Are You Sure?

 Evil turns to statues and masses form a line But I know which way I’d run to if the choice was mine The past is knowledge, the present our mistake And the future we always leave too late I wish we’d come to our senses and see there is no truth In those who promote the confusion For this ever-changing mood, yeah” — The Style Council

Our new wrecking ball, Dr. Lisa Swanson, is a powerhouse and left us with a fantastic opening salvo last month. Taking a wrecking ball to the machinery of prior authorizations and bureaucracy would be a welcome swing, for sure. 

Dr. Swanson is very good at seeing the upside, but she and I do share the frustration of trying to get patients their therapies and counsel them on what to do (and what not to do). Most importantly, we are to treat patients in 3D, reminding them of the value of touch, of conversation, and of relationships. In the end, that’s what it’s all about.

More interesting to me as a source of endless misery in our everyday quest to help patients are the verbal and nonverbal ways in which patients express their doubts about our expertise and opinions. That look of, “Are you sure?” that just deflates any patient interaction is a familiar one, and we can thank Dr. Google for the “assist.” 

Is this issue unique to dermatology? I don’t see many electrophysiologists having this problem. Who responds, “Are you sure?” when shown a rhythm strip and told,  “Sir, you are in atrial fibrillation,” or to the neurologist who has the MRI showing a brain tumor. What I think is that because everyone sees their skin, they are then experts at matching the computer and phone screens to the images in their minds. 

When does contempt as a customer border on disrespectful behavior? When the patient asks, “Are you sure?” and the physician responds firmly with data and evidence, is that shared decision making productive when the patient is sharing negativity? Is it the clinician’s duty to keep the patient safe even from his or her lack of knowledge, or the danger of too little knowledge, as the old adage goes? Of course not.

The AMA Code of Medical Ethics, updated in 2020, addresses the question of unacceptable behavior from either side in Opinion 1.2.2, “Discrimination and Disruptive Behavior by Patients.”¹ The responsibility for patient disrespect seems to fall at the feet of the physician; it is our job, per our own association, to follow our own guidelines until the step of firing patients from our care. 

However, the opposite occurs when the physician who stands up for mutual respect and defending a staff from bullying is labeled as “burned out” or even “impaired” by new standards of customer service—all in the name of mindfulness and wellness in healthcare.² Lost somewhere in the training manual for dermatologists was the course on being “the bad guy;” these models create a lose-lose situation.

Listen to the lyrics of The Style Council. Be true to yourself, your training, your experience, and the reason you are doing what you do. When the next patient who rolls up on you tries to schedule another appointment, refer them elsewhere. When your next good patient comes back, greet them with a smile. Either way, enjoy the ride because, in the end, we only get to do this once. As the song says, “The past is knowledge, the present our mistake, and the future we always leave too late.” Let’s get back to work.

"Evil turns to statues and masses form a line

But I know which way I’d run to if the choice was mine

The past is knowledge, the present our mistake

And the future we always leave too late

I wish we’d come to our senses and see there is no truth

In those who promote the confusion

For this ever-changing mood, yeah”

— The Style Council