In quest of satisfaction

There were three of them. A young man of 20-something sat in the back, his gaze distant, a tracheostomy scar at the base of the neck hinted at a long complicated illness. The parents sat in front. The father spoke with a quivering lip and an unsteady voice, anger pressed down but unmistakable. It was all about me and it was not easy to hear. Their son had been hospitalized with severe acute disseminated encephalomyelitis in another city. He required ventilation and months of rehabilitation. I was to blame, he said, because when the hospital had called me to arrange a transfer, I declined. They lived near my hospital but instead had to drive hours every day, leaving their jobs behind. “And look what we've got” the father said, glancing at his son. I remembered the phone call from that hospital. I had been sitting in this very room with my head nurse, who wordlessly signalled her utter resistance to admitting a patient who might need a bed for months. I felt as though I had no choice. I refused the transfer., and now I had to face the consequences. Turning to the young man, I asked how he was doing, not expecting a reply. To my surprise, he grimaced and managed to say “I am OK,” gesturing to his left “with his help.” Now I noticed, for the first time, a small, middle-aged man, obviously his caretaker. And then I woke up. It was 4.22 a.m., nearly time for me to start my day, but the dream clung to me over the entire morning, forcing me to jot it down lest I forget. None of it ever happened. My two-dozen years as Chief of medicine often involved decision-making under uncertainty, but also, having to practice rationing, withstanding pressures to authorize expensive—but unnecessary tests and medications; or discharging patients who could benefit from another day or two, in order to free a scarce bed for new acute admissions. But I had long since stepped down, happy to dispense with the burden of administrative chores, and nothing in my current practice resembled that scene. Yet, I could not shake it, and kept pondering the bizzare dream in between seeing new patients. What raw nerve had it touched? The answer, I think, is guilt, eternal guilt perhaps. Not guilt over a particular patient, but the familiar guilt every provider feels when facing the anger or disappointment of families. The dream reminded me that no matter how carefully we practice, no physician escapes this ordeal. Alongside the guilt there was something else: compassion. Even in the dream, I turned toward the young man and spoke to him directly. That pleased me somehow. Why was the dream so disturbing? Because it revealed a truth I often try to ignore. Our patients′ and families perception matters to us deeply. They are not peripheral. They are mirrors in which we see ourselves. Physicians who demonstrate attentive listening, noting and reacting to patients' cues and feelings, providing empathy and sincere respect while maintaining humility, and patient-centeredness are rightly esteemed. Far from just making the patient/family feel good, such an attitude adds interest and meaning to the clinician, at the same time gaining patients′ satisfaction, trust, adherence, decreased symptom burden, and less utilization of healthcare services, and likely, improved quantifiable health outcomes. Clinicians inwardly crave the satisfaction of their patients and their families. Their occasional absence, or worse, disapproval, provokes unease and anxiety, sometimes a guilty feeling. Far from being aloof and indifferent, physicians treasure their patients' esteem and are vulnerable to its absence. And worse is censure, which cuts even more deeply. The unexpected dream startled me because it exposed this vulnerability. Patient disapproval is ultimately a measure of failure. Thus, our patients′ opinion matters to us more than we are willing to admit, and our practice must constantly improve to achieve not only patient-tailored, “best evidence” decisions, but also their commendation and trust. Contrary to common belief, achieving this is much more a matter of attitude than time. Genuine curiosity and interest in the patient and his or her circumstances, can be easily conveyed in words and body language. It is keenly felt by the patient and family and always warmly and openly reciprocated. We are all familiar with the deep satisfaction and meaning this gives to the provider, but negative feelings leave us vulnerable and miserable as my unexpected dream vividly told me. The author has no funding to report. The author declares no conflicts of interest.