Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."
You would think she was in grade school and had just gotten her report card. In a way, you'd be right.
Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.
How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.
If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.
But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.
Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.
Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.
This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.
▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.
▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.
▸ There is another basal cell, but you have fewer actinic keratoses than last time.
And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.
Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"
This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.
My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.