The Importance of Therapeutic Alliance (or how I fired my surgeon and what I learned from that)
Recap: I had a really invasive surgery with a really abysmal recovery and bonus issues to boot and my doctor just told me that none of it had to do with my sketchy vagina bump that was now getting bigger. Internally, I was starting to panic.
She continued, “I didn’t appreciate at the time that this was abnormal. When I dilate your urethra I want to also do a cystoscopy so we can see what is going on.” Dilation of the urethra involves the placement of metal rods of increasing size in order to stretch the tissues – it’s similar in idea to putting gauges in your ears, although luckily no one wanted my urethra to be sharpie sized.
Before I agreed to I wanted to know whether I could have a referral for pelvic floor physical therapy before scheduling the dilation.* I wanted to see if I could get my urethra back to its normal size on my own, a request that shouldn’t have been surprising given our past conversations about my interest in pelvic health.
To this day, the most shocking thing about this interaction is that I was able to keep my voice calm and even when I replied, “I have concerns that I had a surgery that didn’t address my symptoms.”
“You had a urethral diverticulum,” she replied, defensively. “And urethral diverticula have a correlation with bladder cancer. I had two women just this month whose bladders I had to remove because of cancer.” She went on to tell me that she would have to sedate me to do the dilation and cystoscopy because of my bad experience with the catheter. As she’s talking, I can feel myself getting more and more tense, crossing my legs tighter and tighter under my paper gown, ultimately ending with my legs twisted like a pretzel, once at the knees, and once at the ankles. I used every last once of professionalism to keep my tears at bay: “Is it possible that I have increased pelvic floor muscle tone from the surgery, causing my urethra to shrink, impacting my ability to void?”
She refused my request, telling me that there would be no benefit to physical therapy if my urethra was too small, causing increased resistance* against urine, telling me the treatment would be “a waste of time”. I managed to refrain from pointing out the irony of that statement, as I had once again been in her officer for longer than 2 hours at this point. “But you can get a second opinion if you want one,” she ultimately compromised.
“Great. Where do I go?”
It’s difficult to convey in writing how deferent and respectful I was in spite of my growing frustration and concern. I didn’t then, nor do I now, fault her for her diagnosis or her plan of care. However, it infuriated me that she tried to scare me into believing in her treatment, rather than acknowledge my (valid) concerns. It was also unacceptable to me that she ignored my request for physical therapy, an intervention with very little risk associated, especially knowing my background.
I walked out of there knowing I needed a new doctor, not because this one’s treatment didn’t work, and not only because I didn’t feel like she listened to me or my values, but ultimately because while I was sitting there, I realized that I didn’t trust her or her opinion. To say that I didn’t trust my healthcare provider did not mean that I didn’t trust that she was trying to help me. It didn’t mean that I didn’t trust her motives. It didn’t mean that I didn’t trust her billing practices. It didn’t even mean that I didn’t think she would be successful in terms of her surgical goals. What it did mean was that I didn’t trust her to return my requests for information. I didn’t trust her to consider my goals and my values in her plan of care. My trust was so diminished that I was willing to undergo pretty serious pain for the sake of keeping watch over the procedure, and that’s when I realized that no matter how much potential there was that she was correct in her plan of care, there was no way it was the right choice for me.
I’m still on the search for the right medical provider, but I got something very valuable out of my experience with this surgeon. I learned that sometimes you have to follow your gut, even if you can’t always articulate what the problem is in that moment. I learned that good providers will give you the option to get a second opinion. If they believe that their plan of care is the best one, they will be confident enough to have that validated by another party. I also learned that choosing a new practictioner doesn’t have to be personal. In my experience I can’t say that I wanted to drink a beer with my surgeon, but even if I had, that doesn’t make her the right person for the job. And here’s the thing: if it isn’t personal for me to find a new provider who is a better fit for my needs, it is also not personal for one of my patients to find a new provider to better fit their needs. Sometimes that reminder is easier said than done – as a student physical therapist in my last clinical rotation it can be disheartening to have a patient that doesn’t want to work with you. For some people, it’s too much to have a student – it can be overwhelming and anxiety inducing; the opposite of what you want in a rehabilitative and healing experience. So while it’s easy to take it personally, there’s something more important than my ego: and that’s the health and well-being of the patient, which is important to me as both a patient and a provider.
*When you have increased activation in your pelvic floor muscles, it can impact the size of your urethra, and create more resistance that your bladder muscle has to fight through to get all of the urine out. Sometimes, if you can decrease the over-activation, you can improve your ability to void completely.