Posted by: notdeaddinosaur | December 4, 2014

Customizing Communication, or Which One I Sent

It’s been a fascinating week or so listening to everyone weigh in on which response they thought I sent to my patient (also here.) The general consensus, unsurprisingly, was that the first was far too cheeky — not to mention insulting — to effectively convey the necessary information.  The second, of course, was the one I send every day, day in and day out. Just this once, circumstances conspired to allow me to send the first.

Let me explain.

I’d like to begin by quoting myself:

I find it amusing to intentionally adopt a far more curmudgeonly attitude here than I would ever dream of displaying in meatspace. It’s part of the fun of blogging, which is why I’ve been doing it now for almost eight years.

All I ask is recognition that my public blog persona is different from my personal, real self.

The first message was perceived as an expression of my frustration with a patient who wouldn’t comply with recommended treatment while complaining about one of the manifestations of her condition. (There were also some interesting digressions about hypothyroidism and weight loss, none of which actually apply. Remember the first rule of blogging: anonymize! Suffice it to say that her TSH wasn’t 7; it may not have been a woman; the issue may not have been weight loss; etc.)

Here’s the thing, though: in real life, I don’t actually get frustrated with my patients. Really. I’ll admit this wasn’t always the case, however the older I get, the less I care. Not that I don’t care about my patients, but it’s become much easier to actually live the truism embodied by the old Polish proverb, “Not my circus, not my monkeys.” ie, My patients problems are not mine. If patients don’t take their medicine, they’re the ones who live with the consequences. (I take my Synthroid.)

This particular patient was also a health care professional herself. In fact, when I read my first email aloud, my work-spouse said, “That sounds exactly like how she talks to her patients.” Because it was. She’s a cheerful, vivacious, funny, sarcastic person who doesn’t pull punches with her patients, her family, or me. When she said, “Nah, I stopped taking [the synthroid],” it was with a sardonic smile that conveyed recognition of the fact that she was being irrational. Cost wasn’t an issue. Understanding its purpose wasn’t an issue. I don’t think she could articulate precisely why she stopped it. But she had, and here she was, back again, bitching yet again (albeit good-naturedly) about her weight.

So when the repeat blood work confirmed the condition (or at least the distinct possibility that taking the med would help) the first response kind of wrote itself. In a way, I may have been channeling her voice talking to herself. One thing I’ve learned in my own weight loss journey is that no one can be harder on me than I am on myself.

Couple of other things edited out for the sake of the blog:

After the CAPS, I added “(Sorry for shouting)”, and after “Dig?” at the end, I added (“Love you.”) Finally, before hitting the SEND button, I picked up the phone. I didn’t reach her but I left a message, “Just to let you know there’s an email coming, meant to be funny, hope you don’t take offense.” The rest of it, BTW (except for the clinical specifics) was verbatim. ie, “Big girl panties” and all.

Bottom line: She loved it. Message received loud and clear, along with a good laugh. Customized communication at its finest.

Would I ever write such a message again? Perhaps. But only if I were absolutely certain it would be received as intended, as it was this time.

Thanks again to all who responded.




  1. Fair enough, given your relationship with this person. If all the details have been changed, it’s impossible to argue about the science, and you recognize, in fact list among your “laws”, the fact that you can’t make an asymptomatic person feel better. Still, when patients don’t do what you order, especially when they have tried doing it and then quit, that usually shouldn’t be dismissed as “they are irrational.” People always make decisions based on their own values, which are always linked to emotion, even – if not especially – in those who claim otherwise.

    When patients stop taking a drug, that may be because it did not improve their condition, or because it caused new symptoms that were more annoying or worrisome to them than the original symptom or risk factor for which it was prescribed; either of those motives is supremely rational. Or, very commonly, they cannot afford both the drug and other necessary or valued expenditures (unlikely in this case, if Synthroid is indeed the drug involved and you allow generic substitution). Or perhaps it’s just that for that person, the emotional burden of feeling chained to a pill box for life outweighs that caused by the symptom the drug mitigates or the health risk it is supposed to reduce. Unless someone can come up with a purely logic-based argument for the superiority of a healthist value system, it is usually not justifiable to call either of those irrational either.

    There are at least two reasons why doctors don’t elucidate such explanations from patients. The universal reason is that most of you just don’t have time to have long philosophical conversations with patients. Another is that too many doctors approach such a conversation with the overt or covert attitude of “Tell me what irrational motivation is causing you to balk, so that I can lecture you about how stupid it is.” Sensing that kind of attitude directed at you by a higher-status person whose anger might have serious consequences for you makes it hard for most people to articulate their feelings.

  2. Not sure what kind of medical professional she is, but I have observed that doctors (for example) are often terrible patients!

  3. I know you said that the patient had asked to be notified by email. But if a patient asked you to send their test results on the back of a postcard and send them, totally unshielded, through the regular snail-mail system, would you comply? Or would you put on your own big-girl panties and say “The postman doesn’t need to know that she has chlamydia, I’m going to put that in an envelope”? Seriously, emails are totally open to everyone running servers that they travel through. Confidential medical advice and email just don’t mix, unless both parties have a secure gateway system between them.

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