Physicians

Why Is the Doctor Angry?

I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy.  Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out.  Day-by-day he lay in bed, as he grew weaker and multiple systems failed.  No one contacted me.  Finally, he sent an email to a doctor 3000 miles away, in California.  That doc forwarded the email to me.  I sent the patient to the hospital.

Did we rush to the emergency room, to salvage his life?  Of course.  Were there innumerable tests, complex treatments, multiple consults and an ICU admission?  You bet.  Did I patiently explain to him what was happening?  Yes.  Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor?  Did I remind him what I expect from him and what he can expect from me?  You better believe it, I was really pissed!

The practice of medicine for most doctors is fueled by a passion to help our fellowman.  This is not a vague, misty, group hug sort of passion.  This is a tear-down-the-walls and go-to-war passion.  We do not do this for money, fame, power or babes; we do this because we care.  Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning.  Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.

I know that patient autonomy gives each person the right to decide what path they wish to walk.  I really understand, after 27 years in practice, that not everyone is going to listen to me and that I occasionally fail or am wrong.  I welcome a healthy debate and ongoing interaction about decisions.  In the end, the patient is in charge and I am just the guide. That does not mean that I am not going to try to do the best for every patient and that certainly does not mean I do not care.

Often when a patient makes poor and arbitrary changes in medical care, it reflects denial and an attempt to maintain control.  These are critical needs and must be respected. However, there is a line which if patient or doctor cross, tragic, unnecessary things occur.  The dread disease gives not quarter, even if I am tired, distracted, depressed or ignorant.  Cancer demands my complete commitment to its destruction.  It demands the same focus on battle from patients.

Therefore, when patients stray without good reason, I get anxious.  When they make bad decisions I get upset.  When they needlessly modify treatment, my head begins to spin.  When patients yell at my staff, while I understand their stress, I worry they will undermine their care.   And because this is oncology and because the stakes are so high, in the most direct and supportive manner, I will let the patient know.

I think one of the differences between young doctors and us old salts, is we how express such anger.  Newer docs are full of fresh vim-and-vinegar passion and so upset by the harm that is about to occur, that they raise their voices and may berate their patients.  Senior docs know, because they have fallen into the losing-your-temper trap, that this backfires.  Patients, already under stress, cannot cope with a shouting off-the-wall physician.  Experienced voices instead drop, words slow and we sit down on the bed and touch a hand, rather than pace and punch the wall.  Do not mistake controlled continence for calm or uncaring; inside we are seething, fuming, on fire.  I tell you, until the day we die, we really get pissed!

Beating difficult disease involves an unwritten contract between patient and doctor.  Each has their role, and the patient has much more to lose by violating that agreement.  If you do not like the treatment, make a change.  Let the doctor know, negotiate a new plan, change caregivers if you need.  But, once you set that plan, once the two of you decide on the steps to be taken, it is up to you and your doctor to each do their jobs.  Cancer cannot be beaten any other way.

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

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pulsa aquiP. DelaneyGreg PawelskiPaulaJames Recent comment authors
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pulsa aqui
Guest

Buenisimo post. Gracias por publicarlo…Espero màs…

Saludos

pulsa aqui http://www.pequenaspromesas.com

Greg Pawelski
Guest

There is some innate goodness of people who go into oncology. At the time when most oncologists practicing today made the decision to become oncologists, there was no chemotherapy concession. Most of them probably had a personal life experience which created the calling to do battle against the great crab. At the time people make their most important decisions in life, people are at the most idealistic period of their lives. In their environnment, it is mandatory from a purely human standpoint, to take refuge in the smallest of successes. The shrinkage of a tumor lasting four weeks. The temporary… Read more »

Paula
Guest
Paula

Fascinating post. My own suspicion is that if a patient under these circumstances is not following the doctor’s plan of care, there is a reason. I don’t mean to suggest that the doctor isn’t “right,” insofar as “right” means that he has prescribed the “correct” treatment or course of action based on considerable experience and training … but as the daugher of a woman who eventually took her own life to end her suffering from terminal cancer, I have seen a patient’s failure to comply from a cancer patient’s point of view. Here are a few reasons why a patient… Read more »

Vince Kuraitis
Guest

Paula, WOW! what a thoughtful answer to my earlier question of “I wonder what the patient’s side of your story would be.”

Thank you.

James
Guest
James

In the course of my work I get to see the large patient populations and an overview of speciic cases. A lot of time is spent looking at super-utilizers. Things I wonder about in this case: 1. Was the patient, as mentioned earlier, perhaps “out of it” due to effects of the chemotherapy or other medications. 2. Was the patient suffering from a mental illness? Someone with severe depression may lack the motivation to respond to their own decline. They are, as another comment noted, tired of it all. 3. Was there something else going on with this patient that… Read more »

JS
Guest
JS

This is from a patient ofvminewho i sent this to; Now you want to hear why the patient is angry? “Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out.” So, instructions on when to reach out, who to call and when, and what to look for, were not clear enough, regardless of what the doctor thinks. “Finally, he sent an email to a doctor 3000 miles away, in California.” This doctor should be ASHAMED that a doctor 3000 miles away was more… Read more »

Steve Wilkins
Guest

Dr. Salwitz speaks of “an unwritten contract between patient and doctor” with respect to what is the role of the physician and what the patient’s role is. What exactly are the terms of that “contract”? Does each party to said contract understand and agree their respective roles? Was there ever a discussion between you and you patient as to your respective roles and what those roles looked like under circumstance such a the scenario you described in your post? Did you ever tell the patient that it was OK for them to “challenge” you on your treatment recommendations? Did you… Read more »

Merle Bushkin
Guest

Is it possible that your patient’s behavior reflected his desire to throw in the towel?

Mighty Casey
Guest

Kudos for your humanity, Doc. During my own cancer tx, I fell under the tender ministrations of a guy I came to call Doctor Drive-By because he spent so little time actually *talking* to me. I would certainly have called him (and did) when experiencing any side-effects, expected or not. The response was enough to make ME mad, but I got over it.

There’s a gaping hole in your narrative, though – what your patient said was his thinking behind acting like a dope. Because, given the story you’ve told, “dope” is pretty right-on, IMO.

RN
Guest

It’s refreshing to hear a real and honest opinion on this topic. In this case it sounds perfectly natural for you to be angry…You’re putting your life’s work into helping people, and it’s only normal that you would expect that they hold up their end of the bargain. This is true for any job really, but becomes especially important when one’s life is on the line.

P. Delaney
Guest
P. Delaney

What is this ‘bargain’ you speak of? There is no bargain. This doctor exhibits no skills at interpersonal relationships with an understanding of this client’s life situation and personality. There are those who will not ask for help for various reasons (culture, age, family background). I would be pissed if a doctor came to give me a lecture in the ICU. What a jerk!

Vince Kuraitis
Guest

I wonder what the patient’s side of your story would be.

Ren
Guest

Wow, I never thought of how doctors feel about their patients, Thanks for sharing that story.

P. Delaney
Guest
P. Delaney

Yes, it’s frightening, actually.

Cy Cedar
Guest
Cy Cedar

I’d be a lot more enthusiastic about your message if there was some mention, any mention, of the patient’s support system. I suggest that there is a problem when you expect responsible self advocacy from a chemo patient, doubly so from a chemo patient experiencing serious side effects. Perhaps some of the phone calls you expected could have come FROM your office, perhaps to the patient’s family. Perhaps the patient education you undoubtedly performed was misdirected, if it had a single point of failure (the chemo patient). How does the money spent on emergency care, in this failure, compare to… Read more »

Jerod Loeb
Guest
Jerod Loeb

As a stage IV cancer patient, 35 year health care professional, and quality/patient safety zealot, I can only say kudos for your incredible insights. You have hit the nail on the head with this post. In my 20 month cancer journey (so far), I have had exposure to oncologists like you who “get it” and those whom, unfortunately, will never understand disease from the patient’s perspective. Finding a caring, compassionate, knowledgable and humanistic provider is not a given…..especially in oncology, where occasional thinking outside the box of “standard of care” should be a routine expectation. Evidence based medicine is a… Read more »

Sandra_Raup
Guest

It makes me sad when hearing about patients and/or physicians getting mad at each other. I wonder if this is part of why a team approach works better than a solitary physician-patient relationship. Patients often have such fear of not having medical care when they are in vulnerable states of mind that they don’t feel free to be frank with their “saviors”. (This has been studied.) And physicians often don’t give the impression they have lots of time to talk, anyway. Patients value the expertise of their physicians and don’t want to challenge it, but they may need to have… Read more »