I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.
We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”
This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.
No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.
But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.
Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”
I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”
A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.
Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.
I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.