Is the customer always right?

“Bad news,” I heard Dan, my GI consultant, say on the other end of the phone. “Your patient has a rectal carcinoma. I just finished scoping her.”

Maggie was a retired health care worker who, like many of us, chose to ignore a warning sign. The previous summer, on her annual exam, she had one guaiac positive stool out of three. She ascribed it to hemorrhoids, but I told her that, at her age, we had to prove it wasn’t a bad character. I recommended a colonoscopy. “Let me think about it,” she said.

It took six months for her to see bright red blood in the toilet bowl, and then she was ready for the procedure. Afterward, she said flat out, “I won’t wear a bag,” so we looked for alternative therapies on the Internet. A quick search of the American Family Physician Web site yielded an article about the local treatment of rectal cancer, including local excision, electrocoagulation and endocavitary contact radiation. While continuing my research, I sent Maggie for a chest X-ray and abdominal and pelvic CT to make sure the cancer hadn’t spread to her other organs. It hadn’t.

I contemplated what to do next: Should I refer her to an oncologist, radiation therapist or surgeon? Living in a small town where some types of consultation are unavailable, I often find myself at the same disadvantage as my patients in finding specialists to take care of them. They use the yellow pages; I don’t. One of my patients had seen a colorectal surgeon at Stanford for care of a chronic anal fissure. I remembered he had written me a note suggesting that topical nitroglycerine ointment might help (it had), so I found the chart and gave him a call.

“Yes, all those limited procedures are possible,” Dr. Shelton assured me, “if the tumor hasn’t invaded the rectal mucosa. Endorectal ultrasound is the gold standard test.” Maggie went to Stanford to have one done, and that news wasn’t good either. “It’s into the rectal wall,” Maggie told me afterward, “and in one lymph node besides.” Now her options for a cure were few: six weeks of chemotherapy and radiation followed by a radical surgery that might involve taking her uterus and part of her vaginal wall as well as her colon. The colostomy was a certainty.

“I’m sorry it didn’t work out for one of the lesser procedures,” I told Maggie. I couldn’t help but wonder if it might have worked out better if I had been more persistent about her having a colonoscopy six months earlier, instead of merely advising that she have one. The customer may always be right, but in our business, the patient may not be.

Unprofessional conduct

My office manager, Dalia, was due to have her first baby on May 29. Although I knew months ahead of time that I would need a temporary replacement for her, I found it almost impossible to find one. Advertising brought me a slew of calls from people who were neither medically trained nor bilingual. I was willing to overlook that for the short term, but none seemed personable enough or up to the task. My daughter, Margot, had agreed to work while Dalia was on maternity leave, but she wouldn’t start until after school let out for the summer on June 16. With Dalia planning to leave two weeks before her due date, that left almost five weeks uncovered.

It was with some trepidation that I called Gloria to offer her the job. Gloria was the mother of Isabel, my former office manager, and she was a pistol. She was bilingual, had some medical experience and was definitely an “up” person, but Gloria was, well, Gloria. I wasn’t sure I could live with her for five weeks, but I was definitely sure I couldn’t do it on my own. My wife wouldn’t volunteer, and I was tired of interviewing. “Dr. Brown,” Gloria said, “If you want me to, I will do this for you.”

Gloria was Dalia’s aunt, so they got along famously and her training went fairly smoothly. But there were some things about Gloria that I just couldn’t abide. Finally, I had to say something. “Gloria,” I began, “you have to stop calling the patients ‘honey’ and ‘sweetie,’ and after you give them an appointment, please don’t say ‘You’ve got it!’”

“Why?” Gloria asked, “Do you think it’s unprofessional?” I hadn’t actually thought about it in those terms, but yes, by golly, it was unprofessional. “OK, Dr. Brown,” Gloria said, “I’ll try not to do that, but let me tell you about not being professional. You don’t wear a white coat. That’s unprofessional. And your office is not clean enough,” she said, demonstrating dust on the top of some picture frames and scuff marks on the linoleum.

All right, I thought, if I can dish it out, I can take it too. I thanked Gloria for her criticisms and asked her to make a list of what needed cleaning, but I would not concede the white coat. “A dress shirt and tie should be enough, sweetie,” I said with a wink.