Friday, October 10, 2008

"C'mon, Dear" (or, How Many Buttons II/Revenge of the Buttons/Buttons Redux/Son of Buttons)

I try to be a nice person, but the truth is, I am not always a nice person.

I'd rather not admit or draw attention to that on my blog, my beloved refuge for sorting out my thoughts and stories. But it's the truth.

Being honest about myself and my experiences has in the past invited lots of judgment from those superior folks out there who ALWAYS make the right decisions and NEVER make any mistakes or commit any sins, but what can I do - I DO stumble, I'm not always perfect, I'm just learning, and I'd be lying to myself if I only described rosy, feel-good moments during which I was brimming over with compassion and behaved like a veritable paragon of sweetness.

Not long ago I got irritated with an elderly male patient who kept addressing me as "dear." And I told him so - not explicitly, but unambiguously nevertheless.

The irony is, I've been guilty of the same myself.

In his post "Don't Call Me Sweetie," KevinMD highlighted a recent New York Times article about how the affectionately-intended habit some doctors and nurses have of calling elderly patients by terms of endearment, such as "Sweetie" and "Dear," comes across to many elderly patients as condescending, belittling, and offensive. I have been guilty of using such terms of affection, usually because I feel protective, and genuinely HAVE affection and a feeling of nurturing for many of my patients, and it spills out into the language I use.

But I've tried to avoid it recently, even before this article came out, because I realize, too, that many patients, understandably, feel as Elvira Nagle, an 83-year-old woman from California, feels: "When I hear it," she says, "it raises my hackles." I have never meant to be insulting - only kind - but perhaps I have expressed that intention in a way that causes patients to feel insulted and patronized.

So the patient I'm referring to probably never meant to be insulting either. In fact, like me with my patients, perhaps he felt protective and nurturing, in this case because I was so much younger than he. That's a kind attitude, really, not a degrading one. But like Elvira, it "raised my hackles."

Part of the problem was the baggage I brought to the table. People make comments about my young appearance ALL THE TIME. I've had patients ask me on more than one occasion, "Are you old enough to be doing this?" and when I look at their chart, I happen to be older than THEY are. I just don't look it, I guess. I'd be happy under other circumstances, but when people start forming opinions about you professionally based on how you LOOK, and calling you "Miss" or "Young lady" or any other moniker that fails to recognize your hard-earned PROFESSIONAL ROLE, and it happens almost daily, it's ANNOYING.

Another piece of luggage I carry is that I never see my male colleagues treated with this same skepticism. And most patients will NEVER call a male clinician in scrubs "Mister" instead of "Doctor," or assume they can just address him by his first name without so much as a by-your-leave. It's almost amusing to see the confusion on people's faces when I show up with a male nurse. Almost.

Part of the problem with my particular situation, too, was the clinical interaction that was supposed to be going on. I was seeing the elderly gentleman as part of a preoperative evaluation. I was looking at his various test results and trying to form a judgment on whether one of them should be repeated, and as I thought out loud about the possibility, the patient said, "Aw, c'mon, dear, I've been through that so many times. You don't have to make me do it again." Would he have said "C'mon, dear" to a physician who did not appear so young or who was male? Would he have tried to direct an older physician's decisions like that, repetitively and argumentatively - as he continued to do, for a minute or so? ("It's just a [insert name of minor procedure] dear." Have I mentioned how much I hate it when people describe any surgery as "just" a little surgery?)

I curtly but politely (I hoped) asked him a few more questions, and after a couple more "dears," I stopped, looked at him, smiled as sweetly as I could, and said, "Please don't call me dear."

"Why not?"

"I prefer not to be called 'dear.' "

"Well, what should I call you, then?" he asked, almost-but-not-quite disrespectfully.

"Um, doctor?" I replied, almost incredulously, and resumed my perusal of his chart.

We went back to exchanging medical information about elements in his history. Then it was his turn to shift the conversation. "Can I ask you why you don't want me to call you 'dear?' I meant nothing by it. Do you find it demeaning, or something?"

"Yes, actually." You said it. Not I. Somewhere in there, you know you wouldn't be talking this way to an older person, a male person. But it wasn't just that he called me that; I've had other patients call me "dear" before and not minded. It was the TONE he used that I found grating.

He seemed taken aback by my candor, then must have sensed my implication that he was being sexist or age-ist or both, because he then made the mistake of bringing up (as if to justify his over-familiar language with me) the example of a woman he and I both knew of - let's say, for example, a City Council member in that town - who appeared youthful but had achieved a great deal professionally. I was too ticked off to refrain from commenting on the example because I thought the example itself just magnified the sexism I was hearing.

"To be honest, in my opinion, that woman is ignorant, uneducated, unintelligent, and self-aggrandizing, and not an example I wish to emulate," I said, in as gentle a tone as such an opinion can be uttered.

"Oh. Wow. Oh well," he said. We stuck to medical points from then on.

I learned something from the intensity of my own irritation. That I am imperfect and fallible I knew already, all too well. But I also learned, or re-learned, that I may very well be unwittingly causing the same offense to people whose safety, well-being, and comfort I genuinely care about. For all my attempts to show outward kindness, I might actually be making my patients very upset, or at least creating some bad feelings.

You know what part of the trouble is? The English language. There's no deferential word, as there is in Tagalog (the word po), to address people and convey, regardless of age or sex or profession or role, respect and attentiveness with some of the warm sentiments contained in English terms of endearment but without any of the condescension (po is never used to talk down to children as terms of endearment can be, hence, I think, some of the sense of insult when endearments are used with adults). I miss that word/particle/concept in English. It would totally get rid of this entire conundrum.

The truth is, when I hear my colleagues use terms of endearment with patients, I hear only warmth, sincerity, and genuine compassion, and I hope that's what my patients have heard in the past coming from me. But I can see how such terms, if used in a dismissive, insincere, or almost snide or sarcastic way, can transmit all the destructive negativity described in the New York Times article.

Such a small moment in the middle of a stressful day. Yet it was an island of lessons at which I felt I had to drop anchor for a while in the midst of trying to navigate these sometimes choppy seas.

Let's pretend for a moment that my name is Dr. Smith.

TWO WEEKS after the above incident I had this conversation with a patient and her son:

Me: "Good morning, I'm Dr. Smith."
Son: "Oh. Hi Smith." Hi Smith? SMITH?!
Me (to patient): "I'm going to be your anesthesiologist this morning."
Patient: "Oh. Really? Wow."
Me: "What is it?"
Patient: "Nothing, I'm just suprised."
Me: "Oh? How come?" As if I didn't know. Wait for it...wait for it...
Patient: "Well, you're a GIRL. I was expecting to get a man." Bingo! There it is, ladies and gentlemen. "And I didn't expect the anesthesiologist to call herself a doctor. We were just expecting..."
Son: "The bone doctor." C'mon, you know you wanna say it. The "real" doctor?
Surgeon (walking in): "Good morning, everybody."
Son: "Dr. Brown! Hi! How are you?"

Patient and Son proceed to ignore me despite the fact that our conversation has been interrupted and is not over and I was just beginning to ask about important medical information.

Just another day at the office...


Kim said...

Spanish has a similar idea in that the use of the Usted form of any verb , or even the word Usted, is a sign of respect, a formal way of addressing any adult and you can never go wrong with it.

It isn't something an adult would use with a child, so it doesn't have the "dearie" or "honey" aspect to it.

Frankly, I think you did just fine in this interaction. The patient was being disrespectful and dismissive of your ability, your years of education and the fact that you were female.

You set the professional relationship in the proper perspective and you did it in an appropriated fashion.

Kim said...

Because I am obsessive compulsive and because I don't want to look dumb, please note the above word should be "appropriate" and not "appropriated".

Thank you. : D

T. said...

LOL! I do the same thing. I hate it when I've left a typo up.

Thank you very much for stopping by. I've been doing a lot of thinking about the language we use and how it not only reflects our thoughts/concepts but also defines our reality for us...maybe it's the English major in this whole incident stayed with me for a long time.

On related subject, I LOVED your post on nurses describing themselves as "just" nurses, and how ill-suited a description that is to what real nursing entails. Bravo, and thank you!

Old MD Girl said...

So true. The other day a patient commented as I entered the OR, "Oh I get ANOTHER NURSE??" I said, "Actually, I'm a medical student," and he gave me a funny look, like I'd been rude to correct him. Well, whatever. I'm *not* actually a nurse, dammit!

Also, since you wrote a post on my post about anesthesia a few months back, I thought you might find it interesting that I've been spending a fair amount of time with the anesthesiologists during some of the surgeries where there's no room for me to scrub -- and it's been REALLY interesting. I'm not quite ready to admit I was wrong about your field in public or anything, but I thought you might be amused. Now, you can write a post about the hubris of medical students. ;-)

Kathleen said...

Great post T! I read that NYT article and it did make me rethnk how I interact with the elderly. Here in the south, many times those "endearing" nicknames usually have a double meaning...

You also don't want to be on the receiving end of "...well bless her heart". 95% of the time, it is not a blessing.

Bardiac said...

Sounds like you handled this really well.

It seems like there's an interesting power differential being played out, no?

Do patients feel empowered to ask you not to call them "dear" or to ask you to use their surname?

A little example: I needed some travel vaccines, so I had to go to the clinic for travel vaccines rather than the doctor I've seen before. The doctor there introduced himself as "Dr. So and So" and then proceeded to call me by my first name (which is legal, but not what I use by choice, ever). I needed the vaccines, so I didn't say anything, because that's how serious the power differential is, and I didn't want him messing things up for me. (That was the least of his rudeness, but at least stays on topic.)

Is there a conscious power play in addressing patients by their first name or as "dear" (which seems the case with the patient you describe). Or is there something else in play? It seems like the choice is sort of insidious because it can be "excused" as mere friendliness, so it's all the harder to work against.

catarinolas said...

once again, your post helps me to think how I interact with my patients.
quite frequently, when the induction agent is being administered, I'm using affectionate terms (in my opinion) with my patients, in an attempt to reassure them, not having the faintest idea that this may have a counterproductive action...
thank you anesthesiahumanizer! :)

I'd like to share with you the passage that I've been meditating about (Deut 30:11-16)

"The Offer of Life or Death
11 Now what I am commanding you today is not too difficult for you or beyond your reach. 12 It is not up in heaven, so that you have to ask, "Who will ascend into heaven to get it and proclaim it to us so we may obey it?" 13 Nor is it beyond the sea, so that you have to ask, "Who will cross the sea to get it and proclaim it to us so we may obey it?" 14 No, the word is very near you; it is in your mouth and in your heart so you may obey it.
15 See, I set before you today life and prosperity, death and destruction. 16 For I command you today to love the LORD your God, to walk in his ways, and to keep his commands, decrees and laws; then you will live and increase, and the LORD your God will bless you in the land you are entering to possess."

today I am thankful that Someone tells me to choose Life and Love... and that they are within my reach!

T. said...

OMDG - *Sigh* Welcome to the female-doctor-assumed-to-be-a-nurse club. And I did smile seeing the next part of your comment...

Kathleen and Catarinolas - thanks! Lots to think about...

Bardiac - you're absolutely spot-on to point out the power differential in any medical interaction.

I can only comment on my own experiences and observations. I never address patients by their first names without asking for permission first (but then, I usually never address people by their first names without explicit or implicit acquiescence anyway, because my parents brought me up to ask first). Moreover, most of my colleagues consistently address patients as "Mr." or "Mrs." so-and-so too. Maybe we're all "old fashioned" that way, and still believe in common courtesy?

There is a practical reason why I DO ask for aforementioned permission, though. When someone is coming out of anesthesia, it's been my experience that they respond more readily when called by their first name than by the more formal "Mr." or "Mrs." so-and-so. Those responses can be very important for the safety of the wake-up. So I always make sure to try to ask ahead of time if it's ok if I use patients' first names.

My own primary care physician always called me "Dr. T," until I asked her to please just call me T. But I feel I should continue call her "Dr. Y." She's my DOCTOR, not my pal.

dr_dredd said...

Hi, Dr. T. I have exactly the same interaction with my own internist. (Also a Dr. T) The same was true with my previous internist in another city. Even a GI family friend who has known me since I was 12 since calls me Dr. D.

Love your blog!

dr_dredd said...

Oops. I meant "still calls me Dr. D."

I can't type today...

Bongi said...

i had a patient that took to calling me by my first name. it irritated me no end, but i let it slide.
he complicated and came close to dying. after all the dust settled i was so glad i just let it slide. in the greater scheme of things it suddenly seemed trivial.

~M~ said...

I live in an area where people are called sweetie and dear a lot, no matter what their age or gender. It used to strike me as odd, at the very least, but I don't seem to mind it anymore.

I laughed at Bardiac's comment because every time a physician introduces him or herself as "Dr. So-and-so," I'm mightily tempted to respond with, "Nice to meet you. I'm Dr. M." I don't mind calling them "doctor," but I do think it's disrespectful for them to call me by my given name without my permission.

Having said that, I may well be a hypocrite since I expect my students to call me "Doctor" or "Professor," but I generally call them by their first names. Most of them are 18 or 19, but some of them are older, and a few are old enough to be my parent or even my grandparent. I currently have a student (older than I am) who signs her emails as "Ms. K," and I do not call her by her first name. I don't know...I think it's a little different from a doctor-patient relationship because I am required to maintain a position of authority in classroom. I consider my physicians to be experts, but not authorities over me. (I don't consider myself to be an authority over them, either, although I know some patients do.)

I very rarely get called by my first name in the classroom, but I do regularly get called "Ms. M," or worse, "Miss M." I find it irritating, if for no other reason than that it makes me feel like a kindergarten teacher, but I figured it was just because they were coming out of high school where their teachers' appropriate titles were Mr. and Ms. However, my male colleague recently pointed out that students never call him "Mr. R." He thinks it's reflectlive of an underlying problem with women in positions of authority. I explained that some students who refer to me as Ms. are quite respectful in every other way, but he stands behind his analysis. Tough to say...

I think you handled the situation with your patient just fine. You are the expert in that environment, and he was trusting his life to you in a very real way, whether he fully understood that or not. You have every right to be addressed courtesously, especially given that you return the favor.

Anonymous said...

I am conflicted about the use of "Doctor" as a form of address. As a patient I sometimes address my doctors as "Doctor" and sometimes by their first names. In my experience, some doctors insist upon the honorific for power reasons, while others do it to reinforce the professional nature of the relationship.

I don't think it makes you a not-nice person to assert yourself in a strong, direct way. Aren't the majority of med students females now? Times are changing and today's children are used to seeing female doctors. Just a generational thing, I think. I wonder if on a different day you would have just laughed this incident off.

T. said...

Perhaps coming from a culture in which respect and deference are expressed linguistically, I have never gotten used to the more informal American habits of people calling each other by their first names without agreement.

I prefer being addressed as doctor by people who are coming to me for that professional capacity. I don't know why everyone keeps mentioning power as if doctors are these power-hungry arrogant people all the time. It's a PROFESSIONAL title. We all went through more years of grueling study, labor, and academic pain than most, and I think the title is EARNED and should be respected.

Perhaps there will come a day when patients will no longer ASSUME when they see my face that I am a student or a nurse. After all, they never assume that about my male colleagues or insist on calling THEM by their first names. When that unlikely day comes, I may revise my preference for a more formal form of address in PROFESSIONAL situations. Nothing to do with power - just respect. Like I said, I and most of my colleagues usually continue to call my patients "Mr." or "Mrs." so-and-so. I think people who are not BUDDIES have a habit of being entirely too familiar with each other in this country.

BTW, that said, most of the time when nervous patients are trying to remember what the heck my name was as I'm applying monitors on them before an anesthetic, and they've given me permission to use their first names, I usually repeat, "I'm Dr. T, but feel free to call me T. (I give them my first name) - it's easier to remember."

PJ Geraghty said...

I confess to being on both sides of this issue, myself.

As a paramedic and later an organ donation coordinator, I always address patients and families as Mr./Ms., correcting that only at their insistence (rare). I generally the physicians and surgeons with whom I've worked extensively by their first names, and less familiar ones (and those taking care of me) as Dr. Soandso.

The one exception was when I was in the ED with a pulmonary embolus (a complication of a tibial plateau fracture). The ICU resident and intern who came to admit me happily informed me (not knowing what I do for a living) that such a condition "is usually diagnosed on autopsy!" Already a little stressed out (and, in fairness, still a little hopped up on pain meds) I growled back "Listen, sweetheart...I know that. But your next patient isn't going to take it quite as well, so you might want to consider your bedside manner a little, ya think?"

Don't know if it stuck or not, but I felt better, and I never saw her again.

T. said...

PJ - you just reminded me: I do call everyone here on this blog by his or her first name, as they do me, because in this forum I guess we are all sort of blog-pals, and I am certainly NO ONE's doctor.

But you also reminded me: all the nurses, paramedics, scrub techs, other docs, housekeeping staff, etc. all address me by my first name, at my insistence. I am NOT their doctor; we are colleagues and friends. (Though sometimes they still call me Dr. T anyway, then I try to keep encouraging the friendlier form of address amongst ourselves...)

I have to say I smiled at your story of having admonished the intern. I think we've all put our feet in our mouths like that, either as interns or later in our careers, and we do deserve to get called on our tactlessness, whether we're clueless docs, nurses, paramedics, or whatever! You did her a favor... :)

T. said...

I am reminded that two comments ago I should have written "As I said" instead of "Like I said," technically.

Kim - I can be obsessive compulsive about grammar errors too, even informal/conversational writing, especially because I tend to point the grammar finger at others myself. :)

Anonymous said...

I think a lot of people equate a sense of being entitled to respect/deference with power issues. People perceive a power dynamic in play whenever you get into hierarchy/social status. I don't think it makes you power-hungry to want to benefit from all of your hard work and success. "Deference" is more of an English social value than an American one. Just go to a town board meeting in any American town to see what I mean!

Americans are a crazy bunch. Some Americans will defer to the MD and some will say an MD and $1.25 will buy you a cup of coffee. Most will probably call you whatever you want to be called as long as they get good care.

Also, maybe you have a different relationship to patients as an anesthesiologist than some of your colleagues in other specialties do. It's not unheard of for doctors to be friends with longtime patients.

T. said...

That is true, Anon - rarely do I ever anesthetize a friend or a friend-of-a-friend!

In those rare instances, of COURSE they call me T. rather than Dr. T., as per our usual customs. :)

Anonymous said...

Um, that's "Sir Mister Doctor Anon" to you, please.

T. said...

LOL! :)

anna said...

When my mother was hospitalized recently, she was constantly referred to as "young lady" and, occasionally, "gorgeous" or "sweetheart." (And we don't even live in the South!)

I'm quite sure that the doctors and staff weren't trying to be demeaning, but it grated on our whole family just the same.

I think as a society we often infantilize older people, especially women. Would you call a 35-year-old male patient "young man"? Patients are often powerless anyway, and it seems like these terms of endearment reinforce - even subconsciously - that the staff is all-knowing and powerful, and the patient is the one who's condescended to and has to just submit to it all.

On a scale of 1 to 10, I guess the name-calling falls near the lower end. But it's something that bothers me just the same.

Re your not-so-charming gentleman: You know, most normal people in this situation would have apologized and/or backed off once they were aware that you didn't appreciate the condescension. The fact that he wouldn't leave it alone suggests that he really did see it as a power thing. Continuing to needle you about it is, IMHO, rude and sexist and inappropriate. I think you had every right to call him on it.

I deal with physicians fairly often in my own (health care communication-related) line of work, and I'm not really comfortable calling them anything other than "Dr." Many of the younger ones often leave off their title when they introduce themselves to me, so my impression is they're not particularly obsessive about being called by their title. But I still feel I should be respectful. I would only use the physician's first name if he/she asked me to do so. ("Oh, don't call me Dr. Schweitzer, it makes me feel so old. Just call me Al.")

I have noticed that my doctor doesn't use my name at all. No first name, no Ms. XYZ, just... nothing. So what's up with that?

T said...

Anna - not sure about that one. Perhaps unintentional, or perhaps, avoiding the possibility of offending?

You're so right - there is indeed that infantilizing tendency, albeit well-meant, I think, by most. I'm glad the NY Times brought it up. It certainly made me re-examine my own habits and try to do better.