Maxine
Although she has diabetes, high blood pressure, and occasional arthritic pain, Maxine is a relatively healthy 55-year-old woman. She came to the clinic, however, complaining of knee pain. I evaluated her and diagnosed the pain as worsening arthritis. We discussed the treatment plan: adjust the oral anti-inflammatory medicine and start physical therapy.
As I got up to leave the room, she mentioned one more thing: she had a jury duty summons. She requested that I give her a medical deferment.
I sat back down to discuss the issue. Why didn’t she think she could serve on a jury? She responded that she was concerned about her knee. It seemed to stiffen and hurt more when she was seated for extended time. She was also concerned about facing the subway and courtroom stairs.
I was a bit incredulous. She was working a full-time job and getting to and from work in the subway. I knew her arthritis pain was relative minor and should improve with our treatment. But she was insistent. She even got mad that I would question the need for the excuse note.
I took her deferral form and let her know I’d research the issue and get back to her. She looked at me like a little kid trying to manipulate her parents. She begged me to disqualify her. Her eyes even welled up with tears. My heart melted and I felt like a jerk for fighting her.
Regardless, I wanted more info. So, after Maxine left, I called the official phone number on the jury summons. After maneuvering through a phone tree, I finally spoke to a court worker. He first explained that the court complex has elevators. Also, he noted that judges allowed frequent breaks for jurors to stretch. But then he told me that it’s very common to give medical deferments, and I shouldn’t hesitate. He said that no specific guidelines or rules existed to explain why someone should be excused. It was simply up to the doctor.
I hung up the phone and felt resigned. Both my instinct and my medical knowledge of arthritis told me that Maxine could be a juror. But because of the subjectivity of pain, I felt uncomfortable forcing her to do something against her will. I enjoy my role as healer, but not as arbitrator. I sighed, filled out her form, and put it in the mail.
Joshua
Last year, on his fiftieth birthday, Joshua had quintuple bypass surgery. Up to that point, he felt fine–until the moment he had severe chest pain and collapsed at work. After the surgery, and on his discharge from the hospital, he was put on five medicines to keep his heart and grafts healthy. I saw him a few weeks after last year’s surgery. He had lost his excess weight, was taking his medicines, and felt great. His survival was a miracle of modern medicine. He left my office excited about his new lease on life. I waved him goodbye. Then I didn’t hear from him for a year.
Last week Joshua resurfaced. He was supposed to follow up at least every three months for monitoring. He explained that he was too busy. He had run out of some of his medicines months ago. He hadn’t seen his cardiologist or any other specialists. He had gained thirty pounds. But he said that life was great.
I discussed with him the fragility of his heart and the importance of regular medical care. He said that he did feel guilty for not having come in. (Guilty for not living up to my expectations?) He agreed to restart all his medicines and see his cardiologist. He asked for Viagra. When he left the office, I wasn’t sure I’d ever see him again.
Did I feel better that, even though his behavior courts death, at least he seems to be enjoying himself? Is my role to simply support patients even if I feel their ultimate health goals are too low?
My favorite part of this, Cedric, is where you sigh. I can see that scene so clearly. And yet when I imagine you sighing it seems so performed that I wonder about your sincerity in representing these clinical anecdotes as dilemmas. Do you really face dilemmas in these situations, or have you long ago resigned yourself to the fact that you’re beholden to some really dumb people you’re committed to serve?
That said, I think you should have sent her to jury duty.
If you can possibly compare experience in a retail setting to being a healer in the sense that the public shows up on your door step with a need–then the dilemmas, the sighs must be real. They, the masses, never cease to surprise you . . . and not necessarily wth joy. But I think it is facinating to have that much power, the power to excuse, to illicit guilt. That to me is the real dilemma, what do you do with that?? In Dr. Cedric’s case I respect his ironic approach, absurdity is the only antidote to how much we mortals expect our doctors to save us from personal responsibility.
cedric,
i know that sigh so well. and not just because i’ve spent uncountable hours with you, but because almost weekly i am presented with patient’s disability paperwork. I am asked to decide whether this person’s mental illness is sufficiently impairing that they cannot work and the government should pay them $600/month (atleast in PA) for that fact. sometimes it is so clear and I am grateful that such a program exists. (god bless FDR). But most of the time i face a great dilemma. Certainly this person is suffering from an illness, BUT does it make them incapable of working? As my politics are quite socialist I am generally inclined to sign the requests–especially because there is a box for “temporary disability” and i can choose any amount of time up to one year which somewhat assuages my guilt. Still, it is a hard position to be in. I know that in certain political circles some of my decisions would be very controversial. and at times the subjective descriptions of the symptoms of mental illness are as easily manipulated and overstated as arthritic pain. sigh.
I was really impressed by how seriously you took your role in whether or not the give the patient the deferral. I imagine that a lot of people in the same position would just sign off on it.
Interesting how jobs can bleed into areas that one may not have imagined they would. I used to have to deal with keeping junkies from shooting up in the bathroom when I was a coffee jerk on Haight St.
Anyway, always an incredibly thoughtful and interesting post. Thanks
you fawcett-cedarbrook brothers and your sighs.
but okay, i believe you both.
The combination of this post and Pandora’s response led me to think of the ways in which we all, or many of us, must make decisions about other people’s “ethical dilemmas” in professional situations, just different ones. Since she brought up doing it in retail, it made me think of how many student excuses Jeremy and I must weigh and decide how lenient to be (didn’t your all four of your grandparents already die this semester? etc.) When in doubt you have to give them the benefit of the doubt, of course, but I know we get rooked all the time–as I think you did with Maxine, but what can you do. (I’ve been a lot less dismissive of our duty towards jury duty since the OJ trial–I never even try to get out of it anymore, just defer it till after the semester.) She definitely could and should have served, it seems from your post, but it’s impossible to force it without being a complete hard-hearted jerk (or being framed as one, anyway). And similarly, I can’t really question aNOTHER car accident just like the one you had the LAST time you had a paper due . . .
On another note, I was emailed this book recommendation today, for “The Placebo Chronicles,” which sounds like a fabulous compendium of Tales from the Office-like stories: http://www.powells.com/dose/cgi-bin/biblio?isbn=0767919491 (can’t do the link thing in my 1970s computer). Sounds like you should be a contributor, Cedric, though your comments are less humorous (and mean) than this book’s, and more concerned with ethics (like Randy Cohen meets that doctor Lisa Someone in the NYT magazine who does mystery diagnoses). I love reading both of them on Sundays, which is why I love your “Tales from the Office” even more: so many philosophical questions!!! I always look forward to these posts.
Bryan,
Unfortunately, the jury duty dilemma is recurrent , real, and universal. (When a doctor friend read my post, she sighed and knowingly shook her head.) I still spend (waste?) lots of my time trying to convince my patients that they can (and should) participate in jury duty. It would be so much easier to just resign myself and fill out the form each time without argument. But I keep trying to do what I think is right. I could write every one of my posts about patients with jury duty excuse forms, I have so many cases–including when a patient fired me because she was so mad that I wouldn’t relent (she really wasn’t disabled but had a trip planned during the jury assignment). Sigh.