Doctors learn to solve riddles. After residency, I wanted sick patients that guaranteed a challenge. If I was asked to solve a problem that did not include a medical riddle, I became — well, maybe an analogy will show what I mean.
In JRR Tolkien’s, The Hobbit, the hero, Bilbo, is lost in a cave where he must negotiate with a vile creature, Gollum, to find the way out. They agree to a game of riddles to decide whether Bilbo gets eaten or guided out.
“Sssss” said Gollum, and became quite polite. “Praps we sits here and chat with it a bitsy, my precisousss. It likes riddles, praps it does, does it?” He was anxious to appear friendly, at any rate for the moment, until he found out more about the sword and the hobbit, whether he was quite alone really, whether he was good to eat, and whether Gollum was really hungry…
“Very well,” said Bilbo…
So Gollum hissed:
What has roots as nobody sees,
Is taller than trees,
Up, up it goes,
Any yet never grows?
“Easy!” said Bilbo. “Mountain, I suppose.”
…[After 8 riddles] Gollum was disappointed once more; and now he was getting hungry, and also tired of the game….
“What have I got in my pocket?” [Bilbo] said aloud. He was talking to himself, but Gollum thought it was a riddle, and he was frightfully upset.
“Not fair! not fair!” he hissed. “It isn’t fair, my precious, is it, to ask us what it’s got in its nasty little pocketes?”
“Handes!” said Gollum.
“Wrong, guess again.”
“Knife!”
“Wrong!” said Bilbo. “Last guess!”
Now Gollum was in a much worse state… He hissed and sputtered and rocked himself backwards and forwards, and slapped his feet on the floor, and wriggled and squirmed… Bilbo knew, of course, that the riddle game was sacred and of immense antiquity, and even wicked creatures were afraid to cheat when they played at it.
Medical Riddles
While not wicked creatures, many physicians act poorly when people cheat at the medical riddle game. I used to act poorly, all the time. Medicine trains physicians that patients come with riddles to solve. If patients have no riddle, they get sent away. Most consultants bristle if colleagues refer patients without riddles or a riddle beyond their riddle-solving capacity. Someone – GP, triage nurse, parent – should filter out the non-riddle patients. If everyone follows the rules, the sacred and ancient game runs smoothly.
The trouble is that
- many patients do not have a medical riddle to solve (most, in some cases)
- referring physicians may not be certain there is no riddle
- patients often need to hear from another authority that they do not have an undiagnosed medical riddle
- in the case of ED visits, patients often cannot access their primary care physician (or the tests required)
Compassion
When people cheat at the riddle game, patients need compassion, not Gollum.
It begs the question, “What compels physicians to care in the first place?” Is it the medical riddle? The hunt for broken anatomy and physiology inspires us of course. But should it be the primary motivation to see patients? What makes us attend to a patient crying out?
As a new grad, I went to find out what was going on and see if I could fix it. Nothing “wrong” (drug-seeker, demented, etc.)? Not that interested.
Most people – even those with true medical riddles – want, not just a fix, as much as they want compassion. Patients want attention to their greatest felt need, not necessarily their greatest medical need. They need a human to care about their concern, address it, and offer medical treatment if necessary. They need compassion; providers motivated to care.
Great medical systems put patients first, treat all patients as privileged, and are motivated by compassion, not just medical riddles.
(photocredit: hobbitdifferences.blogspot.com)
Patients dying on wait-lists is bad. People left without any care at all is worse. Medicare wait lists cause untold suffering. But, at least you get on the list even if you live in poverty.
