Sunday, November 05, 2006

Apologizing is easier (than asking for permission)

The GI fellow I’ve been working with this month recently was telling me about her daily interactions with a particularly grumpy middle-aged patient on our service. When I say grumpy, I mean the kind of guy who responds to a cheerful “Good morning, sir,” crossly with “what do you want?” – and that’s if you’re lucky enough to find him, because most of the time he’s out in the hospital courtyard puffing on cigarette after cigarette. In any case, my fellow confessed that every morning as she would examine and press upon his hip, the maneuver would incite shouts, invectives, and in all honesty a substantial amount of real pain. She would then quickly apologize.
“Why do you do that, when you know it’s going to hurt him?” I asked bemusedly.
“Well, I keep forgetting that he’s tender there.”
“And he keeps letting you examine him day after day, despite this profound agony?”
“Yeah, well, he keeps forgetting too. His memory is pretty bad you know—he still doesn’t even know who I am.”

No wonder the guy’s always pissed off.

You see, as physicians, we’re horrible at asking for permission. Sure, we obtain the required written informed consent before administering blood, performing spinal taps, dialysis, and other major procedures, but when it comes to medications, lab draws, iv lines, and just plain old physical examination, we have a tendency to shoot first and answer questions later. After all, when you only have a couple of hours to run through your census of 20 patients, stopping to ask, “may I now press upon your hip?” is going to be at the bottom of your list of priorities—it’s not that big of a deal (hopefully), and you really don’t have time for negotiations. Granted, it would be nice to have the patient’s permission, and maybe to give him some warning that a little bit of hurt is coming his way, but in the grand scheme of things, it’s just more practical to commit the offense and then to apologize. It’s an imperfect system, and we are bound by the multiple conflicting demands of our work. Hopefully our patients understand that; in fact, we rely on their forgiveness for a lot of the little things we do. In return, I suppose we can cut a guy a little bit of slack when he doesn’t greet us in the morning with a cheerful, “Good morning Doc, it’s good to see you!”