Spent a sweaty week operating in a hilltop Hospital Nacional in Guatemala a while back.
A patient gave me a hat in thanks for her surgery. It’s a full-brimmed canvas safari number – I’m sure Hemingway shot a rhino in one. I’m just mature enough now to value sun protection and always grateful, sometimes to the point of pain, for gifts from those who have almost nothing. I was also given a painting of the neighboring volcano, a tee-shirt depicting a local politician, two kisses, many back-breaking hugs, and endless expressions of muchisimas gracias plus the quiche version of same.
The biggest gift of all, though, was the respect our patients gave us.
You’ve heard of doctor shopping. This is when a disappointed patient leaves the ER or the doctor’s office in search of a doctor who understands them better. How about patient shopping? Doctors have a choice too. They engage in patient shopping in various ways.
1. Specialty (ie, a plastic surgery practice has a different clientele than a trauma surgery practice)
2. Location of practice
3. Private vs hospital-employed vs public health practice
4. Exclusion of payer types (eg, Medicare/Medicaid) or limiting to cash-only
If I were to hand pick a patient clientele, they would be Native American Guatemalans. By dint of history, DNA, culture, nature, nuture, or whatever, our patients and their families treated our mission group as royalty, priests, or benevolent dignitaries. We were like travelers of long ago, scaring them and making them laugh with our strangeness. Medicine is a world of hopes and mysteries for them, not a world of choices. I sensed their prior patient experiences, if any, hadn’t fostered a sense of consumer entitlement. They trusted us implicitly, even when things went wrong.
We had a complication. On post-op day three after a vaginal hysterectomy, I had to tell Maria's family she would need another operation. I worried about her mere survival. I approached the family as I do in America—firm in my judgment, apologetic that a complication had occurred, and prepared to explain (defend) the sequence of events to date. There was no need. "I'm sure you know best," said the husband.
I found Maria’s husband again after surgery, I explained that indeed she had suffered a near-catastrophic surgical complication, but that I expected she would recover. “Thank you Doctor, thank you,” he said. Sisters and nephews thanked me. I felt guilty from the gratitude, like I had gotten away with something.
At home, medicine has been demystified in the age of information, packaged and marketed in the age of conspicuous consumption, and cynicized in the age of litigation. When a bad medical outcome occurs, it is reflex to research. Why? We are trying to tell malpractice from mere bad luck – in a world where bad luck is increasingly exposed as bad choices, bad training, bad equipment, bad people, and other controllable bads. Good science, good will, and good processes have raised our expectations such that any post-op event is suspect.
So, our spirits soared in Guatemala. We were trusted and thanked and bestowed with gifts. Between our team and our patients formed an intoxicating chemistry.
The gynecologist and I fussed and fretted over Maria, our only complicated patient, all week. She improved.
On our departure, my last goodbye was to Maria. I brought the incoming surgeon (my replacement) to the bedside to explain her case and introduce patient and doctor. The gynecologist and team medical director joined us. Maria, her husband, and their children looked star-struck by our visit. They thanked us yet again for Maria’s two operations. They expressed their honor in our last-minute visit and told their children we had come from far away to help their mother. Maria asked for a kiss. I held her naso-gastric tube to one side and complied. I wished all patient hand-offs were this heady.
During the swerving mountain bus ride to Antigua, I watched shepherds and soaked up a glory which seemed to belong to another century. As we approached the airport, my mind wandered back to home and work. Guilt crept in.
 Ergodynamics were sub-optimal in the tiny makeshift surgery suite – the operating table only went so high. Add twelve-hour operating days plus short-statured huggers and the low back cries for bed, or cot, as it were.