I had not seen jaundice that bad in years.  He was Caucasian, in his fifties, about five feet, ten inches tall, 150 pounds, maybe less.  He wore straight leg jeans and a thick leather bomber jacket zipped all the way up, and his face was noticeably yellow, even from 100 feet away.  We walked toward each other along a busy sidewalk, on an overcast spring day.  I immediately scanned down to his hands, looking for a hospital patient ID bracelet.  “Why is such a sick man walking around on the street?  Which hospital did he just escape from?” I thought.  I saw no ID band, and his hands were not yellow, though they did look slightly thick—maybe swelling from liver disease?  He walked at a normal pace, no listing or shuffling.  Aside from his yellow face and apparent thinness, he actually did not appear ill.  As I got closer, I noticed that he wore Top Gun, Tom Cruise-style sunglasses, with lenses the shade of a perfect urine specimen.  His skin color was normal.

Would a non-medical person have immediately assumed he was an escaped liver patient, wandering the streets under the influence of hepatotoxic encephalopathy?    “How fascinating,” as Ben Zander would say, that I jumped to these conclusions, having only glimpsed this man from a distance.  What if I had turned an early corner and not gotten a closer look?  In the space of a minute or so, I perceived something shockingly abnormal, and with just a little more observation, reconciled it as only mildly out of the ordinary (I think not a lot of people wear pee-colored glasses).

Weeks later, a headline appeared on my Facebook feed: “Dad’s reply to school on kids’ absence is best response ever.”  The school principal had sent a letter to the family informing them that absences for family vacation were unexcused.  The father replied with a page-long justification of the high educational value of their trip.  Like many, I congratulated the father on his response, feeling righteous and indignant on his behalf.  My sister posted a subsequent article on my page, pointing out that the principal’s letter was merely informational and a formality, not a personal indictment of his choice of vacation timing, and that the father’s public shaming of the principal was both uncalled for and petty.

I feel embarrassed for holding him up like I did.  I don’t condone public shaming, what was I thinking?  I believe now that the headline attracted me for a reason.  Maybe I myself feel defensive around my own children’s school absences for family vacations.  I think I was preconditioned to take the dad’s side, to take the principal’s letter personally, as my medical training led me to see that man’s yellow face as evidence of end-stage liver disease.  Now I am the one wearing pee-colored glasses.

When I first read the father’s response, I wondered about the principal’s purpose in sending her letter.  But I did not take the next step to answer my own question.  Had I read it again, as I did after my sister’s post, I might have realized sooner that it was simply an informational form letter, and did not at all deserve the father’s negative public retort.  How was I able to correct my initial conclusions about the man on the street, and not about the principal?  My observations of the man were objectively inconsistent—apparently jaundiced face but normal colored hands and not otherwise ill-appearing—and I have no personal feelings about people with jaundice.  I do, apparently, have feelings about receiving notices from school about my decisions regarding my children.  My judgment of the principal’s letter came from that emotional place, and impaired my ability to see objectively.

These two very different situations remind me to monitor and manage my biases–inspect the tint of my glasses–early and often.

One bright, spring Saturday morning in clinic, I met a pleasant middle-aged woman with a cold.  She was new to me, but I recognized her right away—educated professional, mother of two, loving wife, keeper of all schedules and task lists—the command center of her complex world.  Her symptoms had followed the typical arc of a viral upper respiratory infection—fatigue, sore throat, nasal congestion, headache, fever, cough—and it was the green snot that brought her in on day 5.  My physical exam revealed no signs of strep throat or pneumonia…

The relaxed calm I had felt heretofore began to unravel as I contemplated telling this woman, suffering at the peak of acute illness, that I would not prescribe an antibiotic.  In an instant I heard familiar scripts in my head:  She did not have time to be sick; she needed something to kill this infection right away.  She was about to travel and did not want to feel this badly on the plane.  Her regular doctor always gave her an antibiotic for this before.  The snot is green, that means it’s bacterial (it doesn’t)!  My mind’s eye saw hers widen with disappointment, then anger, her posture turn aggressive.  My inner conflict escalated quickly:  Sacrifice the rapport I had just established in the name of antibiotic stewardship, or give in to the misguided pleas of a wrung out fellow working mom, and contribute personally to the scourge of antibiotic overuse and resistance?

Maybe it was the sunny weather that day, or the initial connection I had felt when we talked.  Amid the flurry of mounting anxiety, I had a flash of clarity:  What if I just asked her what she needed?

“What are you looking for from me today?” I queried.

“I just want to make sure I don’t need antibiotics.”

Imagine the absolute and complete relief of realizing that my swelling dread was, in fact, unfounded and unnecessary.  She needed reassurance, and probably formal permission to leave the air traffic control tower and go take a nap.  I cheerily listed all of my self-care recommendations, including a firm admonishment that she take care of herself ahead of all others for at least the next 24 hours, doctor’s orders!  The visit ended happily for us both.

“What are you looking for?”  Such a simple question, and key to understanding one another, as well as ourselves.  I was looking for connection, authority, relationship, and affirmation.  I wanted her to like me, and to trust that I knew my stuff.  And more than once before, I had given my best advice in this situation, only to be rejected as a power-tripping antibiotic extremist.  I had one eye out for an ambush.

What if we ask ourselves more often, both as patients and physicians, “What am I looking for?”  Could we identify biases and fears more readily, and then challenge them?  Would it make asking for and getting what we need a little easier?  What do you think?