The Way I See It

Being Dr. Nice Guy can backfire

Going out of your way to help some patients may get you into trouble with others, says this physician.

By Charles Davant III, MD

"No good deed goes unpunished." In medicine, that's no joke. A harmless kindness or small expression of friendship can lead to problems and ill will among your patients. I've learned the hard way how the law of unintended consequences can cloud the doctor-patient relationship.

Take a funeral I once attended. As funerals go, it was a good one. The deceased's departure was expected and ended her long suffering. She'd been an old friend, and I felt honored to have been her doctor. I barely made it from my office to the church before the service began, and an usher squeezed me into a pew near the front.

I'm sure I wasn't the only one to hear the whispered comment from a few rows back: "Well, the doctor didn't come to our mother's funeral."

The whisperer was the daughter of an elderly woman I'd cared for as her ovarian cancer drained her life. The daughter had called me at home the evening before her mother's funeral to let me know the time. As it turned out, I was on call, in the office, with patients hanging from the rafters. I'd have been hard-pressed to make it to my own funeral that day. But my absence at her mother's funeral had obviously offended her and her family.

The incident led me to rethink my attendance at funerals. As a geriatrician, I can reasonably expect most of my patients to die eventually under my care. But I no longer go to many funerals, even though I'm very close with patients and their families.

Now, I attend funerals only if I'd have gone anyway, even if the de-ceased weren't my patient. I have the same policy for flowers and memorial contributions. If I can't do it for everyone, it's better not to do it at all. I still send sympathy notes to some patients, since they're private. A floral display, on the other hand, is there for everyone to see, and to wonder why you didn't send one for their Aunt Maggie.

It's not just funerals that can turn a decent gesture into something troublesome. Many years ago, I was looking forward to a day off with my family when the phone rang. It was one of my grade-school classmates. I'd cared for his elderly mother for several years, although she "wasn't much for going to doctors," but I hadn't seen her for months.

"Mom's awful sick," he told me. "She's had a fever for the past three days."

I suggested that he take her to the hospital emergency room where my partner would be able to see her.

"You know how Mom is," he replied. "She'd never agree to see anyone but you. I think she might die if she doesn't get seen today."

Sighing inwardly, I agreed to meet them at the hospital. I arrived to see Mom sitting up in a wheelchair, announcing to all present that she "ain't got no confidence at all in any doctor but Dr. Davant." Sitting next to her, looking quite ill, was one of my favorite patients.

"I almost called you this morning, but I know it's your day off," she said. "And I'd never bother you on your day off."

I knew then that I'd be examining her also, leaving the other patients to wait for my partner, already burdened with Mom's announcement that she "ain't got a bit of confidence in him."

I walked into the exam room to find Mom fitted into a gown, sitting on the table, fixing me with a steely glance. "And who are you, anyway?" she asked. So much for confidence. Seeing me just minutes before obviously hadn't registered with her.

And so much for being too available. Play favorites among your patients, and you'll find yourself working overtime. You can't help but offend those you just don't have the time to see. Now, whenever I hear, "Mama won't see anybody but you," I don't waver. It's better to have a hard-and-fast rule and stick to it. My friend's mother wasn't all that ill, but treating the other lady wound up taking all morning.

Think about that "no good deed goes unpunished" axiom the next time you want to call in a prescription for a problem you haven't personally evaluated. I still recall the ire of a mother when I wouldn't call in a prescription for her daughter's ear infection while they were on vacation. I'm sure she badmouthed me while they waited in a strange ER. But we were all lucky that an alert resident did a lumbar puncture and diagnosed the child's meningitis. Had I been a "nice guy" and called in the prescription, I'm sure there would have been a long delay in diagnosis, neurological sequelae, and a major malpractice suit.

Another mother wanted something for a child's infected hand. She lived on my street and offered to "meet me at the fence" so I could take a "quick look." I referred her to the ER, where the child was soon admitted with erysipelas.

We doctors sometimes forget, at our peril, that it's dangerous and dumb to treat patients without actually seeing them. It's smarter and safer to have the same policy for all patients. If they are ill, they should see a doctor.

Shortly after I started practice, I did a physical on another old friend, a home improvement contractor. He had no insurance, but wanted a top-to-bottom going-over, which he got, along with a standard bill. "I didn't think you'd charge your friends like that," he said, hurt and insulted. "I like to think of all my patients as my friends" was my reply. "Were you really going to pave my driveway for free?"

Fees, billing, and collections are areas where a little kindness can sometimes do more harm than good. Patients often ask their doctor to waive a copayment or give them a discount. That's a bad idea. Waiving copayments is illegal under many contracts and can affect your entire fee structure.

I refer all requests about billing to my office manager, who is authorized to accept any "sufficiently sad story" and set up a payment plan. I ask only that the uninsured spend at least as much a month reducing their debt to me as they spend in a week on cigarettes.

Dispensing free samples is another area where generosity can go awry. I knew Joe was having a hard time buying his medications. So when he asked, "Got any samples, Doc?" I readily fixed him up with the latest thing, titrating his doses appropriately.

Things went well for several months until the samples dried up. Although the manufacturer had a generous indigent patient program, it required a copy of Joe's last income tax return. He didn't come close to qualifying. Now he's got to choose between dropping $100 a month on what he's used to, or starting over with an older generic he can more easily afford. Did I do him a favor? Probably not. Better to have taken his finances into account before starting the medication.

Transmit that same rule to your office staff. Tell them that the one sure way for you to monitor patient compliance and progress is by watching refill requests. For instance, if three dozen of a patient's antihypertensive pills have lasted him eight weeks, you'll know that his compliance leaves much to be desired. But if your staff is stocking the patient's medicine cabinet from your sample closet, you won't be able to keep track of his compliance.

No more Dr. Nice Guy? Not really. You can still be the doctor everyone loves, known for your kindness, wisdom, and compassion. Just be sure to temper your urge to do something nice for someone with the reflection that you may have to do the same for everyone. If you don't, you'll suffer for it.

The author, a family physician in Blowing Rock, NC, is a contributing editor to this magazine.

Charles Davant III. Being Dr. Nice Guy can backfire.

Medical Economics

2000;4:125.