Provisions

Impersonal and self-absorbed as Manhattan may be, it’s still embarrassing to cry on West 32nd Street.  I looked for a store, any store, and ducked inside.  The pace of my steps and angle of my head as I buried myself into a back corner, thumbing through pants twice my size, gave me away.  A store clerk walked over and asked if I was okay.  I knew I’d have to meet her eyes, unable to hide the tell-tale redness and puffiness of my own.  I asked if they had a bathroom I could use.

Being Manhattan, there was no customer bathroom, but the store clerk very gently led me to the staff bathroom and told me to take the time I needed.  After five minutes of some fairly heavy crying, I spent the next ten desperately trying to disguise what I had just done.  I scrubbed my face until it hurt and molded my expression back into that of stoic, aloof New Yorker.  My insides didn’t feel much better, but at least my outsides didn’t betray that anymore.   I emerged, thanked the clerk, and took comfort in the fact that I’d never see her again.

My little episode had only intensified the all-consuming ringing in my ears.  The tinnitus had started two years ago, suddenly and unrelentingly.  Five doctors and five clean bills of health later, I was left with the unchanging advice: “We’ve ruled out anything organic and tinnitus isn’t dangerous, so you’ll just have to get used to it.”  No follow-up appointment necessary.

I was left to my own devices–which included the Internet, snake oil supplements, and my own obsessive mind–and I wasn’t using them well.  Besides being sleepless, irritable, and depressed, the far more damning thing was that I was without any hope.  I couldn’t imagine being able to live happily in my body.

Thinking back, I still can’t figure out why it didn’t dawn on me to consider a psychiatrist instead of an ENT or a neurologist.  The idea to see him wasn’t even my own.

After getting to know me, the psychiatrist eventually suggested medications.  I wasn’t afraid of the side effects, and I began immediately.

A year and a half later, everything is much better, objectively and subjectively.  Though not gone, the auditory disturbances are manageable to the point where they hardly register emotionally.  I don’t much like talking about it, for reasons better articulated by Russell Crowe’s character in A Beautiful Mind:  ”I still see things that are not here. I just choose not to acknowledge them. Like a diet of the mind, I just choose not to indulge certain appetites.”

Of course, most times I go to the doctor, for any purpose, I am asked about the reasons I am on certain medications.  Usually my answer is acknowledged, and the appropriate empathetic response is conveyed.

Recently, I was surprised by one doctor’s version of empathy: “Oh, yes, tinnitus can make you literally want to drive off a bridge.”

Of course, this doctor doesn’t know that 18 months ago, I broke down in midtown Manhattan and wondered how I could live out the rest of my life at this rate.  She assumes by my demeanor that I am well-adjusted and perhaps always have been.  She doesn’t know that sometimes when I listen with my stethoscope for a patient’s heartbeat and I hear ringing, that familiar fear makes my own chest tighten.  Or that sometimes I “indulge” in anxiousness when a tinnitus spike occurs that I cannot ignore.  Or that the very condition she was treating me for was creating such a spike at that moment.

Regardless, I was in “no acute distress,” as the medical lingo goes.  I let it go.

I wasn’t even angry with her off-the-cuff remark.  I say silly things to patients on a weekly basis, and the only reason it isn’t more frequently is that I only see patients once a week.

What reminded me of her remark was a piece by Dr. Danielle Ofri in the New York Times, which was inspired by a New England Journal of Medicine article by Dr. Jerome Groopman and Dr. Pamela Hartzband.

All three doctors rail against the term “provider” instead of “doctor” for a number of reasons: the generic term connotes sterility, commodification, distance, and interchangeability.  ”The words we use to explain our roles are powerful,” Groopman and Hartzband explain.  ”They set expectations and shape behavior.”

This is all fair.  And, as a medical student, I should be in especially staunch agreement.  But I’m not.  As a patient, I’ve seen far more “providers” than “doctors.”

I went to the doctor who made the unfortunate comment about my tinnitus because I had an unrelated problem.  She took me seriously, she diagnosed me correctly, she prescribed the appropriate medications, and I got better.  Technically, flawless.  She provided excellent care.

But, Groopman and Hertzband write when we use a term like “provider,” it ignores “the essential psychological, spiritual, and humanistic dimensions of the relationship.”

From a patient’s point of view, though, all it takes it one insensitive comment from the physician to lose that humanistic dimension.  When my doctor made that remark, I relegated her to the impersonal role of provider, someone incapable of understanding my experience but capable of treating my physical problem.  I just wanted to get better.  As Dr. Ofri writes, “It makes [physicians] feel like a vending machine pushing out hermetically sealed bags of ‘health care’ after the ‘consumer’s’ dollar bill is slurped eerily in.”  That is exactly how I saw my doctor.

Was I happy with the care I got?  Sure.  If I have another problem, will I see her again?  Probably.  Was I bothered by her remark?  A little.  Did I care?  Not really.  I didn’t care because I depersonalized her immediately after.  If I cared, the remark would hurt.  I don’t want to hurt.  Is that fair to the doctor?  Maybe not, but I care more about me.

This example is far from unique, for me and for others as well.  There are many reasons people dislike doctors, and many of these reasons are not particularly fair.  But when the same complaints are heard over and over again (“He doesn’t listen to me!”  ”I can’t believe she said that!”  ”He doesn’t understand!”), one has to wonder which came first–the term “provider” or the doctor acting like one.

I’m not dismissing the argument that “provider” is irksome or suggesting that we shouldn’t spend space discussing its consequences.  But I wanted to spend some space on rationalizing why patients may already think in these terms: on how in many cases physical provision of health care is exactly what doctors do, and on how depersonalizing doctors can actually protect patients when their emotional or humanistic care is lacking.  And the term “provider” sometimes fits, even if doctors don’t want to wear it.

“But words do influence us,” Dr. Ofri writes about what doctors are called.  Yes, they do.  Now let’s take those thoughts and apply them to what doctors say too.

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24 Responses to Provisions

  1. Kevin Nasky says:

    I know everyone is different. I would have interpreted that “can make you want to drive off a bridge” comment as very empathic. It’s the exact opposite of dismissive (“you’ll be fine…no f/u needed”), and rather acknowledges how horrible such symptoms can be. Your reaction, though, highlights how difficult this bedside manner thing can be. I frequently “misfire” with new patients (occasionally with established patients), i.e. say the wrong thing, at the wrong time, or in the wrong way. However, as docs get to know patients better over time, they’re better able to “spotter adjust” their bedside manner to accommodate each patient’s unique personality.

  2. Shara Yurkiewicz says:

    Definitely a point I’m aware of and considered at the time, which is why I didn’t get angry. There’s some balance between dismissive (which I’ve also experienced) and so hyperbolic you make the patient feel bad. The hard part, of course, is that the line is different for every person.

  3. Lonnie says:

    Shara, your writing is inspiring.

    Also, I have not once felt that any of my doctors have empathized or even slightly cared about who I am. I kinda just figured that was how it worked.

  4. You didn’t end up at all where I thought you were going when you started. What a thoughtful argument to make, Shara. I look forward to meeting you and talking more about doctors in a couple of weeks.

  5. Nora Miller says:

    Shara, excellent post. I admire your pragmatic understanding of human weakness. You were lucky to get excellent care from the insensitive doctor. When my sister lost 30 pounds because she couldn’t swallow solid food, her “provider” accused her of hysteria and asked her daughter if she knew how to make a peanut butter sandwich. As we waited for hours in outpatient services for the results of an MRI to help diagnose the problem, I asked another “provider” (nurse) when I could take my sister home. She looked at the chart and said “Oh are you the esophageal cancer with metastasis to liver and lungs? Yeah you can go home.” No sign that either of these people cared one whit about my sister or her condition or thought twice about the impact of their words. We only found the answer because one doctor (not a “provider”) saw her as a human with a problem and considered what else might be wrong. She was in tears after seeing him, not from sadness but simply because somebody believed her. Yes, words do influence us, and yes, health care professionals will serve us better if they apply that thought to their own words. Thank you for highlighting this issue!

  6. Jenny says:

    I’m with Kevin (first comment). I interpret the doctor’s statement in a very positive way. I also suffer from tinnitus, as well as some facial paralysis and other problems after a car accident. I find that my most common problem when meeting healthcare professionals is that they don’t get that these issues impact my quality of life. I’d love it if they’d start out with acknowledging my feelings about that before saying that nothing can be done.
    Also, a hearing aid actually helped me, albeit marginally. By enhancing surrounding noise, the noise in my ear is slightly less noticeable. And medication improves the situation for me as well. My final tip: Never quiet! Keeping a radio on, especially when trying to sleep, makes my life bearable. But what works for me may be totally wrong for someone else.

  7. Shara Yurkiewicz says:

    Thanks for all the input. The differing opinions alone highlight how tricky the humanistic side of medicine can be.

    I think what put the statement over the top for me was her use of the word “literally.” I didn’t find it productive to be told that people in my position could understandably be suicidal, since she didn’t know my past or exactly how depressed I had been (or if I had in fact been suicidal). Too much for a first interaction.

    It’s a tight rope to walk, certainly. On one hand, I did hate the dismissiveness of other physicians since my symptoms had no organic cause. But I also didn’t like hearing that my plight was so bad that it could make me feel that my life wasn’t worth living. (And having recently come off some psychiatry rotations, the trivialization of suicide didn’t sit well with me either.) But… again, that’s just me. And that’s the challenge of medicine!

  8. Jenny says:

    Yes, you’re right of course. It was over the top and insensitive to the possibility that you might actually have been in that position. But maybe it’s the fear of going too far that makes a lot of physicians avoid any comments on your experience. It’s a difficult issue!

  9. Shara Yurkiewicz says:

    @Jenny: Yep. And I absolutely see your point of view as well.

    @Nora: I’m so sorry to hear about your experience. Wishing you all the best.

  10. Leo says:

    I’m not sure I would like to be visited by someone who’s listening to his/her internal noises instead of mine during the auscultation with the stethoscope. Good will and disposition, as valuable as they are, will not make a doctor… are you sure you have chosen the right track?

  11. Shara Yurkiewicz says:

    It takes an extra minute at the worst for me to “tune in” to hear a murmur when that (occasionally) happens. But if you’re looking for a physician whose health will never change the way she does her job in some small way at some time, I wish you luck with your search. And you just ruled out Jerome Groopman as your doctor, who also has tinnitus.

  12. Emily says:

    Hey Shara,

    I really really like this post. You bring up so many great issues here, from putting yourself forward as a physician-to-be-as-patient to the whole issue of the provider vs. doctor terminology. I’ve certainly used the former terminology myself in writing about health policy or in my health services research, but I definitely understand the resistance to using it as a self-identifier because that seems to allow license to a certain lack of empathy. However, I think you bring up a really good point here: as a patient, there can be a very definite point where the doctor crosses from being a “doctor” who seems near omniscient and someone who is able to care for you to a “provider” who is there to provide a specific service. I wonder if that is an artifact of your own experience being part of this dialogue. Unfortunately, comparatively patients write about how they feel about the “provider” vs. “doctor” terminology.

    I also wanted to offer a question about the comment your doctor-turned-provider made. From your perspective, was it helpful that the comment was meant to be empathetic even if it didn’t ring true for you individually? I had to read your piece a few times to realize that this was the doctor that you decided to term provider, but you did not seem to have any issue of considering the many doctors who referred to your problem as not-organic and not-deserving of follow-up as non-empathetic providers.

    Sorry for the rather long and rambling comment. First day of school, not quite all here and all.

  13. Shara Yurkiewicz says:

    Thanks, Emily.

    I did find it helpful that the doctor was trying, so I wasn’t too bothered by it. Also, being a medical student has probably made me more understanding of the difficulties in talking to new patients, and I think doctors and nurses are more candid when they talk to me in general. It was more just a “Yikes, she probably shouldn’t say that; someone could really take that the wrong way and I probably would’ve 18 months ago” comment than anything.

    And it’s probably misleading that I didn’t mention it in the article, but I actually found this insensitive comment in some ways preferable to the incredibly dismissive attitudes I had gotten from previous physicians. (Perhaps they were “providers,” though I don’t want to use that term in a pejorative way. They were just bad, period, since they didn’t even try to help me with my problem.) The reason I switched doctors so many times is because I found them entirely non-empathetic. (One of them was on his phone the entire time, deemed me “healthy,” and didn’t let me ask a single question.) If forced to choose, I’d take the “insensitive” over-the-top doctor over the “dismissive” one any day. Apologies for the lack of clarity and possible misrepresentation.

    I suppose I just found this particular example more interesting to write about because it was more out of the norm. There are plenty of stories about aloof doctors, but I found it ironic that one who was trying to be empathetic overshot it to the point of alienating the patient in a similar way.

    Hope this helps! Thanks for commenting, and good luck with school.

  14. Shara Yurkiewicz says:

    Aw, all these posts making great points make me wish I had thought of them myself. I guess that’s what discussion is for, and I’m really happy to see people thinking and sharing.

  15. Shara,

    Thank you for such an excellent posting. I am infuriated at the doctors who were so dismissive of your feelings. I really like your distinction between “provider” and “doctor”; you covered this in a way I never thought of before. I’m a breast cancer survivor and have had doctors be rude and abusive to me, so I do understand where you are coming from. One second-opinion oncologist basically told me that I would die soon if I didn’t undergo his treatment protocol — and that was 10 years ago!

  16. Shara Yurkiewicz says:

    Thanks, Beth. Obviously you’ve had much more serious and intense experiences than I have. I’m so glad you’ve managed to get through it, both because of and in spite of your doctors.

    I agree, when one has a problem, it’s not really helpful to hear, “Oh man, this is awful, I’m so sorry, I don’t know WHAT I would do if I were you,” even if they are trying to be empathetic or candid.

  17. Elena says:

    Hello!

    I’m a third-year med student. Though it’s only been 6 months since I’ve been allowed to work with patients (vs reading/studying), I’ve consistently been told that I have good bedside manner. My plan/dream is to work with people who have problems that lie on the border of physical and psychological (or combinations of them – physical problems exacerbated by psychological factors, psychological factors triggered by physical conditions, etc), partially because I have found that medicine as it stands doesn’t really know what to do with patients with complicated conditions that span a variety of different specialties (and I like talking to people about their feelings).
    I felt it necessary to write that all out because I think it contributes to my experience reading this piece.

    I can see myself saying something like that. In fact, I may actually have said things like that a number of times. I never meant to be dismissive or to be insensitive, I actually said those things in an awkward/goofy attempt to communicate to the patient that they are not alone, they are not “crazy” (a worry I often have, myself), and that they are not the only ones suffering in whatever situation they’re in. I am a little self-conscious about having said those things to my patients, because I assumed that being less formal and “doctory,”and perhaps more like a real person was a positive thing. Maybe that’s just what I’d want out of a doctor?

    What would you have preferred? I am not saying this defensively – I really would like some more tactful approaches to this kind of thing. I did not realize until now that I could have been hurting someone’s feelings.

    -Elena

  18. mizmarcie says:

    A lot of great people have suffered with what are suffering from, but I have a few quesions. Do you realy want to be a doctor?, Do you like feeling sad and bad inside?, are you really doing things that make you happy?

    You go to alot of doctors and seem not to get a curer.

    Get away from everything that you do, just for a while. Take a trip to a place where you can have peace and quite, while there try and remember all of your early years; go through the hurts and good times, think them through and try and resolve everything. Alot will make you very sad, but remember nothing in your past can hurt you now. Get mad at what and who hurt you and made you mad or feel sick. But most important forgive them for that was probily how they where treated and knew no better.
    \
    As for seeing things that are not there, see though them and tryand see if they fit into your past. A bad memory can be understood and if not they will come back to haunt us. Get read of them by reliving them and then file them away as you would a bad photo of yourself that you would not like anyone see including yourself. If they come back remember thay cant hurt you, only if you let them will they.

    As for the ringing in your ears; it may last a life time or it may go away as quick as it came. There are alot of people out there that suffer from it, you are not alone with this condition. You and only you can make your life good and happy; unless you like feeling bad inside; that is what you need to solve; me I rather be happy, who in the hell wants to feel bad. Evil breeds evil sadness breds sadness, hurt breeds hurt, goodness breeds goodness, happiness breeds happy person.

    I am a 67 year old person who has many a sad day, many ahurt day, many a day I wished I wasnt living; but God and my will to be happy inside won out. Why because I would not let, sadness, hurt, sickness, win out.

    Be strong
    Mizmarcie

  19. Shara Yurkiewicz says:

    Hi Elena,

    I don’t have a problem with informality. Personally, I prefer recognition that something is tough without sounding like “oh, sucks to be you.” I suppose an example would be, “From what people tell me, that sounds like it can be really rough at times.” Not too much, not too little. I wouldn’t mind hearing an anecdote either. If it’s the first time with a patient and it’s hard to gauge him, I’d err on the side of being more neutral (note: different from being dismissive).

    Things that wouldn’t work for me would include be being TOO sorry, which would include actually saying “I’m sorry” too much. If I’m doing relatively okay with my condition, saying that would make me feel more vulnerable and almost as though there is a widened gap between the doctor (healthy) and me (sick).

    I think it’s also important not to be cavalier about real problems that occur with specific diseases. For example, tinnitus sufferers do have higher suicide rates, so that’s why the comment struck me as insensitive and uninformed.

    Hope this helps.

  20. emmy says:

    Until I read the comment above comment I can’t say that I understood what you found objectionable about your doctor’s comment. For me, that would have said “Oh, she gets it” but we are all different in what we need. I also think that it matters what level of relationship you have. Recently a doctor that I have been seeing for almost 20 years looked at the results of a sleep study that I had done (he’d been asking me to take one for years). When he saw the report, he looked at me incredulously and asked how I’m still alive. If I had just walked in his door, I probably would have been thinking “who does this jerk think he is?” but because of our history, the remark was actually kind of funny. Anyway, I’m glad you are giving your doctor another chance.

  21. Shara Yurkiewicz says:

    Yup, the point I was trying to make is that context is everything. That’s why I inserted the personal details.

    After twenty years, I’d probably have your reaction as well :)

  22. Old Geezer says:

    I really think you are dealing with two distinct issues here. One is manner, such as the doctor who told me, “Yeah that’s Cancer, go make an appointment with the nurse and I’ll deal with it later.”

    The other is the use of the word “provider.” I consider anyone who is involved in the provision of health care is a “provider.” That dental technician who cleans your teeth is a health care provider. The hospice nurse is a health care provider. When you call the doctor’s office and can’t get through to the doctor, the nurse who back with instructions is a provider. Bless them all for the care they provide.

  23. Hal Amens says:

    As a blogger about electronic medical records, particularly for physicians’ offices, I use the term “provider” to include doctors and all of the people who are not doctors but but are part of the doctors extended staff including those who work in the practice and those who support it from outside such as labs and pharmacies.

    In the context of “doctoring” the distinction “doctor” and “provider” is a useful bit of shorthand.

    Dr. Bene Brown has done some interesting work on factors that affect our ability to show empathy, i.e., the difference between doctor and provider. http://www.ted.com/talks/brene_brown_on_vulnerability.html Maybe some of this needs to be incorporated in Med School.

  24. Shara Yurkiewicz says:

    When I worked in health policy in D.C., I always used the term “provider” as a simple catch-all.

    When I entered medical school, I made sure not to let the term slip into my lexicon. A lot of physicians and physicians-in-training have strong negative opinions about it. I am not one of them.