Office visits often begin with "How are you?" I recently experienced an unexpected dilemma of how best to answer. Exploring my little conundrum may expose opportunities for clinicians to offer healing words. Here's what happened.
I was waiting alone in an exam room, holding my index card of questions. The door opened. My pulse quickened. The nurse walked in and gently asked, "How are you?" I stammered, frozen with confusion about whether to reference my physical condition, how I was coping, or the imminent arrival of my sixth grandchild.
My stutter surprised me. Early in my survivorship I'd explored my dread of that question in social situations. Readings and discussions had led me to insights that helped me thereafter navigate all the "How are you?" queries from friends, family, colleagues, and acquaintances. (See "Surviving 'How ARE you?'" at http://tinyurl.com/wshhowareyou) Today, I respond without hesitation in whatever way works for me. I often take the question as a colloquial "hello" (no matter how intended) and answer, "Great!" (even if I'm anything but).
I could have simply answered the nurse with the same "Great!" and gotten on with the visit. Except I couldn't. Doctor visits are not social visits. To get good care, I must provide accurate information, no matter how uncomfortable doing so is for me.
What probably threw me off that day was that I'd not yet adjusted to my new diagnosis or the routines of the specialty clinic. Different sides of me competed to answer, jamming up my tongue. The responsible patient wanted to report succinctly, "Exertion exhausts me. I wake up in the middle of the night and cry." The Healthy Survivor in me wanted to exude confidence that I was working around my limits and making life the best it could be, an outlook that defines me. I squelched the snarky voice of the anxious patient who wanted to snap, "I have no idea how I am. I'm about to find out."
In the moment, I didn't consider answering, "Great." Don't for a second think I didn't want to. On occasion, I even daydream of doctor visits where I'm beaming brighter than the sun while answering: "I'm doing great." An obvious explanation for my fantasy is how unbelievably wonderful it would be if true. Hand me a magic wand and-swish-I'm on it. My reality is that my days are shaped by aftereffects.
Decades ago, I stopped hoping to feel great after realizing that my happiness depended on accepting and adjusting to my discomforts and limits. That's why I hope only to feel good enough to do things that bring meaning or joy. Good enough is good enough.
My theory for the source of my recurrent daydream hinges on my problem with gratitude. (See Thanks at http://tinyurl.com/WSHThanks) Back when I practiced medicine, a soul-filling reward was seeing a patient in follow-up, fully recovered after a long or high-risk illness. Now, as a patient grateful beyond words for my superb medical care, I yearn to give each of my doctors and nurses a success story. I want them to enjoy the gift of that same energizing satisfaction, instead of my prettily wrapped books and fancy chocolates.
A lesser explanation for my daydream has to do with my public persona. Perhaps more than I want my doctors and nurses to see me as thriving, I need to see myself that way. At doctor visits, the necessary focus on my symptoms often causes a brief bout of post-visit blues because my losses are sad and suggest I'm not doing great. Contrast that with social situations where my cheery, if automatic, "No complaints!" boosts my self-perception as a thriver.
What are my intended takeaways of these personal stories? Let me be clear: I see no need to analyze a patient's response to your "How are you?" greeting. Just be aware of possible subliminal bias. A patient's enthusiastically positive response may suggest that the symptoms you subsequently discuss are well-managed when, in fact, that patient would benefit from further evaluation or intervention. Conversely, a patient's negative or odd response may reflect momentary distress and not a need to sound the alarm.
Consider the possibility that your patients who answer, "Great!" may be...
* Treating doctor visits as social visits. Patients may worry about disappointing you, or they don't realize how inaccurate reporting can jeopardize their care.
* Encouraging you to keep treating their cancer. Patients may fear that reporting symptoms will lead you to lower their doses or stop treatment.
* Putting on a good show. Patients may dress meticulously and sound energetic throughout the visit, for themselves as much as for you. Then they go home and collapse for hours.
Thanks to my experience as a clinician and my work exploring the patient side of getting good care, I know what sorts of things make it easier to care for patients. In my efforts to be an effective yet low-maintenance patient myself, I'm committed to candid reporting and complying with therapies. Despite my clarity of purpose, I still find patienthood uncomfortable. Without a doubt, the compassionate way my doctors and nurses validate both my difficulties and my efforts helps me live my best life between visits.
You may comfort and inspire your patients going through rough times by....
* Validating their experience of adversity. "I hear you that you feel...."
* Sharing your perception of how they are coping. "It sounds like you are (or aren't) well enough to do things that matter to you."
* Expressing gratitude for their reporting. "Your candid explanations help our evaluations and treatment decisions."
For patients, "How are you?" may be taken as a meaningless greeting, an invitation to summarize their medical condition, or a profound question about their whole life. The recognition that a variety of factors plays into a patient's answer may assist your assessment and open opportunities to offer healing words.
WENDY S. HARPHAM, MD, FACP, is an internist, cancer survivor, and author. Her books include Healing Hope-Through and Beyond Cancer, as well as Diagnosis Cancer, After Cancer, When a Parent Has Cancer, and Only 10 Seconds to Care: Help and Hope for Busy Clinicians. She lectures on "Healthy Survivorship" and "Healing Hope." As she notes on her website (http://wendyharpham.com) and her blog (http://wendyharpham.com/blog/), her mission is to help others through the synergy of science and caring.