by Danielle Ofri
New York Times
“What can I help you with today?” It’s the question I open every visit with, but it heralds a moment of suspense. The reply is what doctors enter into the chart under “Chief Complaint,” but it’s really a moment of suspense because you never know how a visit will unfold.
I recently posed this question to a patient, a healthy middle-aged woman whom I’d seen once before, a year earlier, for a routine checkup, as I ushered her into my office. I smiled as we sat down, prepared for a straightforward visit.
She stared stonily at the wall in front of her as my question hung, too long, in the air. “I almost didn’t come back today,” she said. “I was ready to choose another doctor, but I decided to give you a second chance.”
There was a reflexive start in my chest from her unexpectedly harsh reply, but I held my composure. What could this be about?
I quickly scanned the chart from our last visit to see if there had been anything we’d disagreed about or any unresolved issues. But no, it had been a routine checkup. Nothing beyond standard health screening issues and some run-of-the-mill acid reflux.
“Someone had said you were a good doctor,” she said derisively, still addressing the wall, “but I was not impressed. My previous doctor, even though he was just a resident in training, was much better than you.”
That certainly stung, especially since I still had no idea what had transpired between us, but I endeavored to stay quiet and let her finish speaking.
“But he graduated, and now I’m stuck with you.” She folded her arms across her chest, pursed her lips, and then was silent.
I kept my voice as low key as possible. “I’m so sorry if there was something that upset you. I’m trying to recall — —”
“You don’t remember?” she snapped. “It figures!”
Now I was scraping desperately around in my mind. What had I done? Making a patient livid isn’t something you typically forget, but I couldn’t come up with anything for this patient.
“I apologize,” I said, as genuinely as I could, “but I honestly don’t recall what happened. Could you tell me?”
She looked at me for the first time, her eyes taut and icy. “You didn’t do a physical exam! All you did was talk to me, and then you handed me a prescription. My old doctor always did a physical exam, but you didn’t even bother.”
My jaw actually dropped when she said that. I’d forgotten the physical exam? How could I have done that?
As an internist, I’m well aware of the limits of the modern physical exam. For most medical ailments, nearly all the crucial diagnostic information is gathered in the history, in the conversation between doctor and patient. The physical exam serves mainly to confirm the diagnosis, though once in a while something unexpected does turn up. And, as I’ve written here, it remains an important part of my interactions with patients, a refuge from the encroachment of technology that can help foster intimacy and often uncover a patient’s true concerns.
So now I really did feel like an idiot, both negligent and a hypocrite. Looking back at my notes, I honestly couldn’t tell if I had been running late that day, or was distracted, or simply had a momentary lapse. But the simple truth was that I’d neglected part of the medical visit and the patient was appropriately calling me on it.
“I am truly sorry,” I said to her after composing myself. “I honestly have no idea why I didn’t do a physical exam that day. I really don’t.” I placed my hands down on the desk between us. “I can only offer you an apology, both for my shortcoming that day and also for the bad feeling that it left you with.”
She gave a small nod of acknowledgment, and the muscles of her face softened somewhat.
Our gazes simultaneously traveled to the exam table and then back to each other, questioning. “It’s up to you,” I said. “I would completely understand if you would feel more comfortable with a new doctor.”
She shrugged. “Like I said, I’m willing to give you a second chance.”
It was an awkward physical exam, no doubt for both of us. I felt like I was being given a test but appreciated the opportunity to face up to a mistake and work through it.
Though “objective” measures of “quality” abound in medicine these days, getting meaningful feedback is actually quite rare. Getting it directly from a patient, rather than on a spreadsheet from an institution, is rarer still. And even though it’s never pleasant to be reminded of your shortcomings, I actually felt quite lucky that this patient had the grit to come back and tell me directly. She could just as easily have moved on to another doctor, and I never would have known.
It makes me wonder how many other times I may have disappointed a patient but been completely unaware. I’m sure the number is larger than I’d care to acknowledge, and probably rising as time pressures and documentation requirements mount.
I thanked my patient for giving me a second chance and we parted cordially. I’ll find out next year if I passed. (from the New York Times)