Why is the doctor ANGRY?

I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy.  Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out.  Day-by-day he lay in bed, as he grew weaker and multiple systems failed.  No one contacted me.  Finally, he sent an email to a doctor 3000 miles away, in California.  That doc forwarded the email to me.  I sent the patient to the hospital.

Did we rush to the emergency room, to salvage his life?  Of course.  Were there innumerable tests, complex treatments, multiple consults and an ICU admission?  You bet.  Did I patiently explain to him what was happening?  Yes.  Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor?  Did I remind him what I expect from him and what he can expect from me?  You better believe it, I was really pissed!

The practice of medicine for most doctors is fueled by a passion to help our fellowman.  This is not a vague, misty, group hug sort of passion.  This is a tear-down-the-walls and go-to-war passion.  We do not do this for money, fame, power or babes; we do this because we care.  Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning.  Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.

I know that patient autonomy gives each person the right to decide what path they wish to walk.  I really understand, after 27 years in practice, that not everyone is going to listen to me and that I occasionally fail or am wrong.  I welcome a healthy debate and ongoing interaction about decisions.  In the end, the patient is in charge and I am just the guide. That does not mean that I am not going to try to do the best for every patient and that certainly does not mean I do not care.

Often when a patient makes poor and arbitrary changes in medical care, it reflects denial and an attempt to maintain control.  These are critical needs and must be respected. However, there is a line which if patient or doctor cross, tragic, unnecessary things occur.  The dread disease gives not quarter, even if I am tired, distracted, depressed or ignorant.  Cancer demands my complete commitment to its destruction.  It demands the same focus on battle from patients.

Therefore, when patients stray without good reason, I get anxious.  When they make bad decisions I get upset.  When they needlessly modify treatment, my head begins to spin.  When patients yell at my staff, while I understand their stress, I worry they will undermine their care.   And because this is oncology and because the stakes are so high, in the most direct and supportive manner, I will let the patient know.

I think one of the differences between young doctors and us old salts, is we how express such anger.  Newer docs are full of fresh vim-and-vinegar passion and so upset by the harm that is about to occur, that they raise their voices and may berate their patients.  Senior docs know, because they have fallen into the losing-your-temper trap, that this backfires.  Patients, already under stress, cannot cope with a shouting off-the-wall physician.  Experienced voices instead drop, words slow and we sit down on the bed and touch a hand, rather than pace and punch the wall.  Do not mistake controlled continence for calm or uncaring; inside we are seething, fuming, on fire.  I tell you, until the day we die, we really get pissed!

Beating difficult disease involves an unwritten contract between patient and doctor.  Each has their role, and the patient has much more to lose by violating that agreement.  If you do not like the treatment, make a change.  Let the doctor know, negotiate a new plan, change caregivers if you need.  But, once you set that plan, once the two of you decide on the steps to be taken, it is up to you and your doctor to each do their jobs.  Cancer cannot be beaten any other way.



  • So, did you ever find out from the patient why he did not reach out to you?
    • James Salwitz, MD
      He was in remission and at the end of treatment. I think he was hoping to move on from the burden of medical care and just be a person and not a patient anymore. His timing was nearly fatally off. jcs
      • I completely get that. It's what Dr. Victor Montori and his Mayo Clinic-based team are working on - the concept of Minimally Disruptive Medicine and the "burden of treatment". Given that doctors spend their lives trying to save lives at all costs, this may be a near-impossible concept to accept, especially when it may mean not being able to help an exhausted and frightened patient live longer. But as a patient living with debilitating cardiac issues every day, day after day, I completely get it. More at: http://myheartsisters.org/2013/02/16/living-with-the-burden-of-treatment/
        • James Salwitz, MD
          Thank you for a really interesting link. Dr Montori's concept that we need to adjust for each patient just how much treatment ("care") with which they are burdened (i.e. just how many pills can one person take?) is quite fascinating. This gets back to the need for a primary coordinating doc, as apposed to multiple uncoordinated sub-specialists, so that there is not too much medical intervention. In there end if the patient cannot comply with reasonable treatments, it does not matter how good are our intentions. jcs
  • gopja
    Our practice lost a patient to renal failure following urosepsis, while in a similar situation. He had six years to relay his story in the waiting room for follow up appointments, squeezed in between dialysis sessions, and was a powerful example for many. I have never understood why people accept miserable toxicities due to not reporting manageable side effects early on. I surmise it may be they misplace blame on the physician treating them and hold them personally responsible for the side effects. Anyone I have ever dealt with that has the tendency to underreport side effects appears to have acceptance and trust issues. Keep fighting the good fight, sir.
    • James Salwitz, MD
      I too have found that it is hard to convince some people that if they really tell me what is going on, that I can often help them to live better. Frequently, people are scared I will medically intrude on their lives and make their lives more miserable. jcs
  • I can only imagine the frustration in dealing with a patient who does not understand that partnership means taking responsibility for their action (or inaction). Probably the over empowered patient is equally frustrating, who challenges each and every recommendation ... But whether it be cancer care or life in general, calm generally works better than angry.
    • James Salwitz, MD
      I always tell my students that a physician's job is pour "oil-on-the-water." jcs
  • I would also be interested in reading what this patient gave as his reason for contacting a doctor 3000 miles away. No doubt it would shed some light on the crux of the matter. We know treatment outcomes are often not predictable. We know knowledge regarding treatment evolves within a rapid influx of discovery/change with much yet remaining in the realm of the unknown. We know people die despite the best of treatment intentions. I commend you, the oncologist, striving to do your best to treat wisely to alleviate pain and suffering despite the fact that a good outcome is often at best iffy. Being angry with what could thwart the success of your intent I can relate to. All things considered, however, it does appear a mistake not to think of the scenario you relate as anything other than inevitable. You deal with the element of uncertainty treating your patients. The patient must also deal with panic provoked by the uncertainty of a life or death prognosis . . . powerful emotions to deal with.
    • James Salwitz, MD
      I believe he reached out to a doctor 3000 miles away hoping to find an "easy" solution and avoid exactly what happened, a difficult trip to ER and hospital. Still, it does make one worry about trust. The boiling pot of emotion that all carry in dealing with life threatening disease is hard to overstate. I often wish I had a "fear and anxiety" meter in my waiting room. I am certain the needle would spin round and round and round and... jcs
  • Good piece. But you, and I, are more than guides. We are teachers. We must use our patience and knowledge to teach not only our patients, but their families of the Truth as we perceive it. Ofttimes I have learned in follow up of a "crisis" that 2d cousin Sophie KNEW what I had told her family was "wrong and twisted." Overandoverandover. We have no option. It has become not our duty, but our troth. And at 10-11 p.m. when the body's sore, the wife's worried, and the kids are on their own path, we rest. To do it again tomorrow. We are identifiable in a crowd. Slightly drooping in the shoulders, generally unsmiling, but quick to respond angrily to inadequate information at meetings and such. No butt slapping "Everything's gonna be O.K." for us. The ghosts of men like Tom Frei, E.J. Freireich, Monty Lane and Chuck Coltman haunt our dreams, followed by vague memories of a thousand dead. This we do every day and night until one day we don't. This was decided for me, like most everything in my life-with the exception of a pretty young woman in a bright red dress and the greenest eyes I'd ever seen. But I digress, and that's another story. You do good stuff, doctor.
    • James Salwitz, MD
      It is a indeed a history of noble men. Thanks, jcs
    • Kathleen Denny
      This is a wonderful discussion. I am one of Tom Frei's success stories, nearly 40 years out from an adnexal carcinoma that had metastacized. I had radical treatment in every department (surgery+radiation+chemo) and none of you would do some of that today, but I always appreciated that Tom (who gave so much of himself) never pretended that he knew all the answers, and I understood that my recommended course was based on analogy and the very best they could do at that time. That experience set a high standard, fundamentally changed my relationship with every doctor since, and long-term effects of treatment guarantee that I have seen a good few.
      • James Salwitz, MD
        I am honored to hear your words and remarkable story. Many of the early oncologists were not only great scientists and gifted physicians, but their great love for their fellow man drove them to push boundries and discover. Their legacy penetrates all we do, not only through stories like yours, but by their teachings, passed down. Thank you for a powerful comment, jcs
  • D Someya Reed
    I'm still stuck on that first question, too. It was mine when I read this piece. Perhaps if I ask it another way and no disrespect intended for we all know that sometimes nothing works. The question is...Did you ask the patient directly if there was some reason why he didn't feel comfortable asking you the same question he asked the doctor in California? In answer to the second time this was brought up, you said you 'believed' you understood the patient's intent to find an easy solution. You didn't say you knew. This situation could be due to so many things you've already mentioned...trust, denial, grabbing at straws...anything. I think the hardest thing in being any kind of medical practitioner is trying to find the right answer to this question for each and every patient. The second hardest is being angry and not showing it (to the patient's detriment).
    • James Salwitz, MD
      When I asked why he had not called, he said gave the vague answer, "I figured if I waited, I would feel better." When I asked if he understood the previous instructions he had received, to contact me with any problem, he said yes, but somehow this acute event seemed not to apply. When I look broadly at the patient's life, I see someone who has tried to maintain a maximum of control, not only now, but throughout his life. Trust of others, even critical doctors, does not come easy to him. jcs
  • IBS
    I am a patient, and I don't agree with one word each have you suggested. Why? Everything you do is analytical and you're thinking too scientifically. Dr. S said the patient was in remission. What the patient is now thinking, perhaps I can finish my Bucket list before I pass. I am PRESENTLY PERFECT! Dr. S. made me well!! Perhaps I can fly to see my grandchildren I might want to take a trip to Ca. If I travel to Ca., I might need an MD. Perhaps I feel I should have a checkup after I fly? Since I haven't made up my mind yet, there would be no reason to tell Dr S yet until I get all my ducks in a row and think. Meanwhile, Unbeknowst to the patient, all files were sent over. I would want to make sure I had a good MD in Ca. And then....AFTER I made a decision, I would ask Dr. S if he thinks it's a good idea. What apparently happened is that the Ca. Dr thought he had a new patient and Dr S thought he lost one. Although once in a while, I do cheat and read Inspire But sometimes, I do help people just in my words. The first thing that the patients say is "I am NED" I am going to take a trip with my family now. Not one of them mentioned "I am going to ask my doctor first." They are experiencing pure joy, and they are planning. This is how a patient thinks and feels. What I would suggest is that any doctor that works with cancer, should speak to a neurologist about the after life, and if the patients that are sensitive enough could really hear, feel or see them souls. They will tell you, "yes..." If you can start to believe by a neurologist, in an analytical and scientically way, this will help your patients too. Even if only the words, "a neurologist explained to me that there is an afterlife." Also, please don't use the word, DEAD. Please use "Passed On." I had certain feelings my entire life, and I did ask my neurologist if others feel as I do? He said "Yes"... After an article I read, I never realized that if an MD is having coping skills, they can't go for for help without losing their license. WRONG! An Md is not G-D. They have feelings. They care for their patients; that's what makes them human. Give them a vacation, they need to have fun and laugh or a retreat to be able to talk about their feeings and then lock the files up. Give them certain ways to get rid of anger in an industructive way....Bring a therapy dog to work.
    • James Salwitz, MD
      Wondeful insight. Thank you very much. I have not doubt that the patient really wanted to "move on." After all we oncologists are not a lot of laughs. It reminds me of the need during transition moments in care (i.e. when a treatment is complete or, in reverse, when a cancer returns), of the vital need for intensified commmunication. Clearly while I thought I had closed the loop by telling the patient with every visit to call me with any significant change, I had failed to get that message through or somehow had seemed unavailable. jcs
  • Sally
    What a lovely, caring doctor you are. Thank you for the work you do. I don't think you need a fear and anxiety meter - I think you can safely assume that for many patients it is a time of the most intense stress imaginable. I couldn't sleep for two whole weeks when I was first diagnosed. Lying awake every night worrying about what would happen to my two young children was just awful. As patients we need more onco psychologists to help us and check in on us from time to time. You can't be expected to meet all of our needs. You're too busy saving our lives. Thank you so much and keep up the great work.
    • James Salwitz, MD
      Thank you. I can only imagine the anguish and confusion of 2:00am worrying about 2 children and cancer. There is an infinite need for support and connection. jcs
      • IBS
        I used to work as a volunteer working for "Cancer Care". We all worked very hard to raise monies to help all cancer patients. It also included social workers, people to take care of babies and toddlers so Mom's can nap....we used to do everything for the patients. Please make sure Sally sees this. There are also lots of other organizations that do the same thing too.
        • James Salwitz, MD
          Thanks for the lead and support. jcs
  • I have a rare blood blood cancer and I am also a nurse midwife. I so appreciate my oncologist. He is a true healer as well as Harvard trained. What I appreciate most is that he sees me as a whole person. You have a very difficult and rewarding profession. I so appreciate what you do. I am not sure why this patient did not call. For myself I find that I am hesitant to call. My oncologist advise is when I am having a problem ....if I am even thinking about the ER go. Each patient is so different. Thanks for all your hard work. It is much appreciated.
    • James Salwitz, MD
      One of my partners taught me long ago, that I must remember to call patients with good news as well as bad. Thus, the patient will not always associate our conversations with the negative. I suspect in the same way if I try and avoid, whenever possible, the "go to the ER" reflex, than perhaps patients will be less anxious about calling. There is so much emotion involved in this kind of communication that the doctor must do everything to try and keep the door open. I am thrilled you have a doctor you consider a "true healer." What a wonderful gift. Thanks for your thoughts and stay healthy, jcs
      • Take excellent care of you so that you can continue to take care of us. I wish you a peaceful heart and all the joy that life has to hold.
        • James Salwitz, MD
          VERY much appreciated, jcs
  • Stephanie
    Really? Because I thought you did it for the babes...... Just kidding, of course, but I enjoyed the humor in the middle of a very serious post. Your blog gives me insight into the lives of my own oncologists. You have helped me understand my responsibility in better communication. I appreciate everything that all of you do.
    • James Salwitz, MD
      I appreciate the feedback, thanks. As for the babes ... my wife is Lithuanian, and you know how jealous they get. jcs
  • Mary
    I witnessed similar "bizarre" behavior as my sis in law was treated for cancer last year. I chalked it up to poor coordination.between docs at two med facilities until I met them in person. I realized that nothing they said penetrated her bubble of "I'm getting better" as she behaved in ways counter to wellness. It was clearly stated in a joint meeting that she needed palliative care - I saw their sorrow at having to convey such a thing; I felt their despair at having no more options- yet she refused to sign the papers; she wanted another surgery and a tummy tuck. Such a difficult 60 days until she passed away. Such a terrible journey for patient, doctors and caregivers. M
    • James Salwitz, MD
      That is a really tough story. Somehow the old excuse, "well, you can't win them all," does not come close to covering it. One really regrets the loss and the unnecessary suffering. Thanks for the comment, jcs
  • Hello Dr. Salwitz - FYI, I have linked to this post and quoted your story in my Heart Sisters blog post, "To Just Be A Person, and Not a Patient Anymore" at http://myheartsisters.org/2013/06/08/i-dont-want-to-be-ill/ Interesting comments coming in from patients in the same boat! Thanks so much for the inspiration. regards, C.
    • James Salwitz, MD
      Your piece is very interesting and insightful. I am trying to find a way to surgically implant it into first year medical students. That would probably change the world. jcs
  • I came to hear you speak today and just got introduced to your blog, although I do think I heard about it early on in my treatment. I wish I had pursued it then. I, too have been keeping a blog of sorts (more like a mass email) which I kept throughout my treatment. I am now in the process of putting it all together and editing it. The process of writing has been wonderful for me. I would like to include you on my list. I am also a psychologist and very interested in the emotional aspects of going through cancer....now that I am safely on the other side. Dr. N. gets my blog and is frequently a leading character as he provides such great 'material.' I hope you can publicize your blog as so many patients would benefit. Keep up your musings and observations. I can provide them from the other side of the examining table. PKR
    • James Salwitz, MD
      I am glad you came today, and really appreciated your insights. Should you wish, at any time, I would be honored to post some of your writting as a guest blog. Take care, jcs

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