"Sorry I couldn't be there today. Some questions re: Dad."
The letter, in its familiar loopy script, had been hand-delivered by my patient's aide. Clearly, the old man had a daughter who worried about him, but from a distance. I had never met her in person. And that irked me.
Letters and notes from family members of my elderly patients do alert me to problems I might otherwise not hear about. Some ask one or two concise questions. Some include printouts from medical websites and request my opinion on an alternative course of treatment.
But this letter was single-spaced, written neatly in blue ink and covered most of two pages of notebook paper. I stifled a groan.
Why does Dad have a bowel movement every other day? Why is he losing weight? Why is he scratching his chin all the time? When should he do blood work? Should he do a colonoscopy? What was the result of the podiatrist's X-ray? At the bottom of the second page, she requested that I call her at the end of her father's appointment. Well, I grumbled to myself, she'll have to wait until the end of the day. My next two patients were already in the waiting room.
I put the letter on my desk and looked back up at my patient. He sat in his wheelchair, his lips held in a half-smile; a major stroke five years ago had paralyzed his left side and made it hard for him to speak. He must have been frustrated by his situation, but he usually waved off my inquiries about any concerns with his good hand.
I checked his blood pressure, listened to his chest, looked at his feet and made sure his immunizations were current, the whole time distracted by the letter. I imagined the daughter anticipating my call, tapping her foot impatiently, wherever she was.
I couldn't help thinking that she should have come to the appointment. I knew she worked. I appreciated that it was hard for her to take time off. But her lengthy letters were an imposition. If she had so many questions, why didn't she ask them in person?
A few months later, I figured it out.
A close relative of mine, who can't care for herself and lives a couple of towns away, had a visit with a new doctor. Usually one of the caregivers from her group home brings her to appointments; occasionally, my father goes with her. But he was out of town, and the two caregivers who knew her best were both away. My workday was packed, and I didn't want to cancel a long overdue meeting or reschedule my own patients.
So I tracked down her new doctor's e-mail, keyed in two of my concerns, and ended the message with a request for a follow-up phone call. It would have been better if I'd been there in person, but I couldn't. I was sure the doctor would understand. He knew how busy people were.
As I pressed "send," it hit me. The old man's daughter and I were in exactly the same situation. We both cared about our family member and wanted to make sure the doctor knew that. We both worked, and it was hard enough to steal away for a few hours, much less sit in a waiting room for appointments that were always late.
Feeling guilty about my lack of empathy, I thought about ways to smooth communication between doctors and family members who can't accompany the patient to visits. Here's what I came up with.
• At a minimum, make sure to meet your relative's doctor in person once a year. Family members need to have a relationship with the doctor to serve as a baseline. Otherwise, in the doctor's mind, they'll be little more than a disembodied voice or a line of text.
• It's fine to send along a letter, but make it brief. Expect a response, but it will probably be brief too. The doctor might return the letter along with a few check marks next to completed items or may jot "will do" or "looking into this" next to other questions. For important issues that can't be summed up in a few words, the doctor should call you.
• Talk to other staff in the office who may be more accessible. Many private practices are co-staffed by physician assistants and nurse practitioners; physicians often ask them to return phone calls and e-mails. You may get a return call more promptly from one of them. Be gracious about this: They are competent professionals, and medicine is a team effort.
• Don't expect a physician to update multiple family members about the patient. Families should identify one main contact person and ensure that the office has documentation of any power of attorney, healthcare proxy or conservatorship.
• If the physician accepts e-mail from patients and family members, consider sending a short message that way — just a short one. Ideally, your e-mail should be encrypted.
A few days after my relative's appointment, her neurologist e-mailed me back. In three sentences, he answered my questions and let me know I was welcome to call him anytime.
I telephoned my elderly patient's daughter at the end of that day. After plodding through her list, I invited her to come to her father's next appointment so we could meet in person.
She said she'd try her best, but it might not work out.
I told her I understood completely.
Reisman is a general internist in Connecticut. She can be reached at firstname.lastname@example.org.
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