Dealing with difficult doctors IV: the disbeliever
Here is another post taken from my newest book, How to Talk to Your Child’s Doctor. This one concerns what I call the disbeliever.
All good doctors learn to filter what parents say to them during history taking, to examine each parental statement for reliability, likelihood, and sheer outlandishness. Parents of sick children are a cross-section of humanity and, like all of us, vary in their observational skills, their ability to express themselves, and their tendency to exaggerate or minimize what they see. Parents, not being physicians, may not notice and comment on things a doctor would notice. Good doctors also understand that parents of sick children, especially very sick children, are stressed by their situation and sometimes rendered more than a little incoherent by that.
In spite of all these issues, the fundamental principle of medical interviewing is that parents are virtually always telling the truth as they understand it. They will not see things as through a doctor’s eyes (unless they have read this book, of course), but they will nearly always faithfully report what they see if the doctor is reasonably skillful at bringing out the salient points during the conversation. Unless a doctor has very compelling evidence to the contrary, she assumes goodwill on the part of the parents. What that means in practice is that parents who give disorganized, difficult-to-interpret histories are not intentionally trying to deceive her; they are simply doing the best they can to describe what they see. The disbelieving doctor is not inclined to trust the truth of that statement.
This variety of poorly communicating doctor can be a troublesome one for parents to deal with. She may seem pleasant in conversation, but this kind of doctor also may come across to parents as brusque, even antagonistic and confrontational in demeanor. Parents interviewed by doctors like this sometimes feel as if they are being cross-examined, not interviewed; instead of a two-way, mutual conversation, the encounter feels more like a grilling by a suspicious police officer. That is an extreme description, but it is one parents have used when telling me about unsatisfactory encounters with doctors. Milder metaphors I have heard from parents about these situations include feeling like a teenager being quizzed by a parent over staying out too late, or like a student who has mislaid his homework assignment.
There are several underlying themes for this kind of dysfunctional conversation. One is that parents feel as if the doctor does not really believe what they are saying, as if the parents need to produce some objective evidence to prove that what they are saying is true. The nuance can be subtle, but nonetheless obvious. If most doctors hear a parent say, “Johnny had a fever,” they will follow up by asking how high the fever was. If the parent’s reply is something like “I didn’t take it—he felt hot,” most doctors note that fact and proceed with the interview. In contrast, the disbelieving doctor is inclined to say something like “Why didn’t you take his temperature?” or “Why don’t you have a thermometer?”
Physicians inclined to disbelieve what parents say to them are, at root, manifesting the old tendency for physicians to set themselves above the patient. Treating what parents have to say as being at best uninformed, at worst outright deceptive, is another example of how some doctors regard themselves as superior to others. It is another face of medical paternalism. From what I have seen over the years, I suspect that this attitude and behavior is a little more prevalent in pediatric practice than in other kinds of medical encounters because many parents of infants and young children are, in comparison to the doctor, themselves young. An age disparity between parents young enough to be a middle-aged doctor’s children and the doctor can make the doctor behave a little like a parent herself in how she treats her patient’s parents.
What should parents do if they find themselves meeting this kind of doctor? My best advice is to realize they are unlikely to change the doctor’s behavior much, and that overt confrontation generally does not work well because it tends to confirm in the disbelieving doctor’s mind her impression that parents, rather than being allies in the child’s evaluation process, are more often unreliable adversaries. It works better for parents to recognize what is happening and respond by taking extra pains to be precise and consistent in what they say, perhaps using statements like “This may seem strange to you, but . . . ” or “I know I should have paid more attention to the rash, but it seemed to me at the time that . . .”
An extreme tendency to disbelieve what parents are saying is a bad trait in a physician, and it likely will impede her ability to do the best job for the child. But as with other kinds of poor physician communicators, I think most disbelieving physicians are not fully aware of how their manner interferes with their interactions with parents. Still, it is not a parent’s job to educate the doctor about that, and it is probably best not to try.