An interventional radiologist colleague was bragging to me about an interesting trick he adopted to help him manage hospital consultations. Cardiologists, vascular surgeons, and interventional radiologists are constantly vying to move their cases through the cath lab, with its highly-coveted real estate, and are regularly competing for a precious time slot. My colleague was explaining how he would often get a consultation for a patient in the hospital that needed a procedure in the cath lab but was unable to get a reserved slot for several days. If the patient were to realize that the procedure would have to be delayed because of resource limitations, they would likely be upset and that would lead to negative reviews for the hospital and physician alike. However, if the patient happened to be on blood thinners, my colleague found an alternative reason to delay: The procedure would be "unsafe" for days as the bleeding risk would be too high. Was this true or a white lie?
While blood thinners offered a plausible delay explanation, my colleague admitted to me he would have been entirely comfortable performing the procedure immediately if the room was actually available — the lack of an available time slot was the actual reason but the blood thinning medication offered a wonderful guise. The patient and clinical team would think the procedure delay was only in order to ensure it would be "safely" performed and all would be well. Realistically, no individual was harmed by this alternate explanation and the patient's frustration was minimized. I learned this is a common practice for interventional radiologists who often struggle to compensate for limited hospital resources such as cath lab space: blame another cause that is plausible for the delay, and stall until you can find your time slot. At many levels, I am impressed by the strategy and demonstration of political savvy. But it is also dishonest, or a form of obfuscation at the least. And it isn’t an isolated event, as we often use the same strategy with our colleagues, too.
Conflict naturally arises in the workplace and medical practices are no different. Two individuals may not get along or there may be some frustrating policy that creates irritation. In my practice, I noticed there were times an administrator got involved in these issues and often relied on the exact same form of obfuscation as my colleague with the blood thinners, namely avoiding the root cause and blaming another common frustration. “The problem is really the (insert dummy culprit here). We are all good people but (this new common enemy) is really a bad actor.” In a sense, the administrator is simply identifying a “blood thinner” to blame for the conflict, and then proceeds to fixate on said blood thinner. The more sophisticated administrator will find a more distracting annoyance to entirely remove focus from the conflict or blend unrelated conflicts that have an external enemy. While these strategies may be effective at preventing a blowout, they avoid the actual problem entirely. Does the root cause ever actually get addressed by hiding behind this veil of complexity? Absolutely not. I suspect the practice leaders employing these subtly evasive techniques pride themselves on being able to defuse a conflicting situation. In reality, these attempts at addressing an issue are exercises in deflection.
I have tried the "alternate explanation" strategy and it can be extremely effective in the moment. I work in the field of breast imaging where I routinely recommend biopsies on breast masses. Patients ask me, "Is this cancer?" Sometimes, knowing that the outcome will be malignant, I have avoided this question or answered with ambiguity. "Well, this could come back as many different things. We want to make sure it isn't cancer." A technically accurate explanation that avoids a tough discussion. There is another legitimate reason why it is tempting to tell this "alternate explanation": it is hard to get caught. Dissecting real explanations from those that sound real is an extremely difficult task and requires a mastery of parsing nuance. Only a few individuals would even be aware of the distinction in the case of my patient’s breast mass. If it’s unlikely another patient or colleague could catch me obfuscating, then does this difference in explanation really matter? Yes, yes it does.
As easy as it is to explain away uncomfortable realities as phenomena of complex hospital organizations or as ambiguities of medicine, I have learned to embrace the challenge of the difficult dialogue. Difficult conversations are necessary to establish meaningful trust and patient understanding. For better or for worse, I've gotten fluent with the "I think this is cancer" discussion, along with the emotionally tough conversation that typically follows. As tempted as I may be to explain it away in various manners that avoid addressing patient expectations, I value providing an honest answer for the sake of honesty. Most patients appreciate the direct approach as they view it as a form of respect, which has been my ultimate realization. I’ve gotten better at walking up to a colleague and saying, “Can we talk about something difficult?” In fact, I’ve grown bold enough to preface my thoughts with, “I expect you will disagree with what I’m saying but ...”
A white lie, as innocuous as it may seem, chips away at an otherwise sacred relationship that is rooted in trust. This trust extends beyond clinical decision-making to the honesty of our words. When we rationalize a clever reframing, we jeopardize that relationship, be it with a patient or colleague. Bring on the tears, bring on the anger, bring on the emotional energy — I'm done hiding behind the veil of complexity. As easy as it may be to blame the blood thinners or the nefarious system that brings good physicians down, or even the ambiguous ultrasound that does not allow for complete certainty of a finding, take the real conversation on. Your relationships — both with your colleagues and your patients — deserve the uncomfortable truth.
What's a white lie you've told your patients or colleagues? Come clean in the comments.
Dr. Chirag Parghi is a board certified radiologist with fellowship (subspecialty) training in Breast Imaging and is the proud Chief Medical Officer of Solis Mammography. His clinical interests are focused on the early detection of breast cancer. Dr. Parghi has been practicing radiology in the greater Houston area for 8 years, and obtained his MBA from University of Houston. He is a 2021–2022 Doximity Op-Med Fellow.
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