It's not just what we say

August 6, 2004

This doctor learned the hard way that how he explains treatment options is as important as what he tells the patient.

This doctor learned the hard way that how he explains treatment options is as important as what he tells the patient.

I was a first-year family practice resident when I first met Grace B. She was 62 years old, tall, thin, and still quite active. She had ghost-white hair, a kind, gentle demeanor, and an endearing, cock-eyed smile. As I got to know her, I became quite protective of her. She was the first patient I considered "mine."

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I treated her Bell's palsy, which left her with a wrinkle in her smile, and performed her yearly physical exams, gaining more confidence and experience with each visit. She didn't force me to think hard very often, because her problems were usually routine and minor.

On her final visit with me, she complained of a common problem for elderly women—bladder incontinence.

"It's not anything I can't live with, Doctor, but it's embarrassing. It's getting bad enough that I'm afraid to go out with friends because I'm worried about having an accident."

I presented her case to my preceptor, Dr. R. "Sounds like a cystocele," Dr. R. said. "Did you see evidence of that?"

I'd seen only a few cystoceles before and I wasn't sure, so we went in together to examine Grace. Dr. R. was right (as he usually was), and he posed the question to me: "What are you going to do about it?"

I gave it only a few seconds of thought. "I guess I'd refer her to a surgeon to repair it. We could try a pessary or medications, but she's probably going to need it repaired eventually. We might as well fix it now, while she's still healthy."

Dr. R. agreed that my plan was reasonable. I went back into the examination room and discussed the options with Grace.

"You have a defect called a cystocele. Your bladder is sagging into your vagina, causing urine to get trapped. That's what causes your accidents. You have three main options; a pessary, medicines, or surgery."

Grace cringed when she heard the word "surgery," but I forged on.

"A pessary is a plastic wedge that you place inside your vagina to help hold the bladder in place," I said. I winced as I told her the details of pessaries. "Many women find it very uncomfortable to have a rigid piece of plastic inside," I said.

"The second choice is medication. There are several to choose from, but they aren't very effective. They're expensive and tend to cause a lot of side effects as well."

After a brief pause, I continued. "The final choice is surgery. A gynecologist can tack your bladder to your abdominal wall. He also might try to strengthen the muscles by constructing something called a 'sling' to help hold the bladder in place. He can usually cure your problem with this type of surgery. Plus, you wouldn't have to take costly medicines, and you wouldn't have to fumble with plastic wedges in your vagina."

Grace was a passive patient who rarely asked questions. She sighed and said, "I guess I'll go see the surgeon." I smiled and practically jumped off my stool to go arrange Grace's appointment with the specialist. I was proud of myself and thought that I had done a good job.

I referred Grace to a local gynecologist, Dr. X. Grace thanked me for helping her with this "embarrassing" problem and left my office for the last time. She gave me one of her sweet smiles when she said goodbye.

A few weeks later, I was working in the residency clinic when I got a call from Dr. X. It was rare for me to receive a call from a doctor whom I hadn't paged, so I knew something was wrong.

"Jeff, do you remember that patient, Grace B.?" Dr. X. asked.

"Yes, of course."

"I repaired her cystocele three days ago, and she did wonderfully. Her tissues were healthy and I thought she was going to have a really nice outcome. I sent her home the next day doing fine. She apparently collapsed and came back to the ER today by ambulance. They coded her for an hour, but she didn't make it."

"Oh, no." I didn't know what else to say. I slumped back in my chair, closed my eyes and took a deep breath.

"She had a huge pulmonary embolus. It's too bad, but she suffered from an unfortunate complication of surgery," Dr. X. said. Her tone was apathetic. It was the same tone of voice she probably used when asking her husband to pick up a gallon of milk on the way home from work.

I walked around the rest of the day in a daze. I had violated the cardinal rule of medicine: First do no harm. Most of the time, harm is unavoidable and unintended. It can be tolerated only if the patient is well-informed and accepts the risk herself.

I felt immense guilt for what had happened to Grace. I blamed myself for not paying proper respect to the potential complications of surgery. I didn't warn her of those complications because I didn't consider them myself. I just didn't think.

Since then, I've analyzed and re-analyzed my encounter with Grace and uncovered many more mistakes. First, I had told Grace only about the disadvantages of pessaries, and I'd made painful facial expressions when I described their use. Threatening her with pain had been a sure way of encouraging her to choose something else.

I'd compounded my error when I discussed medications. What patient is going to take an expensive, ineffective medicine with multiple side effects?

Finally, I'd told Grace about the surgical option as if it were the only sensible course. I had tempted her by hinting at a cure and had failed to mention any drawback of the surgery. Grace was reluctant to undergo surgery. She'd recoiled when I mentioned the word, but I'd ignored it and never explored her apprehension.

It pains me now to think that Grace may have chosen surgery to make me happy. But I'm certain that the main reason Grace opted for surgical referral was that I'd given her no palatable alternative. I'd imposed my will on Grace, and that was my biggest mistake of all.

As doctors, we possess great power. It's easy to steer a patient in one direction or another. We might not realize we're doing it, but we are. It doesn't make us bad doctors. In fact, there are many circumstances where it is appropriate to be forceful with a patient, but I don't believe Grace's situation was one of them.

My experience with Grace taught me that I shouldn't push every patient. I've learned to adjust my tone to be forceful or neutral, depending on the situation. I reserve my aggressive stance for times when a patient is making a poor choice that could be life-threatening (like smoking or drinking to excess). Most of the time, however, I hold back, teach patients about the options, and encourage them to make their own decisions about their health care.

Grace B. never had a choice, and I regret that. There is nothing I can do to make up for my mistake with Grace. All I can do is strive to never let it happen again.

 

Jeffrey Green. It's not just what we say. Medical Economics Aug. 6, 2004;81:56.