The Entourage: Between Surgeon and Patient

“Two’s company, Three’s a crowd.”  -popular saying

“But I always say:  One’s company, Two’s a crowd, and Three’s a party!”  –Andy Warhol


100_3568 - Version 2As a surgeon, my patients generally know they are seeing me for a problem, and that problem may require surgery. I am sensitive to the fact that this is a very big deal to them, often the first time they have ever seen a surgeon. Even if they have had surgery before, that only means that they may have some idea as to what the process may entail. Patients are nervous, perhaps frightened, they have questions. They know they will have more questions and concerns as the visit and process moves on. There are big and important decisions to be made.

Many patients therefore arrive to their first visit with an entourage, one or more family members or friends, companions who are there to lend emotional support for this stressful visit. The additional ears to make sure the explanations and descriptions are heard correctly and understood, the extra minds to pose questions the patient may have forgotten or not thought pertinent to ask. This is laudable, advisable. I encourage patients to have someone with them for just these things, to help the patient.

So here is why the first thing I do when I meet a new patient is to excuse the entourage, and send them right back to the waiting room.

I am not selective, I kick everybody out. Oh boy, are they surprised, sometimes even angry with eyes shooting daggers at me. I will have bled to death hundreds of times over if those wounds were real. I get to explain to my patients why I do this; now is my chance explain myself to the entourage and everybody else.

(Exceptions are made, of course, where there is impairment in the ability to get information at all, as with language or cognitive issues, or conditions like dementia. I also make exceptions occasionally if the patient really insists, though this is not as common as you might imagine; this is selective.)

At the first meeting with a new patient, I am tasked with not only evaluating the details of the problem at hand, but also reviewing the medical history. I need to ask about many related and even seemingly unrelated aspects of their health care and their past–medications, past surgeries and procedures. Pregnancies, social and occupational history, smoking, alcohol, drug use, sexual history. Given the invasive nature of the work I do, the exposure to anesthesia, the recovery from surgery, all of this information has important and often critical implications. A lot of this information can be very sensitive. I still need to know. Not for my curiosity, but to safely care for the patient and achieve the best possible outcomes.

There are very real risks to weigh, alterations to consider for the surgical plan, adjustments to promote recovery. The patient must feel comfortable and free to share all of this information with me. I must trust them to share with me just as they are trusting me with their care. This is the foundation of our relationship. This is my opportunity to build this bond, make us a team. This requires trust. This trust requires truth. No lies, active or by omission. In a very real way, surgeons have the most intimate relationship with patients of anyone, including other doctors or healthcare providers, because we will be going into the body where no other person has access. We often know (or should know) more about our patients, more details, than any other person in that patient’s life, even their own most intimate partners/parents/children.

I must honor and respect this trust between us. But first, I have to build it. I must provide my patient a space where they may be confident and secure in sharing their life’s stories and details. I joke that my exam room is like Las Vegas–what goes on here stays here. They are empowered to share and say whatever they must, to react and to feel just as they really do, in that moment.  I feel that is another important way I honor the trust and the bond, by providing the space and time for their reactions.

This is why I draw a line, why I make this decision. My first responsibility, and last, is to my patient. My responsibility extends to doing what I can to facilitate this bond, based in unhindered and open communication.

I have no way of knowing before I walk in to the room filled with people what the relationships are among them; sometimes I can’t even tell which one is the patient. Even after knowing who is who, I don’t know anything about the nature of those relationships. Most often, once alone, the patient  indicates that there would have been no issue with the person or persons remaining in the room. Even then, I have put my foot in it. I remember an adult woman, accompanied by her mother, who during the course of the interview revealed that she had been pregnant. She had no children; it was in that moment that her mother learned that the patient had had an abortion. The tension in the room exploded in that moment, but I was able to redirect the conversation and we completed the visit. I can only imagine what their ride home was like that day, and I felt horrible for the patient being in that position. The patient returned for follow up, unaccompanied, from then on.

A very significant number of patients are relieved to have their companions excused. Nearly all are grateful that I have done this, because even if unnecessary, they appreciate the sensitivity to their situation and privacy. Some companions answer even for the competent patients, and some of those patients are cowed or even bullied by them. It is less clear whose agenda is being served when this happens. Thankfully, I have seen very little abuse, but it would be impossible for me to assess if the perpetrator were to remain in attendance.

I take the brunt of the displeasure of the patient and their entourage. As I mentioned, the patient usually forgives me this, because I get to explain to them that I am protecting their privacy. If there are issues with companions remaining in the room, the patient cannot be seen as the person who is requesting the privacy. In a controlling relationship, the patient can not ask. That would lead to suspicion and conflict. So instead, it focuses on me and the policy I set, uniformly applied. No selection, nobody singled out, just the rules. This is true whether the person excused is a husband or wife, parent or adult child, friend, or partner. This is especially important for those patients who feel unable to share openly. They are free to speak and be heard. It may be one of the only times and places they can be heard, I owe it to them make that space so I may listen.

Only after my patient and I have had our conversation and information gathering, after the physical examination, do we call in the entourage (if the patient desires, sometimes they decide they are ok without them, now that we are better acquainted). We convene together to discuss the impressions, the diagnosis, the plans, the procedures, the surgery; asking and answering questions, and even supplementing with missing information. This is where we put the entourage to work, where they are most needed, when the patient needs the most support. But after the patient and I have had time to become a team, a partnership. Surgeon and Patient.