Okay, so I admit to being a little obsessed with being on time for, well, everything in life. As I used to say to my kids when we traveled as a family, “If you don’t hurry up we are not going to arrive atrociously early for our flight!!” This personality quirk/defect extends to my genetic counseling life, where I fire imaginary heat seeking missiles at conference speakers who go way over their alloted time (and let me say, bioethicists are just about always guilty of this mortal sin), do my best to make sure my patients almost never wait very long beyond their appointment time to see me, and I arrive at work every day too early for my own good.
Because of my preoccupation with punctuality, one of my counseling flaws is maintaining professional equanimity and objectivity when patients arrive unconscionably late for their appointments. Yeah, yeah, I know that some patients are late for reasons beyond their control, but, hey, God blessed us with cell phones so you could call to let us know that you are stuck in traffic or the babysitter came late or there are delays in Radiology or the bus broke down. By the way, my olfactory sense is telling me that you think that you had enough time to catch a smoke before you got here.
So you can imagine my state of mind when just yesterday, in the final hours of my final day before a much deserved 2 week vacation, my last patient of the day showed up 45 minutes late. Up to that point, for a day before starting vacation, I was a whirlwind of efficiency in clearing off my desk, tying up loose ends, and closing out lingering cases. And I had just been thinking that, with my last patient an apparent no-show, I could actually leave slightly early and without the frisson of guilt of leaving unfinished business for my co-workers to clean up for me. At which point, of course, the receptionist notified me that my patient had just arrived and wanted to know if she should tell the patient, “Sorry, you are too late and you will have to reschedule.”
What is a good counselor to do in this situation? Most of you would probably say I was well within my rights to tell her to reschedule. At some point, you must maintain some respect for yourself, your own time, and your own needs. Reviewing her e-chart quickly, I noticed that she had already cancelled several appointments with me and others over the last year, which could mean that she was pretty ambiguous about seeing me in the first place. I vented some nasty thoughts to myself but finally experienced the counseling satori that this was another instance of my personal issues affecting the acuity of my counseling vision. Ultimately, I decided to see the patient, in part because I did not want to lose her since it seemed likely that she might never reschedule and in part because my professional ego wants to reinforce the appearance of being a good counselor.
I decided to say nothing to her about her tardiness. What good would that do? It would not make the situation any better and, besides, I was pretty sure my receptionist had already pointedly addressed that with her. I chose to use one of my favorite counseling strategies – I was silent for a few moments (let me tell you, shutting up is often the most effective counseling approaches you can pull out of your bag of counseling tricks, and it does not require any special skill, though for a loquacious chap like me, it can be difficult). I wanted to see if and how she would fill the conversational void on her own. Which she did, by acknowledging that she was very late for the appointment. So I offered her an out by asking her if she had gotten lost in the maze of the hospital campus. Her refreshingly honest and guileless answer made me smile: “No, I am just late,” she said with a sigh. I was actually starting to like her.
Immediately it became clear that this patient’s life was currently, and pretty much always had been, a mess. She had cognitive and memory impairment, the type that seems to stem from past physical and/or emotional trauma. She retained enough neurological skills to get by in life, but just barely. She was deeply grateful when I gave her a clipboard and pen and encouraged her to write down the most important points, and I slowly spelled even basic words for her. “Thank you,”she said, “a lot of doctors get impatient with me when I forget something that they just said and writing it down helps me understand it better but I am not a very good speller.” Man, I thought, there must be too many care providers lacking basic human interaction skills. That simple smile and unabashed gratitude on her part along made it worth delaying my vacation time.
Many of my suspicions were substantiated when I took her family history. Relatives who died of drug overdoses, plenty of alcohol abuse, some family members she was very uncomfortable talking about. She had no children (“Thank God,” the irrepressible non-professional me” whispered into my internal ear). Genetically speaking, her family history was uninteresting. But psychologically and emotionally, it spoke volumes. Which, by the way, is why I dislike substituting family history forms for constructing a good old-fashioned pedigree. I know I am old-fashioned but so much richness potentially lost!
Truth be told, the counseling session was on the short side (I am not a total sap, after all, and I do have a life outside of the clinic). But I am pretty sure she left with at least a basic understanding of the role of genetic testing and why it might be important for her “Oh, I get it. I might get cancer again if I have the gene. I don’t want that to happen.” She has probably had few positive interactions with medical professionals, which undoubtedly contributes to her history of no-shows. So I could feel good about myself that maybe in some small way her experience with me will encourage her to at least reduce her pattern of canceling appointments. I suspect, though, that she will always be chronically late, and there is not much I can do about the poor counseling skills of some medical professionals.
After more than three decades as a genetic counselor, I still do not have a coherent, uniform approach to deciding whether or not to see patients who arrive unacceptably late. I will also go to my grave being chronically early, though hopefully not for my appointment with The Shroud Tailor. This one episode doesn’t change any of that. But it does remind me of the importance of taking each case on its own merits. I must also continue to try to be aware of ways in which my own personality issues subtly worm their way into my counseling voice, and to recognize the rhythms of the Transference/Counter-Transference Tango we subconsciously engage in with our patients. As the saying goes, it takes two to tango.
And, now, off to Berlin and Prague.
The DNA Exchange 