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When patients refuse to follow the textbook
LIKE pilots and concert pianists, surgeons cannot afford the luxury of an error. Their performance – from one flight, concert or operation to the next – must be flawless.
This is what they train for, endlessly, until they can do what they need to do in their sleep, on their heads, with one hand tied behind their back and with the building/plane burning down around them.
This is what they’re paid for. Perfection. It’s what they expect of themselves, an expectation that often lies at the heart of their career choice.
In GP-land, where the flight plan is a tad more free-form, the interaction with the patient less quantifiable, the world is seen in shades of grey, each representing another level of uncertainty.
So that while the likelihood of a GP mishap resulting in the loss of life is far less than in the case of the surgeon, the probability of such a mishap is far greater.
The corollary is that GPs learn to deal with imperfect outcomes. Uncertainty lies within our comfort zone.
Surgeons, on the other hand, experience few mishaps. The better the surgeon, the fewer the mishaps.
But the human body is not a plane or a musical score and, sooner or later, it will take matters into its own hands.
This is when the true mettle of the surgeon emerges. Or fails to emerge.
When they have done everything right, and yet it all turns out wrong.
When the wound dehisces, when infection supervenes, when complex regional pain syndrome develops, when the kidneys pack their bags. The better the surgeon, the less often they will find themselves in such a situation, the less well-equipped they will be to deal with it.
Their responses will vary – from denial, to blame (usually directed at the patient for perceived non-compliance), to hand-balling (to the nearest non-surgical colleague), to neglect, to downright rudeness.
It’s a phenomenon that never ceases to amaze: the bright, bouncy consultant – usually sporting a bow-tie, positively oozing confidence, competence and bonhomie in equal parts – pleasant, attentive, knowledgeable, thorough and efficient – suddenly confronted by the patient who resolutely refuses to recover.
There is, of course, the obligatory FBE, CRP and UEC, a cursory prod of the affected part, an antibiotic, perhaps, and a reassurance that all will be well. It must be well. It cannot be otherwise but well.
And then it’s not well. And the mood turns ugly.
Information is not forthcoming. Calls are not returned. There is a dramatic drop-off in the frequency of consultations. The patient is chided. Then issued with a prescription for antidepressants.
Then dismissed, often with the words: ‘There’s nothing more I can do for you.’
Which is when they land back in GP-land, often followed closely by a letter trumpeting their recovery and, occasionally, making reference to their obtuse refusal to embrace the reality of their wellness.
The test of a true doctor? One who is at his or her best when things are at their worst.