122 Becoming a Patient
How does he know that it’s not going to spread to this or that
group of lymph nodes within six weeks? He says, ‘‘Oh, I’ve seen
the course. You’re just anxious!’’
The average natural history of a disease does not apply to everyone.
But it is simpler for physicians to believe in and follow these means,
despite often wide individual variation, rather than try to determine the
degree of uncertainty inherent in any particular patient’s prognosis. Yet
Walter found that his own view of his timetable was pathologized by his
physician as due merely to anxiety.
In part, these incongruities arose because doctors are mandated with a
threefold mission of providing diagnoses, treatments, and prognoses, yet
the future cannot wholly be predicted. Hence, physicians may want to
hedge their bets by speaking in ambiguities. But doctors’ and patients’
different experiences and approaches regarding time exacerbate distress.
Why do doctors nevertheless prognosticate? Their clinical experience
enables them to do so because they have observed numerous cases of a
particular disease, and lengths of patients’ survival. Yet, countless unpre-
dictable factors can alter these periods.
Falling Between the Cracks
Physicians’ lack of time had other effects as well, contributing to patients’
tests and follow-ups ‘‘falling between the cracks.’’ Due to managed care,
primary care providers, though ‘‘gatekeepers,’’ are swamped by deluges
of data and detail, and have less freedom and flexibility in their schedules.
Nancy, the endocrinologist with breast cancer, said:
It’s unusual to have a primary care physician who is going to take
care of all the details. Mine gives me referrals, but it’s too much
work to keep him informed about what my oncologist is doing.
Nancy and others came to realize more than before how details got lost
or forgotten.
As a doctor, I often let the ball drop, and did not follow up on
details. Now, being a patient, I realize that’s awful. Doctors don’t go
out there and actually check if the secretary ordered the tests.
You don’t necessarily know when the patient gets a lab test done.
The results don’t necessarily come to your box in a timely fash-
ion. The results could be available, and you don’t know it.