Student Scene
 Tarayn Grizzard Photo by Jeff Cleary |
When Patients Think the Doctor Knows Best
Like a row of dolls, they sit in the clinic waiting room, a dozen or so 14- and 15-year-old girls, all dressed nearly identically in navy blue school uniforms and fluorescent hair dye. With the television blaring real-life family drama overhead, the doctor and I float about getting charts, finding pills in the back room, getting ready for the next patient. I call out the next name and find my patient, a slip of a girl with pink fuzzy hair ties on both long pigtails, frosted purple eye shadow, and the uncertain, gangly gait favored by adolescents and baby deer. I walk her into the exam room.She sits, and without preamble, the doctor of the day begins to ask excruciatingly detailed questions about her sexual activities. I watch, curious to see her reaction to his seemingly invasive interview. She seems comfortable enough with all of this, answering him without embarrassment or evasiveness and venturing that she would prefer monthly injectable birth control. He replies that he does not think she needs anything other than standard oral contraceptive pills, if anything. He ends his questioning just as abruptly as he began and points for her to undress for her internal exam.
Behind a short, completely inadequate curtain, she undresses while the doctor finishes his note, and I scramble to prepare the exam equipment. I help her onto the table and try to chat with her and make her comfortable. Yet she seems at ease with the entire procedure, nearly sanguine, far more so than I would expect for most 14-year-olds. She lies there in stirrups, draped and ready for her exam as secretaries and other physicians come in and out of the room without knocking. The doctor talks to the visitors while she waits on the exam table, the curtain barely shielding her from the traffic brushing it to and fro.
She sits up expectantly as we finish her exam, and the doctor tells her that he has decided that she will take the pill and needs to return in two months. With a nod of his head and eyebrows, she is dismissed, dashing out of the exam room and back to school with a backward glance and friendly smile.
Unquestioning Patients
This scenario isn't unusual, as I am discovering in my work as an intern this summer in Santiago, Chile. After spending three weeks working in an adolescent clinic and the obstetric ward of a hospital, I can say confidently that most of the patients I see are fairly comfortable with these extensive, curt questions about the most personal aspects of their sexual lives, the commotion and bustle of our clinic and hospital that frequently disrupt pelvic and other private exams, and doctors who sometimes make decisions regarding their care that directly oppose what they might prefer.
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Most patients here...absolutely trust their physicians--a stunning contrast to the litigation-ridden health care industry in the United States. --Tarayn Grizzard |
Notwithstanding cultural differences regarding modesty and expectations of the patient care setting, the most striking aspect of this physician model for me is the reason it evidently works. In an effort to explain to me the visit described above, the physician with whom I worked that day said that his goal was to decide what was best for the patient. His job was not to serve as a friend or an intermediary between her and her parents, but to protect her welfare and do what he thought was best. This is especially true with adolescents. He explained, for example, that in the case of this young woman, he was acting in place of her parents in granting her permission to use birth control; and while adolescents frequently do not want to involve their parents, they do want some adult to take charge of this kind of decision for them.
So, far from being affronted that her doctor was acting, as Ferris Bueller would put it, like a "parental unit," the 14-year-old girl the doctor and I had seen expected this type of relationship and trusted that we would only do what we needed to do to take care of her needs. In fact, most patients here seem to desire this type of relationship. They absolutely trust their physicians--a stunning contrast to the litigation-ridden health care industry in the United States.
The Doctor's Motive
And maybe it is Chilean society's greater trust in health care that makes all the difference, although cultural expectations and acceptance of hierarchy undoubtedly make an impact, as well. While there are many private and highly profitable hospitals and clinics in Santiago, doctors in Chile are typically not wealthy compared to their U.S. counterparts; almost all struggle for income and pay very high fees in order to pursue their education. As a resident told me during my second week, patients in Chile know that their doctors must be dedicated to medicine to pursue it and thus will do for them everything that needs to be done--an attitude toward physicians that, at least in the United States, seems to have been lost long ago.But maybe this trust in physicians is not irretrievably lost in the U.S. Declining reimbursements and increasing medical student debt are problems that will result in decreased income and financial security for physicians in the coming decades, closing the economic gap between patients and physicians. Maybe the one benefit to this financial disarray is the possibility of re-equilibrating patient-physician relationships and enhancing patient trust in the physician who they know is present for only one reason--to take care of them.
--Tarayn Grizzard, a third-year medical student at HMS
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.