Personae

Bedside manner, patients' patience, and the grace of God

I am not an outgoing person. Like most people with long-winded Substacks, I’m somewhere on the spectrum, and the process of getting to know people is long, slow, and awkward. I can make friends with people without the mediation of a computer, but it takes months or years of forced proximity in a controlled environment (for example, with coworkers or classmates). Attempts to just walk up to people and get acquainted, like one is supposed to, will be painful for all parties involved, and I typically don’t try.

Interacting with patients is much simpler, because there’s more or less a fixed script with a few variations that make sense. “Hi, I’m theredsheep with Respiratory, and I’m here to do your breathing treatment—is that okay?”¹ Acceptable followup remarks include “Have you been breathing okay since the last time we saw you?” and “Do you ever bring anything up with that cough?” I don’t have to ask what kind of work they do, how many kids they have, or whatever. It’s simple. It is, nonetheless, something of a strain, and at the end of a day after maybe twenty or thirty breathing treatments I’m pretty well social-ed out. I will tell coworkers, “If you want me to help you transport a patient to CT² or do a vent check for you, fine, but I’m tapped out on going in and talking to people.”

Never mind that for now. Rewind the day³ back to, say, 0700. When I go into a patient’s room, I wear a particular kind of social “mask,” I think maybe even more than most RTs do. Nebslinger Sheep is quiet, unfailingly polite, conscientious, attentive, and thorough. You don’t really want to be his friend, and he will rarely express the slightest interest in your personal life, but you appreciate that he’s there because his focus is entirely on making your life easier and getting you out of the hospital. His last question on the way out of the door, beyond “do you want the door open or closed?” is usually “Is there anything else I can do for you while I’m in here?” And he means it. If you want a cup of juice or a ginger ale, he will check with your nurse if it’s okay—he doesn’t know how diabetic or fluid-restricted you are—then get it. If you wonder if the results came back on your test, he will check.

I crafted this persona very carefully, because it accomplishes several purposes. First, an air of bland but punctilious politeness establishes expectations for the encounter right at the get-go. I can’t count the number of times I’ve had the RT at shift change tell me, “oh, this patient is a real asshole, he’s going to give you grief,” and then I find the patient is perfectly reasonable with me. Part of this is that I get shift change report from night-shifters who have to wake the patient up, but I think part of it is also that they approach the patient like they’d approach someone on the street. They aren’t rude, but they’re casual, which can go downhill. If, on the other hand, some guy comes in addressing you as “sir” like a butler, you’re going to instinctively hesitate to yell at him, no matter what kind of mood you’re in, because that would make you feel like a grade-A jackass. Generally, the only patients who are mean to me are the outright crazy ones⁴. That’s worth a little extra effort!

Then there’s the matter of compliance. I’ve used the word before, in my pulmonary mechanics post, to refer to the relationship between pressure and volume in a lung. But compliance has another, broader, more common use in healthcare, where it means, “does the patient do the stuff we tell him to?” How compliant is this patient with the prescribed course of treatment?

Patients’ compliance, unlike lung compliance, is largely a function of their patience (that’s “patience” with a “ce,” if you’re doing text-to-speech). They’re here because they’re sick, and they feel bad, and they never get enough sleep since the night nurse insists on waking them up at 3 AM to check their blood pressure and glucose levels. Everything you ask them to do is to some extent an imposition, since they’d rather be sleeping, or doomscrolling on their phones, or staring at the wall and working themselves into a funk. Different strokes for different folks. Whatever they want, they certainly don’t want to sit there breathing cold, salty mist for five minutes. In fact, I don’t really want to sit there and watch them do it either, but I have to, so it’s vitally important that I be polite and professional about it, since I might need them to do something else later—something that’s actually important—and their goodwill is an important part of that.

This is something I noticed during my very first year out of RT school: when doctors say “it can’t hurt to order breathing treatments,” they are wrong—and I’m not talking about side effects here. Patients take the same breathing treatments over and over, every X hours, even though they don’t need them. If they’re the thoughtful sort of patient—and they’re going to have plenty of time to sit and think—they’re going to wonder why they need these breathing treatments, since they aren’t having any trouble breathing. They start refusing treatments, and while they’re at it they might refuse other stuff, since their doctor is obviously a quack ordering them stupid things that do nothing. This is a clear recipe for a downward spiral and, basic morality and care for patient outcomes notwithstanding, you really don’t want that, because downward spirals lead to a lot more work down the road.

I, as the RT, have the power to slow or stop that spiral. First, I am very polite, in a way which suggests not only courtesy but also maturity and professionalism. I could also secure their goodwill by being warm and friendly, as some nurses do⁵, but the combination of detached politeness and genuine attentiveness goes one step further by reinforcing that I am a licensed professional who takes his job seriously and should be taken seriously in turn. It helps that I’m comfortable using big words and don’t sound phony about it.

They don’t believe the nebs are doing anything? I can’t say, “yeah, the doctor is being daft,” but I can say, “it’s possible that in your case the doctor is just being a little conservative; if the frequency of the treatments is starting to bother you, I can ask her if it’s okay to scale them back to an as-needed basis? Hold on, I’m going to text her now, while your treatment is running.” Why did the doctor order these things anyway? “Well, they’re usually ordered for asthma and COPD; if you don’t have either of those, she might have had other reasons. I couldn’t say what.”

All this has to be backstopped by a willingness to go the extra mile; if they want some ice water or a warm blanket, I get it or give a good reason why I can’t, a reason that isn’t “I’m in a hurry and can’t be bothered.” There’s a thin line between detached professionalism and being a frosty jerk with a stick up his rear. But that part is easy. I like being the person who does the extra things because, being so socially stilted, the knowledge that I’m actually making someone happier and improving their day is pleasant and refreshing to me, a little break from my customary alienation. I don’t care if it takes extra time, because building a relationship of respect and trust is more important than getting all the nebs done within the ordered window.

Beyond that, I view these little favors as a special opportunity I would be a fool not to take advantage of. It being so close to Christmas, I’ll go ahead and say it, and readers who are uncomfortable with religion can just skip the rest of this post: this is a kind of religious duty for me. I think it was St. Basil the Great who said that the rich exist for the material salvation of the poor, and the poor for the spiritual salvation of the rich. Charity has become substantially more complicated since St. Basil’s day, when almost everyone was a subsistence farmer and being unusually poor meant watching your kid literally starve while you ate to keep up your strength for the next harvest. Nowadays a lot of our poor people are fat, the homeless go about in donated clothes, and if you give a random poor person a dollar there’s a fair chance he’ll spend it on Fireball cinnamon whisky. Or stab you, because he’s sure you’re a CIA agent. As for actual charities, which one has the least overhead? Does spending all this money actually improve outcomes? I think that one had a scandal where its CEO bought a bunch of Prada handbags …

As a bedside RT, I can skip all that. “I was thirsty, and you gave Me a drink.” Yes, I did, and it was easy! It wasn’t even my water. I paid for none of this. All I gave up was the tiny bit of time lost to asking the nurse, walking to the dispenser, grabbing a styrofoam cup, ice, water, here you go. You cold? The blankets are pre-warmed, it’s like a twenty-second walk. I’ll fuss with the fancy thermostat, but it’s computer-controlled and they’re always opening your door, so no promises. You … want to watch a cowboy movie⁶? Okay, that’s moving away from the parable a bit, but I agree, the remote is complicated, let’s just hit “Menu” and scroll down to Grit. Hey, it’s Gary Cooper!

This is easy. So easy. I can be a channel for the grace of God to work in this world, and lose nothing but a tiny bit of time I likely won’t miss. At the same time I’m doing my job better. The patient will be surprised and grateful—maybe pathetically so, in some cases⁷—and I can go about my day with a little less social strain. Why wouldn’t I do this, given the chance?

Merry Christmas, everyone.

1. This phrasing was carefully considered, as it foregrounds the patient’s right to refuse care. Since most treatments are unnecessary, I want to do whatever I can to subtly encourage the patient to skip a dose and not waste everyone’s time (and establish grounds for canceling the order later, when possible). But it also allows them to say that it’s not a good time because they’re about to go down for a procedure, etc. and emphasizes that I am courteous and here to help them.

2. Transport will have to be its own subject for a later post.

3. I wonder how much longer it will be before “rewind” as a metaphor sounds strange, because nobody knows what a VCR or audio tape cassette player is anymore? Are we there already?

4. Nebslinger Sheep is an extension and refinement of Pharmacy Tech Sheep, who was scrupulously polite to everyone for four years of retail pharmacy work. In the rare event a customer got mad and complained about this RUDE technician who offered TERRIBLE service, management would laugh it off, because everyone knew Sheep is ultra-polite to everybody. That customer was obviously some kind of nut.

5. Okay, I really couldn’t, it would come across as awful and fake and I’d break down in a fit after the third room. But somebody who isn’t me could. The casually warm and friendly approach probably has its own special strengths, especially since I’m working in the Florida Panhandle which is as Deep South as you can go before getting into the Retired Yankee Transplant Nexus of Florida proper. Your warm friendly nurse calls the patient by her first name; Nebslinger Sheep will at most call her “Ms. Brenda,” and then only after he’s known her a bit. This is a bit of the real me poking through, if I’m honest; I don’t want to be on a first-name basis with somebody I have a professional relationship with. I can like you, I can help you, I can want to help you, but you’re my patient, not my friend. I don’t know how to make it clearer than that. It’s a line I don’t feel comfortable crossing.

6. Everybody wants to watch a cowboy movie. All the time. Grit is the most popular channel. Aside from the nostalgia factor, it’s soothing to vacation in a magical world where all problems—unlike, say, pancreatic cancer—can be solved by finding a guy in a black hat and shooting that sorry son of a bitch fulla lead. If only The Duke could be our doctor …

7. They always say they asked the nurse but she never did it. There might be a number of reasons for that. Part of it is surely that I see a bunch of patients very briefly, while nurses see the same two to five patients all day, and after getting called into the room for a tiny favor for the fifteenth time the shine of being a nice helpful person fades a bit. They have other work to do, possibly very important work; I’m mostly killing time between crises. Also, floor nurses tend to be young and inexperienced, so they need all the time they can get to dot I’s and cross T’s, whereas ICU nurses (who also have fewer patients each) have long since learned to navigate the system quickly and efficiently.

… and yeah, sometimes they’re just lazy. Got a real important medical conversation about mascara brands going at the nurses’ station. That happens too, sometimes. Not gonna lie.