Medical Signs and (Their) Symptoms
Welcome To Dr. Friendly’s Office
Captured during a doctor’s appointment by the patient, an admirably camera-ready friend, the sign in the above photo is an exemplar of everyday clinical office practices that are incongruent with the highly promoted and almost universally endorsed patient-centric approach (which is apparently interwoven with but not identical to patient empowerment) held by some to be the key to enhancing adherence to treatment.
It’s also evil on so many levels that I find it difficult to decide which I find most offensive.
Nonetheless, I’m willing to give it a shot.
Medicine Would Be A Great Business If It Weren’t For The Patients
I certainly admire, for example, how the words, “HMO Patients,” are highlighted in red against the black type of the rest of the sign. Having been covered by an HMO in the past, I appreciate the joy of being in a population designated for special treatment. I was, however, disappointed to discover that this practice does not yet require HMO patients and other clients, such as those funded by public aid, who create special (i.e., fiscal) concerns for that office to wear armbands identifying them to staff and other patients.
Mark My Words
The daring insertion of an exclamation point after “Orders given by doctor require referrals” (or, more precisely, “ORDERS GIVEN BY DOCTOR REQUIRE REFERRALS”) is outdone only by the double exclamation points added to the concluding line.
I am, as noted in Provocative Punctuation Peccadillo, not a fan of the exclamation mark.1 In that previous post, in fact, I suggested the following homebrewed criterion for the usage of that potentially toxic punctuation:
If I Speak Slowly and Loudly, Surely Anyone Who Tries Can Understand Me
And, just as that double exclamation mark at the end of the sign overwhelms the solitary exclamation mark used earlier, that final demand, “DON’T FORGET TO ASK FOR ONE,” is far more implicitly insulting than the preceding “ORDERS GIVEN BY DOCTOR REQUIRE REFERRALS.”
After all, “ORDERS GIVEN BY DOCTOR REQUIRE REFERRALS” could, its all caps format and brusque wording notwithstanding, be arguably characterized as informational – in the same way that commands to “shut up and sit down”2 shouted at a misbehaving, recalcitrant, unreliable, not too bright second-grader are informational – but arguably informational nonetheless.
On the other hand, what possible motivation prompts the final demand, “DON’T FORGET TO ASK FOR ONE,” if not the conviction that the patient not only has to be instructed that “orders given by doctor require referrals” (my apologies – the continued replication of the all caps mode used in the sign is just too fatiguing to be continued here) but he or she must also be reminded, with the emphasis lent by upper case type, that since a referral is required, then the patient must also, dammit, ask for the referral.
Location, Location, Location
There’s more. This sign – or, hypothetically, even an alternative with less adamant language – might be of use to a patient seeing the physician serving as the HMO gatekeeper. Oh, that reminds me, doc. I need a referral slip before I see that orthopedic surgeon you recommended.
It could conceivably be helpful even if the patient were in the waiting room of the consultant. Oh, phooey, I need a referral I don’t have. Well, at least I didn’t waste 30 minutes waiting for an appointment that isn’t going to happen.
This sign, however, is actually located in the examining room of the consulting doctor.
Yep, once the patient has arranged the appointment with the consultant through his or her primary care physician, has shown up at the consultant’s office at the assigned time, has waited for the doctor to finish with the patients higher on the list, and has finally arrived at the ultimate destination, the examining room, where the triumphant entrance of the MD-ordained man (or woman) of the moment is to take place, then and only then does that sign come into the patient’s view.
At that point, what advantage does the patient garner from this information? If the patient has the referral in hand, the sign is redundant. And if the patient lacks the required referral, what choice is left other than confessing his or her failure and slinking off to re-start the entire process of contacting his or her primary care physician to obtain a referral to see the consultant. The only apparent advantage to that which accrues to doctor’s office; i.e., the doctor’s time isn’t wasted on a patient whose third party coverage won’t pay for a consultation without the referral documentation.
The Missing Line
Despite these impressive strengths, this sign is, I contend, incomplete. Much as an archaeologist deciphers a previously untranslated ancient language by extrapolating from the available textual content and taking into account the apparent intent and use of the document, I have analyzed this sign and am confident that I can elaborate the thought behind the sign as well as further emphasize its tone by augmenting the original language with a single word and the appropriate sequential punctuation.
Check it out.
- I have long described the exclamation mark as the grammatical equivalent of laughing at one’s own joke, believing that metaphor to be my contribution to the banter of punctuation debates. It is only in the past several days that I have discovered that one F. Scott Fitzgerald appears to have a prior claim to this phrase, as used in his instruction, “Cut out all these exclamation points. An exclamation point is like laughing at your own joke.” Phooey.↩
- Of course, “shut up and sit down” lacks the splendid ambiguity of “ORDERS GIVEN BY DOCTOR REQUIRE REFERRALS,” a concatenation of words replete with medical connotations which, in a master stroke of passive-aggressive communication, can be accurately decrypted only if the reader already knows the rule which it denotes.↩