Spent a sweaty week operating in a hilltop Hospital Nacional in Guatemala a while back.
A patient gave me a hat in thanks for her surgery. It’s a full-brimmed canvas safari number – I’m sure Hemingway shot a rhino in one. I’m just mature enough now to value sun protection and always grateful for gifts from those who have almost nothing. I was also given a painting of the neighboring volcano, a tee-shirt depicting a local politician, two kisses, many back-breaking hugs, and endless expressions of muchísimas grácias (or the quiche version of same).
You’ve heard of doctor shopping. This is when a disappointed patient leaves the ER or the doctor’s office in search of a doctor who understands them better. How about patient shopping? Doctors have a choice too. They engage in patient shopping in various ways.
1. Specialty (ie, a plastic surgery practice in Beverly Hills has a different clientele than an urban trauma surgery practice)
2. Location of practice
3. Private versus hospital-employed versus public health practice
4. Exclusion of payer types (eg, Medicare/Medicaid) or limiting to cash-only
If I were to hand pick a patient clientele, they would be Native American Guatemalans. By dint of history, DNA, culture, nature, nuture, or whatever, our patients and their families treated our mission group as royalty. Or priests, or benevolent dignitaries. We felt like travelers of long ago, scaring the locals and making them laugh with our strangeness. Medicine is a world of hopes and mysteries for them, not a world of choices. I sensed their prior patient experiences, if any, hadn’t fostered a sense of consumer entitlement. They trusted us implicitly, even when things went wrong.
We had a complication. On post-op day three after a vaginal hysterectomy, I had to tell Maria’s family she would need another operation. I worried about her mere survival. I approached the family as I do in America—firm in my judgment, apologetic that a complication had occurred, and prepared to explain/defend the sequence of events to date. There was no need. “I’m sure you know best,” said her husband.
I found Maria’s husband again after surgery, I explained that indeed she had suffered a near-catastrophic surgical complication, but that I expected she would recover. “Thank you Doctor, thank you,” he said. Sisters and nephews thanked me. I felt guilty from the gratitude, like I had gotten away with something.
At home, medicine has been demystified in the age of information, packaged and marketed in the age of conspicuous consumption, and cynicized in the age of litigation. When a bad medical outcome occurs, it is reflex to research. Why? We are trying to tell malpractice from mere bad luck – in a world where bad luck is increasingly exposed as bad choices, bad training, bad equipment, bad people, and other controllable bads. Good science, good will, and good processes have raised our expectations such that any post-op event is suspect.
So, our spirits soared in Guatemala. We were trusted and thanked and bestowed with gifts. Between our team and our patients formed an intoxicating chemistry.
The gynecologist and I fussed and fretted all week over Maria, our only complicated patient. She improved.
On our departure, my last goodbye was to Maria. I brought the incoming surgeon (my replacement) to the bedside to explain her case and introduce patient and doctor. The gynecologist and team medical director joined us. Maria, her husband, and their children looked star-struck by our visit. They thanked us yet again for Maria’s two operations. They expressed their honor in our last-minute visit and told their children we had come from far away to help their mother. Maria asked for a kiss. I held her naso-gastric tube to one side and complied. I wished all patient hand-offs were this heady.
During the swerving mountain bus ride back to Antigua, I watched hillside shepherds at work. Our team, tired and quiet, soaked up a glory which seemed to belong to another century. As we approached the airport, my mind wandered to the waiting routines of home and work. The closer we got to my usual world, the more I pondered Maria’s case, and I felt honor and privilege giving way to a sense of guilt.
Chris Porter MD
This piece first appeared in Dr Porter’s personal blog.