Edward Davies: Your patient just got punched in the mouth, doctor

Edward DaviesThe infamous pugilist Mike Tyson doesn’t get a lot of airtime in the BMJ and I wouldn’t normally advise he be used as a paean of common sense. The guy has a big tattoo on his face. But here at the Lown Institute conference in Boston, there’s a quote from his early career that seems just about right.

It was in the run up to a big fight that Tyson was being bombarded with questions about how he intended to deal with his latest challenger and was there a strategy in place to cope with their plans?

His response was simple: “Everybody has plans ‘til they get punched in the mouth.”

In boxing terms, this is completely literal sound advice, but as a metaphor for life it’s not bad either. And listening to a patient panel here at the conference this morning I was reminded that this is a worldview that doctors might do well to remember.

In recent years there has been a positive and partially successful drive to improve physician communication: decisions should be joint with patients, doctors need to listen, patients can be vulnerable.

But it is wrong to infer from this that you should classify patients as “vulnerable people”—they are not. They do not fit as one homogenous mass into the “classless fraternity of the stricken,” as one speaker Katy Butler so eloquently put it.

They are individuals with their own story and their own plans. The plan might have been a care plan, a plan for the consultation or general plans for the day which are being eroded by their presence in your clinic. But until the second they meet the doctor they were an individual with a unique history and plans. What happens when they encounter the health system (or your clinic) is not simply that they suddenly become “vulnerable people.” It’s that they get punched in the face and their plans change.

Three patients here told stories of their treatment (or mistreatment) at the hands of the medical profession. The first spoke of the decision of whether or not to treat her cancer with chemotherapy, the second about her experiences of childbirth, and the third of her parents’ end of life care.

Each example had a myriad of conflicting factors and so it’s hard to know if they got the “right” care or not from an objective point of view. But common to each example was the feeling that they were punched in the face by a system that took little notice of their own story or plans.

These were not vulnerable people before they entered the healthcare system and they were not vulnerable people as they sat on the stage describing their mistreatment, but the punch to the face of the American healthcare system had left them momentarily powerless.

For physicians, it means this: many of the patients you see are not “vulnerable people.” They do not need childcare. It is just that your sudden presence in their lives has punched them in the face. The answer is not to pull them out of the boxing ring and take over, it’s to get in their corner with a bucket and sponge and come up with a new plan, together.

Edward Davies is US news and features editor, BMJ.