was sent some good signals by other doctors. My general practitioner was pleased to hear who my oncologist was. Good sign. But the truth is, for all I know everybody likes him because he's easy to talk to, or they play poker together on Thursdays. There's no Consumer Reports on doctors. (And in fact, there's an interesting article on that in The New Yorker and they have an interesting online interview with Atul Gawande about his article at the New Yorker site.)

There's an old joke.

Q: What do they call the guy who graduates last in his class at med school?
A: Doctor.

So I go to the doctor and I'm apprehensive. I'm looking for clues. One of the things that's important to me is how a doctor takes my history. How he or she listens. What questions he or she asks. What he or she does when touching me. How he or she looks at me. And whether he or she talks back to me. I like information, so doctors that say things to me like, 'Do you want to see your CAT scan?" score high on my doctor scale. I particluarly like a doctor that seems to show a little care about how much I want to know. I know some patients don't want too much information. It matters to me that my doctor seems to be gauging how much information that I want. It matters to me that my oncologist seems to have all the time I need when I'm in his office.

And I've been conditioned by years and years of medical shows--from Dr. Kildare, through Medical Center and ER to now, House, that if my doctor gets involved in my case, he'll go the extra mile, and he'll save me. I want him to like me. I want him to show engagement with me. I know I have a rather textbook presentation of a really curable disease and that I seem to be responding to treatment pretty much as expected, but it's not my textbook, it's the doctor's. In my textbook, I have the most serious illness I've ever had in my life.

I don't have a word for all of that. So I default to that wimpiest of words--nice. Yeah, I'd prefer a brilliant doctor who's an asshole over a mediocre doctor who bakes cookies for me, but I don't get to make that choice.

So I hope my oncologist is an excellent clinician. (And actually, I think he is.) But I can report confidently, he's nice.


Blogger Madeleine Robins said...

It took me years to realize that I become very chatty with new doctors: its my misbegotten way of trying to establish myself as a Person, as someone worthy of being fixed.

My primary care physician in NY was an internist--an infectious disease specialist--would always begin with a chat, sitting around his desk, about how things were, what I was doing--and the great unspecified question: how my stress level was, since I turn stress directly into ailments without passing Go. And he listened. I'm not sure that made him a better doctor, but it made my answers and much more thoughtful and useful, and it made me more likely to listen to and follow his suggestions. I really miss that. (The new guy is clearly a good physician, but when I'm talking to him I get the sense that he's already thinking about what he's about to tell me.)

I do notice that on House they surround Hugh Laurie's character with sympathetic junior doctos--and perhaps suggest that they are slightly lesser doctors for their sympathy.

I'm glad you have a nice doctor, Maureen. I'm glad he's good, too.

December 28, 2004 12:28 PM  
Blogger Ken Houghton said...

The only doctor on whom I ever just gave up (and who was highly recommended by a friend whose judgement I respect) was someone whose every opening comment was about the amount of paperwork he had to do.

In fairness, this was the mid-1990s and he had been practicing for a long time during the pre-HMO years, when it was still possible for a GP to make a (very) good living and complete all their paperwork and pay attention to patients.

The strange conceit that being "nice" to patients doesn't matter assumes that it is a teacher-student relationship in which case--as Charlie might note--students will always prefer--and likely learn more from--the teacher who is interested in them.

What good is being the world's best diagnostician if you can't relay the information to the patient in such a way as to make them understand the what and why of how they will be treated and need to act to make treatment a success?

December 28, 2004 5:51 PM  
Blogger Madeleine Robins said...

Or someone who cannot elicit useful information from the patient, for that matter.

December 29, 2004 12:01 AM  
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