What are they thinking?

It always bothers me when patients seem less interested in focusing on their visit than I am.


When I’m in a room with a patient, I try to really be there. The patient is entitled to my full attention and all my mental energy during our usually too brief encounter. It isn’t easy to turn off the thoughts and feelings from the previous patients, not anticipate patients scheduled for later in the day, not think about the accumulating messages and refills or the phone calls that need to be made to consultants, let alone issues from my nuclear or extended family. But it is important so I always pause briefly before I open the door, take a slow breath, and wipe my mind clear of the clutter while I turn down the volume on the internal voices. I like to think the patient can tell by my voice and eye contact when I enter and greet them by name that this is their time, and their time alone.

This week I saw a gentleman after hours for an acute visit. About a week earlier he had been doing work around his yard and had cut himself on a tool, requiring a trip to the local ED for a tetanus booster and a dozen stitches at the base of his non-dominant thumb. He had called mid-afternoon to report that the suture line had been getting redder and increasingly sore and now there was a little drainage from one end. He was worried that it might be infected. and was added to my schedule for an after hours visit.

After my ritual head clearing, I entered the room to see a gentleman in his early forties, trim, nicely dressed, sitting on the exam table with his eyes focused on the smart phone he was operating with his right hand. I introduced myself and noted that I didn’t think we had met before and put out my hand for a handshake which he didn’t see as he didn’t look up from his phone. I sat down and logged into his chart on the medical record while he continued to thumb away on his phone.

It isn’t terribly unusual - or a problem - for people to be using their phone when I come in. I don’t see it as any different from reading one of our magazines, grading papers or making a grocery list. An exam room is boring, and people find lots of ways keep busy while waiting. Generally, usually within just a few seconds, the patient switches their attention and responds to my greeting. Not this time.

I attempted to get the visit started by asking what had brought him to the office this evening. He was my third after hours appointment and it was 6 pm at this point. He continued thumbing with his right hand and wordlessly held his left hand out with the obviously infected suture line showing.

I assumed he was finishing up an important text message or shutting down the phone and took a quick look at his chart: he had no allergies and no serious chronic illnesses but did come in regularly for preventive visits. I looked back at him. He continued to thumb away. I checked his social history and saw that he was not a smoker, was married with children, and employed in a local bank. I looked up and cleared my throat gently but he continued to thumb. His infected hand remained outstretched as if frozen.

My puzzlement was becoming irritation. I put my hands in my lap and sat and waited, wondering what was going on in his mind and how long it would take him to realize I was waiting. After I watched him thumb for about two more minutes, he looked up, saw me sitting quietly and waiting, and said: “What?” I said as pleasantly as I could that I was just waiting for him to finish what must be an important task so we could talk about his infection. “Nothing important,” he said. “I was just playing solitaire.” I was dumfounded. I had expected a comment with a brief explanation for why it was important and had hoped for an apology. Solitaire? I paused to give him a chance to say something, but he did not. Eventually he said, again, “What?”

I asked him how he would feel if, when he came in for his physical, his doctor ignored him and played solitaire on the computer in the room while he waited. He shrugged. I told him I would find it intolerably rude and would look for a new doctor. His response: “I guess. I’m sorry.”  At that point I redirected my attention to his history and his wound, we removed his stitches, found no drainage to culture, picked and antibiotic, discussed soaking and local care, and reviewed what to expect and when to call for problems, and he was on his way. Several patients later I was done and on my way as well.

As I drove home and thought about it,  considering whether or not I could have handled it differently, I wondered if he was also thinking about what had happened. 


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