The Problem With Being Too Persuasive

Photo: aspearing

When I was a first-year resident, I admitted a 34-year-old HIV-positive man to my inpatient general medicine service for fevers.  On physical exam, I found a large lesion on his right retina near the macula (the retina’s center).  I called up an infectious disease specialist, who confirmed what I’d suspected:  he had CMV retinitis.

CMV retinitis is an infectious disorder of the eye to which immunocompromised patients (patients with a weakened immune system) are particularly vulnerable.  Like most of the secondary infections that afflict HIV patients, CMV retinitis is opportunistic, meaning brought on by infectious agents already present in a patient’s body that begin to run amok when normal immune system function becomes compromised enough that it can no longer hold the infection at bay.

Because of the proximity of my patient’s lesion to his macula, he was a high risk for losing his sight.  At the time (the early 90s) two choices for treatment existed:  foscarnet or gancyclovir, both of which had to be administered intravenously for extended periods of time.  For this reason, one way or another, he’d need an indwelling venous catheter placed.

This was no minor procedure:  he’d need to be taken to the operating room, anesthetized, and intubated.  A large-bore catheter would then be inserted into one of the large veins in his chest and the line tunneled under his skin and made to exit at a distant site.  More likely than not, the line would remain a permanent addition to his body.  CMV retinitis tended to recur.

After discussing the options with my infectious disease consultant, we decided IV gancyclovir was the best choice.  Both drugs had significant side effects, but at the time we thought the risk/reward ratio tilted more favorably in gancyclovir’s direction.  So I went to discuss our recommendations with my patient.

He became indignant that all we could offer him was intravenous medication and alarmed that he’d need to take it for so long that he’d require a tunneled catheter.  He became angry that he needed to go to the O.R. to have it placed.  He cried when he learned its placement would be permanent.

I told him how sorry I was that we had no better alternatives to offer.  “But without treatment,” I said, “there’s a really good chance you could go blind.”  And not just in his right eye.  He had a smaller, more peripheral lesion in his left eye as well.

“I don’t care,” he told me, and ordered me out of his room without committing to a decision one way or the other.

Dutifully, I came back an hour later to talk about it again.  The conversation started more calmly, but soon escalated into hysterics once more, with him accusing me of wanting to hurt him.  I told him I’d come back again in another hour.

In total, I spent six hours that day in discussion with him, neglecting my other patients out of an urgent desire to save his vision.  I was convinced that placing the catheter and treating his CMV retinits was the only real option and employed all my powers of persuasion to get him to agree.

Finally, around 4 o’clock in the afternoon, reluctantly, he did. Worried that he might change his mind at any moment, I quickly contacted the surgeons, who jumped at the opportunity and brought him into the O.R. 45 minutes later.

When I came to see him the following morning, however, he greeted me with open hostility.  “How could you have talked me into this?” he demanded.  “I should never have agreed to it.”

Though taken aback, I secretly remained pleased.  Now he would get the therapy he needed.  I stayed to talk through his regret anyway, spending another full hour but accomplishing little.

Other specialists came to talk to him, but he remained sullen and withdrawn.  Eventually, though, he agreed to start the gancyclovir treatment.  I went to see him just before he left the hospital, hoping we could make peace.  But he wouldn’t forgive me.  “It’s all your fault,” he said, and I had the distinct sense he didn’t just mean the catheter, but the CMV retinitis, and even his HIV disease as well.  He’d acted, quite frankly, like a petulant child during his entire hospitalization, but all I could think about was how awful his circumstances were, so I said nothing.

I spent several days reflecting on the experience, unable to shake the feeling I’d done the wrong thing.  I’d helped save his vision, sure, but somehow to him that seemed almost unimportant.

And wasn’t what he thought—what he wanted—of paramount importance?  Who was I to say having a catheter tunneled under the skin of his chest was worth doing in order to save his vision?  In my view, he’d been operating under a childishly limited perspective, seemingly unable to focus on any facts but the ones immediately in front of him, namely, the risk and discomfort involved in having the catheter placed.  But what if the discomfort simply wasn’t worth it to him?  Of course, had we not placed the catheter and he’d gone blind, he almost certainly would have turned around and cursed us for allowing that to happen.  I strongly suspect that no matter what we did and what happened to him as a result, he would have been unhappy and unhappy with us.  And really, I’m not sure I can blame him.

My experience with him taught me two important things.  First, no matter how wise I may believe a particular course of action to be, if I wield all my persuasive power to convince a patient to take it when they don’t really want to, I put them at great risk for regret and myself at great risk for being blamed when things go wrong, as they sometimes do.  As a result, my posture has changed.  I no longer press my case until I win my patients over.  Instead, I present a balanced rationale for doing what I think is best, communicating honestly my concerns about not doing it and my concern about my patient’s well-being—but I now take great care not to imply that I know what’s best for my patient better than he or she does.  For me it’s become more about education and partnership than persuasion.  Even when my patients make what I believe is a foolish choice, I let them know how I feel, but I exert no pressure on them to change it.

Because the second lesson my experience taught me was this:  I may think I know what’s best (after all, who wouldn’t choose to tolerate a permanent indwelling catheter to save their sight?), but any judgments I make about what’s best are, by definition, based on my own values.  If more than sixteen years of medical practice have taught me anything, it’s that people have different priorities.  I must always help patients sort through their fears to arrive at what seems like a good decision, but it must always be a good decision for them, not for me.

Because, of course, neither the patient nor the doctor really knows what choice will prove best.  We only know statistical likelihoods.  And sometimes we all get a surprise.  Case in point:  three weeks after my patient went home, his vision preserved, he developed bone marrow failure from the gancyclovir and died.

Next Week:  The Whimsy Of Serendipity

23 comments to The Problem With Being Too Persuasive

  • George Colombo

    An exceptionally thoughtful post even by your already estimable standards. As a human being who—like most of us, I suspect—just tries to muddle my way through things as best I can, I admire and appreciate your perspective. As a writer, I am blown away by your candor. Thanks for this one.

    George: Thanks.

    Alex

  • This post reminds me of a jingle learned long ago in studying the art of rhetoric and persuasion:

    A man convinced against his will
    Is of the same opinion still.

    In that deeper, longer-range way, the persuasion is useless anyway. But you certainly learned a lot from that experience. Yes, everyone has their own priorities, and yours may not be mine, and vice versa. I would certainly prefer going to a physician who has learned that.

  • Annie

    It was a good learning experience for you and also for me as a reader, who may be faced with trying to persuade someone of a very important decision of his or her life someday and i would certainly put this experience in mind.

  • John Schumann

    I agree with George that the candor and clarity of this post is superb.

    I like the way you reflect on what the years in practice have taught you. It sounds like through a combination of experience and personal reflection you’re able to achieve outcomes as good (better?) by being less “persuasive” and more matter-of-fact.

    Certainly takes less energy out of you, or at least lets you channel your energy better.

    I wonder about your current posture with patients. If you think a patient’s decision is unwise or illogical (or just wrong) and you let them know that, don’t you think that is persuasive in and of itself?

    —John

    John: The answer to your question is yes. But I think there’s a world of difference between allowing the innate authority that comes with my position as a doctor to persuade someone and insisting a patient follow my advice no matter what. I prefer the soft touch of the former, which to me preserves patient autonomy and respect for their values (even if different than mine), to the inflexible pounding of the latter.

    Alex

  • Angela

    I appreciate this post and the lesson illuminated. We are all on this journey of life to learn, and I believe that one of the greatest lessons is that of humility. Despite all that we know, there is so much that we do NOT know, and we only become successful/valuable in our professions when we start to incorporate this inherent ignorance into our rehtoric. I really appreciate you sharing this lesson. Thank you.

  • Chris

    Alex, you say your lesson was to learn to let others make choices based on their own priorities, not yours . . . but you also acknowledge fear in your next-to-last paragraph.

    Patients DO need time to work through their fears. Until they do, they won’t be ready for swift decisions and swift action. And as Will Shakespeare said, “Readiness is all.”

    There is the famous “What would it take . . . ?” approach. The doc asks “What would it take for you to get in touch with your deepest feelings about this?” The patient may answer “I need time to think about it.” Or the patient may say, “I need to get over my fear first. “Then I will be ready to decide.”

    Then, you can propose a time-frame. “Would 24 hours be a good time-frame?” (If this example was emergent, you would have to say that there is some urgency, of course.)

    And/or “Is there anyone who can help you work this out and confront your fears?” which will tell you who supports this patient. Make that support person(s) part of the team. Get them on the phone or get them to the bedside. Have the support person accompany the patient for the PICC line procedure. Have that support person be there in the recovery room, etc. (assuming the patient finally agrees).

    You tried to do all of this yourself, Alex. I see that as another problem in this scenario. You need a team: doctors, nurses, family, support persons/friends, etc. Your patient was in some kind of spiritual or psychological crisis–it wasn’t just medical . . .

    Chris: You are, of course, correct. I didn’t mention that there was a sister in the picture who was fighting as hard as we all were, but he wouldn’t hear her either. I mentioned the helping of patients through their fears for precisely the reasons you give: there’s a subtle but critical difference between a patient choosing one particular course of action because it genuinely coincides with their values and choosing it because they’re afraid of the alternative despite the fact that they know it’s the one they should take.

    Alex

  • kimsia

    “For me it’s become more about education and partnership than persuasion. Even when my patients make what I believe is a foolish choice, I let them know how I feel, but I exert no pressure on them to change it.”

    What about a parent in a parent-child relationship?

    Or a teacher in a teacher-student relationship?

    Kimsia: I think, to varying degrees, the same principle applies. Of course, when dealing with people whose judgment is incompletely formed (i.e., children), you often need to modify this approach. For example, I wouldn’t allow my 3-year-old son to skip immunizations because the shots hurt (as much as I might like to).

    Alex

  • Indiogo Rain

    I appreciate all your posts but THIS one hit me right now as I was in the midst of a tantrum over what I thought was a foolish decision by a client of mine. But she was very clear about what she wanted to do, stay with an abusive baby father. I was FURIOUS because I understand the cycle of abuse especially on the very children she says she’s trying to protect. I am over myself, and am still searching for the the resources to help this young woman when she comes back and wants the kind of help I can offer her. Namaste!

    Indigo Rain: So painful, sometimes, watching people make what seem to us to be certain mistakes. We can only serve as good role models, offer advice when asked, and encouragement when not, and hope people are able to find their way to wisdom out of their experiences.

    Alex

  • Dean

    Sometimes we forget that physicians also stress over medical decisions. Weighing the odds of various treatments must test your skills on a regular basis.

    It has been my experience that some experienced patients have an uncanny ability to know the best treatment for their illness.

    Thank you for sharing this difficult story.

  • thquah

    I think TRUST plays a very important part in the doctor/patient relationship .Knowing very well that the doctor would generally want the best possible result for his patient. If the patient trusst the decision made by the doctor then the power of persuasion doesn’t have to come in. Generally in Asia, the patients tend to trust the doctor more.

    I think it’s best to let the patient decide with the pro and cons laid out. Whatever he decides it will be the best for him and not necessary the best for the doctor.

  • Mike

    I am very surprised that the focus of this story was not on the fact that the patient died from the side effects of the treatment you persuaded him to use. I am even more struck by the fact that no one has commented on this. The deeper and more interesting part of this story was that last line about how your patient died 3 weeks later from the very treatment you convinced him to take! How you felt about that, and how you dealt with that seems like the elephant in the room from this blog post. I would like to see another blog post on that. Did you feel guilty about that? Isn’t that why this story probably stuck with you? Just seemed strange that the most significant part of this story (I guess to me anyway) was a one liner at the end leaving me with many more questions than I had while reading the rest of your post.

    Mike: I didn’t feel guilty. Surprised and sad, yes, but his circumstances had trapped him between a rock and hard place. I would argue he would have been better off being blind than dead (even if he might have disagreed with me), but there was no way to know what was going to happen. As we say in medicine, the restrospectoscope sees all things with 20/20 vision. The point I was interested in making with the last line was that we all may think we know the best choice to make at any point in time based on our values, and we can still be completely wrong (not just doctors but patients as well).

    Alex

  • Abdu

    Alex,

    As an Infectious Disease specialist who has been managing HIV patients for almost 15 years, I really identify with the case you presented and very much appreciate your post. In particular, the dilemma faced by a treating physician in either yielding to a patient’s wishes versus pursuing an often taxing campaign to enlighten them of the potentially catastrophic outcomes if they resolutely refuse to budge, is one that can be exceptionally challenging.

    I find that when my patients, (particularly those with HIV who may be quite disenfranchised for many reasons) react with anger, hostility and don’t appear to be making the wisest decisions for themselves (at least in my view, that is), it is partly based on lack of insight, but mostly due to feeling scared, alone and overwhelmed with their condition. I have learned that sometimes even the most recalcitrant patients can be brought to a better point of understanding with a great deal of patience and an added dose of compassion that they may not expect forthcoming. I certainly appreciate what your saying about not always “knowing best” as the MD, but I DO feel an ethical obligation to apply the “art of persuasion” as much as I can unless I am convinced that my patient is well equipped and supported to cope with what they are facing now … and what may be lurking around the corner.

    Abdu: You raise an excellent point. I suppose what’s changed for me isn’t my sense of obligation to guide my patients toward what I judge to be the best answers but the manner in which I do so (i.e., in full control of my arrogant desire to override their autonomy). Recognizing that patients mostly refuse to make what seem to be the most reasonable choices with respect to therapy out of fear is crucial, and choosing to take the time to help them work through that fear (or whatever objection they may have that doesn’t come from a wise and courageous place) divides the merely good doctors from the ones who are great.

    Alex

  • anne

    Why not ask the patient to tell you WHY they would make their decision about treatment? In other words, give them an opportunity to persuade you? It’s like holding a mirror up to their thoughts. In that process, a lot of people are able to “think out loud” and put their situation and choices into perspective—or maybe come to grips with the source of their fear or the reality of their situation. Maybe say something like, “Given what I’ve just told you about your options, help me understand why you’re thinking that way about it.”

    Anne: Excellent suggestion, which I employ now all the time.

    Alex

  • Chris

    @ Mike:

    I feel the way you do about the surprise ending. And I had the same questions about Alex’s feelings following the patient’s death—which he has now answered.

    I didn’t ask this question because I believe that the one-liner surprise ending is a writer’s device, which paradoxically draws his readers in even as he is ending the story. It is what O’Henry did…

    Some questions can be left hanging in order to give the reader something to ponder, like an aftertaste…It forces the reader to keep re-focusing on the story…

    Obviously, I like this type of literary device.

  • Mike

    What struck me from this excellent post is that most decisions are emotional ones, and people are rarely convinced by facts or logic. If they are, it’s probably because they’re typically not feeling an emotional charge to the issue.

    When discussing such serious, scary stuff, it’s not surprising that trained professionals fight hard against high emotions and habitual prejudices, whatever they may be. It can be frustrating on both sides, especially when time is of the essence.

  • Chris

    I wonder if one can generalize this issue of persuasion to the political scene.

    For example, Tim Geithner appeared on Meet the Press several weeks ago, with a warning that the debt ceiling must be raised or the country will have to default on its debt obligations . . . I would have thought that Geithner’s authority would be taken more seriously. But instead the debt ceiling is being discussed as a debatable and partisan issue.

    How is it that the people who with the highest levels of authority, in some cases, elected officials, have so little persuasive capital? How is this the same/How is it different from the doctor’s persuasive powers?

  • Tara C

    That last line was a real twist. At first I felt really bad for the patient who allowed himself to be talked into something he felt was wrong for him. However, after thinking about it, I can only conclude that it is an example of the impermanence of life. We never know for sure what the right decision is until after the fact, and it was simply his time to go, not a reason for you to feel guilty.

  • Good subject. What I might learn is why does the decision need to be made now? Why not tomorrow, or next week. He has two eyes. Given time to think calmly instead of pressured, he may have made the “right” decision on his own and not been angry. But of course he would still have died. There is the hard lesson to live with. I have seen that a lot I expect in my world.

  • Julia

    Hi Alex. Thank you again for such a wonderfully written post. It always amazes me how doctors-in-training can experience the death of their patients and still continue on in the field.

    Though I wonder if you haven’t changed from being “too” persuasive to being more “mindfully” persuasive?

    Speaking of persuasion, y’all know you do that outside the clinic too… right? My next door neighbor is a surgeon and he’s pulled the whole Dr.-knows-best thing on me at least twice. And about things completely unrelated to medicine or health. Like where to park a car or put furniture. It must be something about white hair, glasses and this tone of voice you guys develop. My close friend is in her 2nd year of professional practice and I’ve started hearing that “voice” every now and then. Jeez, after another 20 years of practice I’ll never win a debate with her again, and I probably won’t even realize it. 😀

  • Chris

    @ Julia, who wrote:
    “It must be something about white hair, glasses and this tone of voice you guys develop. My close friend is in her 2nd year of professional practice…”

    “It must be something about” is spot on. I think there is a perfect storm of personality traits (sometimes called a strong personality), professional status, educational status, and moral authority that creates a persuasive figure. That figure is sometimes called a leader, as well.

    (This week was Oprah’s last week after 25 years of persuasion/sway. Geez, she swayed the whole culture, it seems to me.)

    Then there are others who want to fade into the wallpaper pattern. They want to be invisible. They don’t push, they don’t argue . . . and when they slam the car door, it isn’t really closed and you have to close it again!

  • ramoes gaston

    I can deeply identify with the pain placed by having your position. As a peer specialist an Buddhist I have to deal with the disease of addiction. If people don’t change what is in their heart, then the condition they’re in won’t change to suit their needs. And my clients hopefully strive to live a life full of good health, wealth and happiness.

  • GeorgeM

    I write because there are so many nuances here that remain uncommented upon, i.e.,

    A 34-year-old with HIV facing possible blindness, “he cried”—what tremendous anger and fear he had! How much would his chances improved if he was at peace with the (his) decision?

    “Dutifully, I came back an hour later…”—how easy to mis- or over-interpret “duty.” Why not a day or two later?

    “Worried that he might change his mind at any moment..”—sounds like wanting way too much to win (a good example of dangerous thinking. How bad do you want it? Real bad.)

    “Surgeons who jumped at the opportunity”—don’t they always?

    As with so many life situations, one choice is to act now and lose all other options while the other is to wait and retain those options at least for awhile, e.g. divorce, job quitting, buying this car, having an abortion, cancer surgery, amputation, suicide.

    Always good reasons to thoroughly examine our motives.

  • Thanks for this great post! It gives some new ideas!

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