When a Medical Professional Damages the Provider-Patient Relationship

Years ago, I published my story, “When a Stranger In a Bookstore Mistakenly Assumed I Had an Eating Disorder” in which I recounted an uncomfortable confrontation in a Barnes and Noble bookstore. I explained how a stranger approached me, attempting to persuade me to seek support for my eating disorder. I was so flustered and upset by this experience that I brushed her off and did not take the opportunity to advocate for myself or educate this woman — I did not, in fact, have an eating disorder, but a rare disease called lipodystrophy. This means that I do not have fat cells, and therefore have a frail appearance. I published this story, pledging to do better the next time I was in such a situation. The next time, I promised myself, I would teach the confronter about lipodystrophy, and explain why it is harmful and irresponsible to approach a stranger about such a vulnerable topic.

When it comes to healthcare professionals, however, it is a whole different ball game. The duty to intervene with an unhealthy-appearing individual does not fall on a stranger, but it does fall on a medical professional. With this duty comes another responsibility; and that is the task of intervening in a way that maintains the patient’s dignity and emotional well-being.

This brings me to the last time I was at the dentist. After a successful teeth cleaning, my dentist entered—only it wasn’t my ordinary dentist.

“Hi, Dena,” she said as she entered. The chair I was in faced a window opposite the entrance. I could not see her, as she was still behind me. “I think we met the last time you were here, is that right?”

I remembered that I had seen a new, female dentist the last time I was there, only I couldn’t recall that dentist’s face. It had been over a year, and I had only met with that dentist for several minutes. After all, it didn’t take long to see that I had perfect teeth. Either way, this dentist was still behind me, and I could not see her at all. “Oh, maybe.” I said.

She came around to my side, wearing her mask and face shield—still no way to recognize her—and she towered over me as I laid down in the dreaded seat of doom, covered with a dental bib wet with my drool. “Yeah…how are you?”

“OK.”

The dentist continued staring down, her eyes in a sympathetic smile.

“Mhm…how have you been?”

I tried to figure out if she was asking about my teeth or how I’ve been coping with living in a hellish pandemic. “Things have been fine.”

There was an awkward silence as she continued staring down and smiling.

“Yeah…” she very wittingly states.

The dentist and I stare at each other for what feels like a full minute. In this silent stare down, I feel unsettled.

“…Obviously, you’ve lost some weight.”

And suddenly I’m back to Barnes and Noble. For part of that awkward silence, I felt a comment about my weight creeping up. But I chose to ignore that gut feeling, like I had years ago in Barnes and Noble. Now, my heart stopped and my throat closed. And I became angry — it was impossible that I had lost any weight, because I have neither gained nor lost a net of five pounds since middle school. This was not a question she was asking, but a false statement she claimed to be “obvious.” I now felt more confident that I had never met this dentist before, and felt certain she did not do the job of consulting my records prior to entering the room.

“No, I have not.” I did not have the emotional strength to say more.

The look in her eyes turned to pity. Just like the woman in Barnes and Noble, I could tell that my quick dismissal of the statement did not sway her concern, but inflate it. Now she was not only dealing with what she assumed was a young anorexic woman, but a young anorexic woman in denial.

“No?” She asked. Another awkward silence as I stared her down. In a sickly sweet voice, she continued, “is there anything I can do?”

“No.”

A description of lipodystrophy is at the tip of my tongue, but embarrassment and a feeling of insignificance keeps it back. I was still lying down, and I did not feel comfortable educating a face-shielded figure looming over me. I had recently been struggling with my body image, and this meeting with the dentist was enough to break me.

The dentist quickly checked my teeth, which are in excellent health and in no way affected by my skinniness. She turns and updates my record. I turn and look, and I can see what she’s typed: “patient is severely thin and defensive about it.”

As the dentist exited and the dental hygienist returned, it took all my strength to keep the tears inside for the remainder of my appointment. I was furious with the dentist for the way she approached the situation, and for calling me defensive when it was she who put me in a defensive situation.

It is the duty of a healthcare professional to probe patients with questions that pertain to their health, but there is still a right way and a wrong way to do so. As I delve into my genetic counseling training, I am learning how to interact with a patient in ways that are appropriate and not psychosocially harmful.

I’ve learned the importance of coming prepared. It is not only helpful, but essential to review medical records and other relevant information on file prior to patient interaction. If this had been done, the dentist probably would have already known my diagnosis. I am not certain that the term “lipodystrophy” is on file, but I know that my medications are. A quick look at my list of medications and the dentist could have inferred that I had an underlying medical condition. A quick Google search of one of the medications would have immediately brought up sources for lipodystrophy.

I’ve learned the importance of building rapport. While some people find small talk frustrating and unnecessary, in the process of building a healthy provider-patient relationship, I consider it vital. In this situation, I did not know the dentist’s name, nor what she looked like. Failing to master Small Talk 101, she made no attempt to get to know me. She delved directly into a very uncomfortable topic without ensuring that I felt comfortable speaking to her in any capacity.

I’ve learned the importance of communicating through body language. Putting your patient in a physically inferior position by towering over them is not the way to engage. In 2020/2021, the age of face masks, interacting with patients through facial cues and body language in a way that helps them feel secure is challenging. The least you can do is meet them at their physical level.

I’ve learned the importance of asking open-ended questions, and of not making assumptions. The dentist assumed I was struggling with an eating disorder, made a false statement about my losing weight and did not move away from the topic when I first dismissed it. I’ve learned to be careful with my word choices, and that things are not always as “obvious” as they may seem. Instead of stating an incorrect reasoning for my underweight appearance as fact, she should have approached this sensitive topic using such open-ended questions. Although it always hurts to receive such questions about my weight, asking rather than stating would have given me a better opportunity to explain, and would not have felt as accusatory.

Above all, I’ve learned the importance of the doctor-patient relationship. The two foundational duties of medical ethics requires that medical professionals 1) seek trust and be deserving of it, and 2) use medical knowledge, skills, powers, privileges and immunities for the benefit of patients and society. In order to meet these two duties, the medical provider — and I include dentists in this category — must prove to be worthy of obtaining a patient’s sensitive information by building an appropriately intimate relationship with the patient. An introduction, including your name, is the bare minimum. A 60-second long conversation before delving into the intrusive questions can make all the difference. In order to encourage patients to divulge intimate personal information, one must establish trust and prove to be deserving of it.

I wish I could make the same promise I made to myself last time — that the next time I am put in an uncomfortable situation regarding my thin appearance, I will not hesitate to speak up and educate the world about lipodystrophy. But realistically, there will be days when I am just not in the damn mood to be an advocate. The wrong comment in the wrong place at the wrong time may trigger me into cowering into my defensive mode, rather than proudly assuming the position of “courageous advocate.” What I can promise to do, however, is continue on with my genetic counseling profession and my blogging with this experience in mind, grow stronger from it and educate my readers.

I am proud to enter a profession that focuses so strongly on the provider-patient relationship, and values the concerns, opinions and beliefs of the patient. But these qualities should not be expected only of genetic counselors — all healthcare providers must work hard to uphold the duties of medical ethics and to maintain a healthy and functioning provider-patient relationship. It isn’t easy to build trust in such a short appointment time, but a little small talk can go a long way.