"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.

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Addendum:

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...