I've noticed that there are times when, despite best intentions, a patient and a doctor just don't connect.
Like the doctor thinks the patient is completely on board with what they're saying, yet they're about the opposite of being on board and are actually really upset.
An example of this occurred during my intern year, when I was on the medicine consult service:
We were consulting on this 40 year old guy on the ortho service with end stage liver disease and a recent above knee amputation following a trauma. His creatinine bumped a little (meaning his renal function got worse) and he's got major ascites from his cirrhosis, so they called us to figure out what to do with his fluids.
The patient needed a liver transplant, but couldn't get one due to his amputation. My attending Dr. Smith and I decided to calculate his MELD score, which is a score that determines the 3-month mortality of a patient with end-stage liver disease. His score gave him a mortality rate of 50-75% over the next three months. So basically, he had at least a 50% chance of dying in the next three months.
I knew that the patient wasn't even remotely aware of this. The amputation was due to a trauma, not diabetes or something like that. He had told me that his doc had been trying to get on a transplant list, but his liver disease "wasn't bad enough". He believed he was in the earliest stages of liver disease.
Dr. Smith said that we needed to give the patient a "prognosis report", meaning we should be honest with him that he has a good chance of dying soon and encourage him to go on hospice.
"I don't know about this," I told her. "I think he's going to be really shocked."
"You think the other doctors haven't been telling him this all along?" Dr. Smith challenged me.
"I mean, I saw him trying to do work on his computer this morning," I said. "I think he believes he's going to recover from this."
"I doubt he really believes that."
I said that he's a young guy with small children and he's not going to easily accept going on hospice. I know hospice is an underutilized service and I wasn't saying this guy shouldn't on it... I just felt like it was going to be a big surprise to him to hear all this.
"Are you saying he doesn't deserve to hear all this?" she asked me.
"No," I said. "I'm just saying he's going to be surprised."
We went to see the patient and Dr. Smith told him everything. She was completely blunt with him. She even talked to him about end of life issues like would he want to be on a vent, etc. The guy looked completely SHOCKED. He was just staring at the wall the whole time she was talking. I felt awful for the guy.
When we got out of the room, Dr. Smith said to me, "See? He didn't seem surprised, did he?"
"He's heard all this stuff before," she said. "He's just in denial."
Dr. Smith had done this hundreds of times (I assume), so part of me wanted to defer to her experience. But then the next day, the social worker came up to me and said, "You know that patient you talked to yesterday? He's completely shocked about what you told him and he's freaking out. He's really depressed. You need to come talk to him again."
I was like, "Goddamn it, I KNEW it!"
It was clear when I went back to the patient that he hadn't heard any of this before and he wasn't in denial at all. He was crying and asking me very legitimate questions.
I don't know how this disconnect happens, but I suspect it happens to all doctors. You think the patient is thinking one thing and they're actually thinking something completely different. And you only find out a few days later, when you've been reported to a patient advocate.