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IN PRACTICE

When patients ‘divorce’ their doctors

Dan Page

I had been in practice about a month when I called a new patient to tell her that the lab had lost one of her blood tests. Not to worry, I said. We would repeat it at her next visit.

“There won’t be another visit,” the young woman replied coldly. “I told you my grandfather died of gastric cancer,” she explained, “and you did nothing to screen me for it.”

I mumbled an apology, hung up, and walked down the hall to a more seasoned colleague’s office. How could I have been so ignorant, so incompetent? How could I have failed this woman so utterly?

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“What’s the screening test for people who have a family history of gastric cancer?” I asked my colleague. “There isn’t one,” he said.

A doctor can lose a patient in one of three ways, all of them painful.

When a patient dies, it can feel like losing a friend. This is especially true in a primary care practice like mine, where doctors often know patients for decades. The grief is sometimes compounded by nagging doubt. Even when the patient is old and the death is expected, you ask yourself: Did I do enough? Did I do too much? Many of us write condolence notes and go to funerals, to comfort ourselves as much as the families.

A second way to lose a patient is to fire him or her. In truth, this doesn’t happen very often. A doctor who severs a relationship with a patient abruptly could be vulnerable to legal action. Even the most egregious miscreants — those few who lie and wheedle narcotics prescriptions from several different physicians, for example — must be given time to find another doctor before being discharged from a practice. Tolerating lesser offenses is simply part of the job. I’ve had an occasional patient make nasty, even threatening remarks. And then there was the elderly woman who never hesitated to comment that whatever outfit I was wearing made me look fat. It’s understood that some nice people don’t act very nice when they’re sick or anxious, and that even people who aren’t nice deserve excellent health care. As an old mentor of mine once put it: “I’ve done rectal exams on folks I wouldn’t want to shake hands with.”

Then there are the patients who leave their doctors. Sometimes, the “divorce” is amicable. The patient sends a note regretfully requesting his or her records, mentioning that the trip into the city has become too difficult, or that his or her insurance has changed. Sometimes patients vanish for a few years and then reappear when they’ve got new jobs with different coverage, they’ve moved back from Chicago, or they’re finished having babies. One woman told me, with delightful bluntness, that she decided she didn’t like the doctor she’d switched to any better than she liked me.

When patients leave unhappy it stings, but it may be better for everyone. The woman whose ire I provoked by not ordering the nonexistent screening test for gastric cancer wasn’t comfortable with me for some reason — it really doesn’t matter why. When my patients ask whether they should continue to see a well-respected specialist whom they don’t particularly like, I tell them that they shouldn’t. Sometimes the doctor-patient relationship, like any relationship, just doesn’t click.

I recall a new patient who spent the better part of his first visit telling me how insensitive his previous M.D. had been. When I glanced at his records I saw that my predecessor was a physician who’d won awards for his extraordinarily compassionate care.

Unlike a marriage or a friendship, a doctor-patient relationship can end badly with only one party’s knowledge.

I once had a patient who was a charming and intelligent woman with a unique and fascinating career. I liked hearing about her work and discussing our many mutual interests. After several years, she stopped coming to my office, but I didn’t think anything was amiss. There were any number of reasons she might have changed doctors, or stopped seeing doctors altogether. We’d had no falling out of which I was aware. Unless patients miss appointments, or I know that they are ill, I don’t have a habit of calling them to find out why they’re not calling me. It seems like an invasion of their privacy.

Not long ago, the woman e-mailed me. She said that I’d been unhelpful to her all those years ago; that she’d found another doctor she found more responsive. In her note, she painted the picture of a doctor (me) who had been easily frustrated, unwilling to consider diagnostic testing and consultations to evaluate a series of unexplained symptoms, and unable to acknowledge the humanity she shared with her patients.

There is a trend in medicine now to emphasize the parts of the doctor’s performance that can be measured. For example, I routinely receive lists from my hospital and insurance companies of patients who are overdue for various screening tests.

But the less quantfiable aspects of a doctor’s behavior are left to the occasional patient satisfaction survey, anonymous gripes and gushes on the Internet ... or to silence.

I didn’t recognize myself in the picture my former patient painted. Had I really been so callow then? How had I so thoroughly misread my interaction with this woman? All this time later, what was the lesson to be learned? To be more sensitive? To track down patients who disappear, and find out why?

Perhaps.

But, in many divorces, two good people simply turn out not to be good together.

I wrote back to the woman and apologized for disappointing her. And she wrote back to wish me well.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog on Boston.com/Health. She can be reached at inpracticemd@
gmail .com.
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