I was in a cab yesterday afternoon. I’m at another conference this week and as I made my way to San Diego, I had to count on many people to keep me safe. From the pilot to the air traffic controller to the cab driver. We do this all of the time, of course–step into a moving vehicle, sit down, inform another person where we’d like to go and then just trust. Trust that they know how to drive, that they’ll take care of us, that they’ll do their best to remain aware, responsive, and agile in the face of unexpected events. We trust that they’ll keep us alive and return us to our children. We do this at the clinic and at the hospital, too.
As I sat in the back of the car, I noticed a sticker on the window describing the bill of rights for passengers for San Diego Airport cabs. The list detailed things I was due: a safe car, a working seat belt, a music-free ride for example. And the kicker, a driver who doesn’t talk on the cell phone.
About 1/2 way to the hotel the driver with whom I had been chatting on and off started talking again. The windows were open and so I felt I’d missed what she said. I spoke up to clarify, “I’m sorry, what did you say?” It was then that it happened…like it often does, I realized she was talking on the phone.
So what do you do?
I mean, really, I’m asking, what do you do? Do you demand she get off the phone? Do you insist that she take care of you and provide additional safety? Do you remove a tip and silently strike? Do you wait until after you’ve arrived safely to assert your “rights” as a passenger? Does it matter if the driver is a woman, a man, is older or younger than you? Does it matter if it sounds like the driver is talking to their child like it did in my case?
I couldn’t help but start to think about the health space. The metaphor is striking. Here I am, a 37 year-old empowered, feisty, out-spoken physician who has reviewed and written about the dangers associated with distracted driving and I was intimidated by the sociology in the cab. I didn’t want to upset her, I didn’t want to rock the boat and interrupt her conversation, I didn’t want to cause tension. Something intimidated me. It sounds absolutely ridiculous as I type it this morning, but even though I believe the “inherent risk and implied immorality” of distracted driving, I didn’t speak up. On some level, I didn’t want her to drive faster or more recklessly (this has happened to me once after I asked a Philadelphia cab driver to slow down). And I wonder, if I had a difficult time speaking up in the cab, just how do we help each other as patients, as patient advocates, as caregivers, and as parents speak up in the exam room? When something isn’t going as well as planned, or when a physician or clinician isn’t really listening to what we’re asking, or when a potential medical error is about to occur, how to we learn to SPEAK UP?
Our health (care) demands that we do.
What are your ideas? What has worked for you in the exam room or in the walls of a hospital that allowed you to speak up to a clinician, or physician, or nurse, or receptionist, or technologist, or surgeon who had your life (or your child’s) life in their hands? How do you protect yourself and your family when you need something in the health space?
The end of my story goes like this: I talked with the cab driver after we stopped at the hotel. I told her how I knew that distracted drivers (on phones) were far more likely to be involved in a near-miss or true crash/accident and how I felt it was her obligation to protect her passengers. I told her I was a mother of two and that all I wanted was to return home safely to my boys. I have no idea if she will change her behavior. She did look me in the eyes and express remorse, and she did apologize.
I often say to my patients that “it’s always okay to ask” about anything in the exam room, in the hospital, or on the phone with a nurse or physician or technologist. Yet, my ride in the cab reminds me again, it is certainly more complex than that.
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Susannah Fox says
This post resonated with me because of a conversation I’ve been part of on Twitter over the last couple of days.
Melissa, aka @savingcase, alerted me to a post she’d written about how to advocate for the best care for yourself or your loved one:
https://www.savingcase.com/index.php/2011/10/24/advocacy-series-advocacy-in-4-steps/
Step 1: Educate yourself
Step 2: Educate those you are dealing with
Step 3: Ask for what you need
Step 4: Kindly, but firmly, assert your rights
I especially appreciate Melissa’s insights on asserting your rights: “Unfortunately, people often fall into one extreme or the other when it comes to Step 4.”
When I shared the post, I heard from Shelia Cotten, aka @Shelia_Cotten:
“These steps are good but they are much, much harder for those in disadvantaged social locations in our society.”
I asked for more and she replied:
“Improving educ and literacy are some of the basics that are needed. Also issues of phys authority and dominance.”
Which brings me back to your point, Wendy Sue: How do we learn to speak up? No easy answers, but I have a better understanding thanks to Melissa, Shelia, and now you!
Yolanda @ One Family Table says
Welcome to SD! I love living in SD and hope you have a great time here.
Thanks for this reminder of how complex the dynamics can be. It’s so easy to assume on the physician end of things that all has been communicated. I’m always humbled when I come across an instance when the families I see didn’t quite grasp as much as I thought they did, all the more so when you are working with populations that speak a different primary language. Speaking up is just not that easy, not only due to hesitation, but also in terms of cultural perspectives as to manners, expectations, etc.
J.K. says
Thank you for a thoughtful article.Here is what I try to do, if I feel a need to question the doctor’s advice:
1)
I am likely to preface my question with: “You have previously told me …”, or “Your colleague told me …”. Then I go on to ask about the apparent contradiction: “I there something that has changed since then?” Or, “Is there something I haven’t understood?”
2)
I only secondly mention anecdotal evidence (family, friends), unless it’s the only thing which is making me skeptical. (The whole thing about “anecdata”, and n=1 …)
Those were two thoughts I had on the subject.
Viki says
When my dad was in the hospital last winter, I had a surgeon turn and start telling at me for being offensive, rude, and having the gall to question his expertise. My dad has a cyst on his liver. His drs has been watching it for 40 yrs. In the prior year or two they’d biopsied and done a CT scan and things were still good. He became ill while away from home and his new surgeon looks at a CT he had just ordered and was giving me a pre-op briefing. Granted, I’d spent the night in a waiting room chair so I wasn’t thinking clearly. My offense, the best I can recall, is using 2-3 consecutive statements that started with “Are you certain, because…” What followed the “because” were observations like “his Dr doesn’t think this CT shows a marked changed from the last,” and “his Dr thought an MRI and further testing were needed to determine next steps.” What enraged this surgeon was that I had ZERO knowledge or basis for even discussing the facts, so it appeared my role was to receive the recommendation and decide whether or not to take it. I could ask clarifying questions but under no circumstance question it. The second problem was that, being smarter and better trained, he’d already read the 55 page medical report and incorporated relevant data and input from other Drs. So, not a lot of room for discussion.
I need to understand things like procedures in great detail if I am to give consent on someone’s behalf. And, yes, my manners were quite dulled by stress and fatigue. I wasn’t even aware of speaking the words “are you certain”! Until this encounter, I would have said the way I speak up for myself or those I’m responsible for is through precision questioning. I try to always have something to jot down notes or an outline and organize what questions I have or what questions have come up. In most cases, “I have some questions” is an easy conversation starter that doesn’t make the exchange seem awkward or like a crucial conversation.
Wendy Sue Swanson, MD says
Thanks for all of these thoughts and for including the link and bullet points. I certainly cringe to think about how difficult this is for all of us and the laundry list that comprises the “why.”
I suspect some advanced scripting is essential for all of us. We need to write out and/or plan out what you want from the visit with anyone in health care. Write it down. Think about how you can say it at the onset of the visit–how you can shape and set the agenda. How you can reflect your goals from a visit (in a clinic, in an ER, in a pre-surgical visit). Think about how to convey yourself respectfully and yet with strength. Practice.
When you don’t understand, it’s always okay to ask. And to ask again.
We need to keep thinking about how to converge in the exam room, together, and have a mutual sense of respect for our *mutual* expertise as patients and as doctors. That’s when we’ll be efficient and much more effective. And it will become easier and easier to speak up.