He knows the drill well: He’s dining in a restaurant with his family, catching up on the day when suddenly someone appears at his elbow. "Why, hello, doctor! Imagine running into you here," the person greets him.
Maurice Ramirez, DO, could put money on what the rest of the conversation will center around. The visitor swears she called the office/meant to call the office/should call the office but - could he call in a refill prescription for her? It will just take a minute and she’s down to her last one.
It’s a scenario he inherited the minute he started picking up board certifications in emergency medicine, family practice, and sports medicine to name a few of the specialties he covers in his boutique practice in Kissimmee, Florida. No matter where he goes, Ramirez - along with the other 700,000-plus physicians in this country - are sitting ducks. Blame it on the media, folklore, or gossip, but the American society isn’t set up to allow physicians to be regular people. The pressure, says John-Henry Pfifferling, PhD, the director of the Center for Professional Well-Being in Durham, North Carolina, is always to be on, always knowledgeable, clear and present, never tired or irritable, and an exceptional human being.
"A lot of people look to doctors as surrogate fathers who know everything from stock tips to housing advice, to how to deal with a cold," says Thomas Demaria, PhD, the assistant vice president of behavioral health sciences at the South Nassau Communities Hospital in Oceanside, New York. "The assumption is that they are all powerful."
Physicians feed the image, of course: They answer the telephone as "Doctor Smith." They order family address labels announcing the card sitting in a friend’s mailbox is from Doctor and Mr. Smith. One of Demaria’s friends had the bureau of motor vehicles in his state put the letters MD on his license plate. "I said, ’Why did you do that?’ and he said quite earnestly, ’I want to be available in case people need me,’" says Demaria.
Ego is the other unspoken reason. Counselors to physicians readily admit the requirements for entry into this profession weed out the weak personalities and sharpen competitiveness and perfectionism. Doctors commonly fall into the trap of defining themselves as people by their occupation.
Yet Ramirez’s first reaction to the restaurant walk-ups isn’t that he’s flattered. "It’s the same feeling as when you have one hand on the doorknob to leave and the patient calls out, ’Dr. Ramirez, can I talk to you about one more thing?’" he says. "Every fiber in your body drops to your shoes and the smile on your face freezes into place."
To top things off, this public pushiness is part of the reward for four years of college, four years of med school plus residency - decades of deprivation, dependence, anxiety, exhaustion, and sacrifice. Then lo and behold, the doctor wants to have a real life, and yet he’s not just a dad at a ballet recital or a Little League coach, says Pfifferling.
There are exceptions, of course. Women, thanks to the American cultural pressure to parent, are usually more adept at detaching themselves into various life roles, counselors agree. And younger physicians seem to have a greater appreciation for the need for balance in their lives, bringing different, healthy expectations to the profession, says John Schorling, MD, the Harry T. Peters Senior Professor of Medicine and the head of the physician wellness program at the University of Virginia Medical School in Charlottesville. "But as I help older, established physicians examine themselves, we often find compulsive personality traits," he says. "They have very high standards for themselves and tend to judge themselves very harshly." In a nutshell, they internalize their identity as physicians and get stuck in this rut of not being able to turn it off, especially during off-the-clock requests.
It’s tough to fight the inclination toward helping people too, as psychologically that’s what attracts many doctors to medicine in the first place, says Ivo Drury, MD, MBA, a neurologist and the founder of Career Counseling for Physicians in Ann Arbor, Michigan. "So we’re vulnerable from both ends from the person who is seeking information or whatever," he says.
The first step is to see medicine as a special interest in a life filled with hobbies, pursuits, and responsibilities, Pfifferling teaches his clients. One of his doctors developed a clever comeback for the ubiquitous "what do you do?" question at cocktail parties: "I’m a quack." Pfifferling applauds that direction because it uses humor and subtly signals to the other person that you’re not a doctor right now, just a regular John Doe.
State laws can be life-savers. According to Schorling, his university explicitly teaches students what Virginia law says about practicing medicine outside the office and encourages them to fall back on that as the bad guy when saying no. Drury can’t recall ever mentioning the topic specifically to his residents, although he admits today’s medical schools are more explicit than implicit on everything from how to deal with pharmaceutical representatives to ethical gift guidelines. "I don’t think we’re targeting how to talk to friends and relatives, but we are telling people how to raise the communication bar a bit, add professionalism to our profession," he says.
At worst, Drury classifies the private intrusions as nuisances. "People don’t come to me saying, ’This is killing me.’ I haven’t seen anybody who was completely unhappy because of the degree to which friends and family were invading them for free information, and I’ve talked to a lot of physicians," he says.
Indeed, Gail Gazelle, MD, a palliative care physician, an assistant clinical professor at Harvard Medical School, and the president of MD Can Help patient advocacy practice in Boston estimates someone hits her up for advice "frequently," which she defines as every week. Still, it doesn’t interfere with her life, she says.
Charles Crutchfield III, MD, agrees. "I just have to deal with it," the Eagan, Minnesota-based dermatologist says. "It’s something that will never change, so if it ticks you off every time, you’re going to have a rough life. I deal with it so much, it rolls off like water on a duck. When you deal with things often enough, you get pretty good, and now I can just skate my way through these conversations."
Of course, physicians know that treating folks on the fly is a bad road to go down, with outcomes ranging from hurt feelings to lawsuits. Still, because of a shortage of dermatologists, people pressure Crutchfield to make a diagnosis on the spot at a barbeque all the time. "In fact, you go to a New Year’s Eve party and they set up a separate room in the back so you can hold satellite office hours," he says.
Ramirez laid down a simple law for his family: Unless you are bleeding and dying, no. You have a primary doc for a reason - and physicians are vulnerable to overlooking bad diagnoses with family members. His siblings don’t violate his policy, but a daughter has tested the waters, asking him to take care of a boyfriend’s ingrown toenail. He refused.
Pfifferling has reminded his 98-year-old mother for years that his specialty is anthropology - he spent the last 35 years working with physicians, not as one. Yet that hasn’t deterred her from asking medical advice of him. "My response is always the same: ’I am not your doctor,’" he says. He recommends physicians polish up a speech for families that stresses, "I am your daughter, not your oncologist. If you don’t understand what’s happening, I am more than willing to work with your oncologist to clarify things."
Most physicians say family can be the more difficult to turn away, but not for Drury. When the questions about headaches start to rain down, he treats everyone equally. "I always make the comment that I’m talking in generalities, and then I keep it on a very broad plane and emphasize the positive," he says. That involves phrases like "Yes, it’s a tough problem but most people do well," and "Sometimes it takes a certain bit of trial and error, so it’s best to see a specialist in that area." When his sister called a few weeks ago to describe a dizzy spell she had while out and about with the kids, he told her, "That isn’t unheard of. If it happens again, call your physician."
Ramirez differentiates between his friends. There are the ones who call at 10 pm complaining of an ear infection who want him to fill in for their own physicians who are unreachable at that hour, and those who think they don’t need a doctor because they know Ramirez. For the former, he asks them to drive to his house - requiring them to put some effort on the table - where he runs through a thorough diagnostic check, complete with a chart, which he sends over to their primary physician the next morning. "Theoretically, I could bill their insurance with this procedure," he says, and that makes it both official and proper in his estimation. He used to allow these friends to walk into his office the next morning before he began seeing appointments, but the traffic volume grew to the point he was running late before his day officially started.
The free-loaders he offers to accompany to the emergency room, if it’s truly that bad. Only one guy took him up on the offer, and it turned out he was in the middle of a heart attack, not a sore throat. "Imagine if I’d seen that person for the sore throat, tossed a few antibiotics on it, and sent him home without a primary doctor to notify. If I was even thinking about wavering before, that reinforced it," Ramirez says.
Drury says, "It’s not that people won’t get you stuck up against a wall while they talk about their back pain, but most physicians get to be pretty skillful at protecting their space." Among the smooth lines doctors have developed over the years:
• "I hear you asking me something that relates to medicine and I’m more than willing to meet with you in my office, but I’m really uncomfortable continuing here. We don’t have a relationship and I don’t have my tools." Pfifferling likes this approach because it’s clear, direct, and assertive.
• "Here’s my business card, and if you have some concerns, call me during work hours." Demaria adopted that one after watching the host at a social gathering pull his buddy in the construction business over to look at a door that wasn’t sitting properly in its frame.
• When someone starts spewing information he has found on the Internet, asking for input on various theories, Demaria halts that train in its tracks by asking, "What exactly are you anxious about?" After hearing the answer, he can steer them toward making an appointment during office hours. "Really dig for the real issue - it keeps you from getting lost in the information overload that grips the patient," he says.
• Ramirez typically ends an awkward conversation with, "As an ER doctor, our relationship technically ended when you left the hospital. Would you like to set up an introductory visit at my private practice office?"
Whatever tack you take to deflect the request, resist apologizing for your stance, Drury says. "You don’t have to go into how badly you feel about it or anything. Just say no, that would be a breach of my responsibilities as a physician." Period. Even the sports buddy who asked repeatedly in vain for a pain medication prescription didn’t ream Drury out for his refusal, yet fear of rejection usually lies behind why physicians cave in and call the pharmacist in these circumstances.
Of course, physicians who are afraid they’ll be rejected are right sometimes, Pfifferling admits. Friends and family aren’t above pitching a fit and bad-mouthing the uncooperative doctor. "That’s their problem," he says bluntly. "When most people hear the complaints of upset friends or family members, they know you have clear and defined boundaries, and they respect you even more. The rumors won’t get anywhere, and I’ve watched this many times," he says. The Ramirez family, for instance, can barely contain the laughter each time a restaurant walk-up slinks away without scoring a prescription. "We just look at each other like, ’Did they really think that would work?’" he says of the inside joke.
Gazelle, the palliative care physician, on the other hand, doesn’t feel it’s her role to avoid dispensing advice in social situations. If the timing is inappropriate - she’s on a date or busy watching her child at the pool, for example - she will politely explain that it isn’t a good time to concentrate on the question just now. Otherwise, she’s up for a conversation. "If I have information that can help somebody, I should share it because medical information is all too often hoarded by the profession," she says. She draws the line at writing prescriptions, however, citing literature that proves physicians don’t always use their best judgment when involved in the care of a loved one. She makes sure to use her professional voice rather than slipping into big-sister talk for the conversation.
"I just have to take a mental pause and remember, yes, although this is my parent, they’re calling upon me as a doctor, and I need to frame my responses as I would with any patient," Gazelle says.
And never give in, Demaria reminds his clients. The first time you make an exception, you open the door to even stronger pressure from the next requestor.
Dermatology appointments are difficult to come by in Crutchfield’s neck of the woods. He’s always getting calls from old friends, new friends, good friends, and relatives of friends looking to jump to the front of the scheduling line. They’ve even called his family members looking for special treatment, so he developed a straightforward system: The beggars must make an appointment for the next available slot, but if they check in every two or three days, he’ll slot them in where there is a cancellation. Most of the seekers find themselves in his office in less than three weeks.
To keep the dialogue as light as possible, he assures this group that he’d love to work all day, but he just can’t burn out his staff. He also turned over scheduling to an administrator to handle, taking himself out of the line of fire with the good cop/bad cop routine.
The great and powerful Oz
At times of great stress, the public’s perception of a doctor’s power can really come back to bite. Take the case of the neurologist who had to stand and accept condolences at his father’s funeral. "I’m sure you did everything you could, doc," the cousins told him. "Don’t take it personally. If anyone could have saved him, it was you." The man died of leukemia.
But this is one instance, Schorling says, where physicians have few choices other than to suck it up. "It’s hard to explain those things in a short period of time and make yourself clear without appearing defensive," he says. Doctors who consciously try to understand their emotions of guilt and responsibility that lie at the core of these more upsetting situations usually find it easier to remain internally calm, counselors say.
Doctor, can you spare a dime?
You could make the case that folks sticking their hands out in the presence of a physician is a form of flattery. After all, it’s recognition that this profession is well compensated and represents people with well-above-average resources, Drury says.
On the other hand, don’t get Crutchfield started on how his state taxes physicians at two percent of their income to pay for its prescription assistance program. "Wouldn’t it be weird if they taxed all the attorneys to pay for a legal fund so that people could sue. That wouldn’t fly," he says. "Or why not tax farmers two percent to buy food for people who can’t afford it." The entire situation, in his opinion, stems from the perceived aura that physicians are rolling in dough, and therefore, an easy mark.
Patients are always asking Crutchfield if he would donate to their child’s pageant fund-raiser or to pledge so much in a marathon to raise money for their child’s band trip to Europe. If it’s a silent auction, he donates a $50 gift certificate toward the cosmetic side of his practice. He set up a foundation to handle direct cash requests, so his answer is a cheerful, "Sure. I have a charitable trust that takes applications, just like any scholarship. We review the submissions and make awards twice a year. The vast majority of people just move on. They don’t have time to file forms and wait six months. They want the money yesterday," he says.
Since branching out to do speaking engagements, Ramirez has fielded his share of $50,000 investment requests from strangers, but he says friends who have seen him drive his Saturn about town actually call with offers to loan him money during times of national disasters. That’s because the ER doctor gives up his income to travel to the location and donate his expertise. Those excursions also give him a good reason to say no to other non-profits seeking to have a doctor on their boards.
Of course, if the cause fits your passions, doctors owe it to society to volunteer as much as the next guy, Gazelle says. But when the fit is poor or the physician suspects the group merely wants to cash in on her checking account, these polite turndowns work public relations miracles:
• "It’s a great cause but I’m stretched so thin right now, my wife says the kids don’t even know who I am. I simply can’t commit at this point."
• "I appreciate your request, but I never answer with a yes unless I have 24 hours to think about it."
• "I am overbooked, but perhaps I can suggest somebody."
But no matter the words, pronounce them in kindness and you’re bound to stay on track. "There are many ways to say no nicely," Crutchfield says. The important goal is to determine the boundaries between your personal and professional life then ask people to respect them. Both sides of the equation will thank you - and you’ll live happily balanced between the two.