The voices in my head want you to get the hell out of my office

In all fairness, I was warned that everyone else is crazy.

During my first day meeting with patients, I watched a doctor elicit a woman's family history. The patient had high blood pressure and high cholesterol, so the doctor asked if there was any history of heart disease in her family. The reply was quick, "Nope."

"Any high cholesterol in your family?"

"Nope."

"High blood pressure?"

"None."

"None? No high blood pressure or high cholesterol in your family?"

"Nope."

"Do you have any brothers or sisters?"

"Yeah, two brothers."

"Any high blood pressure or high cholesterol in either of them?"

"Nope."

Was he serious? Did the doctor think his questions were unclear? I was incredulous. I almost felt as if he were insulting the patient by asking the same thing over and over again.

"Your mom, does she have high blood pressure or high cholesterol?"

"Oh, yeah. She had real high cholesterol. I think her pressure was high, too. She had a heart attack last year."

The doctor nods, making notes in the patient's file, "what about your dad?"

"He passed from a heart attack 8 years ago."

What!?

Is it possible that this patient is so uncomfortable in an examination room, that the doctor has to ask the same question a half dozen times before he can get an answer? It's not really so far-fetched. This patient has just been told that she her body doesn't work properly, and then was asked by a serious-looking guy in a white coat, "Is there any history of heart disease in your family?" Should I really be surprised that she rushed to her own defense? "Back off, Doc, my family's fine. And I feel great."

The simpler answer though, is the one I've heard a dozen times from family members, employers, teachers, friends, cab drivers, space aliens, coworkers, and unicorns: Everyone else is crazy. And watch out for them. But once you hear that advice a dozen times from a dozen different people, it turns into a logic problem. I've come to believe that, perhaps, those aliens aren't as smart as they think they are.

It seems more likely that we all think in a way that is fundamentally incongruous with the way everyone else thinks. A not-so-insightful observation that, if true, would make patient care much more difficult than I'd imagined it would be.

We take two classes right now, a science class and a touchy-feely class. Last week in the touchy-feely class, a speaker came in to discuss his experiences as a patient. He's had a string of serious ailments that brought him in contact with a number of doctors and other health care providers over the last thirty years. One of the earliest doctor visits that he recalls took place during his first year of college. While showering, he felt a tender lump on his butt and immediately became anxious. He quickly dressed and headed over to the student health office on campus, where he was seen by an amiable, outgoing doctor. The doctor gregariously inquired about the man's ailment, and subsequently examined the affected area. The doctor declared that the lump was "just a hemorrhoid" and "nothing to worry about." He explained that hemorrhoids will resolve on their own. He suggested that the man try soaking in a hot tub and maybe eat more roughage. The visit lasted about 25 minutes.

I've tried to convey this story in a manner similar to the way I heard it from the patient himself. The only thing I left out were the patient's frequent references to the doctor as a "jerk" (though the description of amiable and gregarious comes straight from him). The interaction described above INFURIATED the patient, so much so that he still recounts this story - now thirty years later - with a seething, undisguised hatred. During his senior year, the patient came down with a horrible infection and refused to return to student health because of that doctor. He finally gave in when his temperature neared 105 degrees.

I heard this man's description of his trip to student health, and I thought the doctor sounded competent, professional, and engaging. All in all, this seemed to me to be a strongly positive doctor-patient interaction. All that's missing is the sticker.

The patient's impression of the doctor was that he was extraordinarily dismissive of the condition, and that he totally ignored the patient's intractable (though never verbalized) belief that the lump was a cancerous tumor. Furthermore, he never said how long the hemorrhoids would last and wouldn't prescribe any medication to make them go away.

What didn't came up during this visit, was that the patient was a recently-outed, gay man. He was coming to grips with his sexuality in the context of a) his new, autonomous life at college and b) his traditional upbringing in a religious, military family. His concerns about the lump on his butt didn't just come from hypochondria; he was terrified that he was being punished for his lifestyle and that this condition would make him less attractive to men.

The patient vehemently believes that it was the doctor's fault that a discussion of these concerns never took place. Maybe it was, I really don't know. I'm not retelling this story to investigate that question. All I want to do is point out that, although his impression of the interaction was drastically different than my own, the patient is probably not crazy. And that terrifies me.

I probably would have treated a frightened college freshman the same way that doctor did, because that's how I'd want to be treated. If I thought I had cancer, and I saw a trained physician who was absolutely certain that I had only a benign condition that would resolve itself with time, I would WANT him or her to tell me exactly that. It would freak me out more if the doctor dwelled on any possible diagnoses that were clearly not appropriate. And if I could clear this condition up without taking any drugs, all the better. Though I might be exhibiting some self-preservation here, I'd like to think that this position is also not crazy.

So we have two, ostensibly sane people considering the same professional interaction. One of these people is entirely satisfied that there's nothing wrong (absence of stickers notwithstanding), and the other is so wildly offended, that he has spent thirty years of his life railing against this doctor to audiences across the country. Is this just the nature of a profession driven by interpersonal relationships? Is there some way that a physician can account for all of the disparate personal needs, histories, and characteristics that walk through the door? Am I doomed to have any patient who doesn't think like I do leave my office in a fury telling people I'm a jerk?

Sometimes the science class is much easier.