The Protective Parent

The Protective Parent by Dr.
Paul Griner
During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of

patient stories. He learned as a medical student and resident, treated as a
hematologist during a tour of duty in the air force, taught as a professor of
medicine in the fields of hematology and internal medicine, led as the president of
a large university teaching hospital, and finally, mentored young physicians.
Most of his stories – and the case studies the IHI Open School will present in the
coming months – are from the 1950s and 1960s, prior to what we now refer to as
“modern medicine.”
With the remarkable technology now available to facilitate the diagnosis and
treatment of patients, Griner says, medical educators have devoted less time to the
fine points of “bedside medicine,” the taking of a thorough history and
performance of a good physical exam.
In his view, there are many reasons why physicians need to develop and refine
these skills:
1. The confidence of the patient in his or her physician is enhanced.
2. The ready availability of sophisticated tests and procedures leads to their
overuse, often resulting in inappropriate or unnecessary treatments with cost
and quality moving in the wrong directions.
3. The practice of medicine has become global. Many physicians (and students)
elect to spend time in underdeveloped countries, providing valuable services
to patients in settings where sophisticated tests and procedures are not
available.
Griner, now Professor Emeritus of Medicine at the University of Rochester School

of Medicine, believes that professionalism and sound clinical skills mark the good
physician. It is with this in mind that he presents these case studies and the lessons
learned from them.
The Protective Parent
One Friday evening, I was called to the emergency room to see a patient for one of
my colleagues who was out of town. The patient was a 17-year-old girl, a senior at
a local high school. She had developed acute lymphoblastic leukemia some years
before, but treatment had resulted in a complete remission.
Recently, she had relapsed and was again under treatment.
The patient’s mother intercepted me before I walked into the examination room to
tell me that her daughter did not know of the leukemia diagnosis. She also told me
not to tell her. I asked her to explain the situation further. She indicated that when
the diagnosis of acute leukemia was initially made, she kept this diagnosis from
her daughter. She requested that everyone involved with her care agree to tell the
daughter that her problem was an unusual anemia. Up to that point, everyone had
complied. And when the leukemia went into remission, the mother considered this
chapter of her daughter’s life to be closed.
When I asked her why she chose not to tell her daughter, she said, “I had enough
problems to deal with. I didn’t need any more.” The mother then asked where I
lived. When I replied, she said, “Oh dear! A number of my daughter’s friends live
in that area. I’m concerned that they will hear of her diagnosis from you.”
I told the mother I was very uncomfortable with the request, but that I would
respect her wishes during the weekend. I indicated to her that I would bring my
concerns to my colleague when he returned.
I supervised the treatment of the patient for the next two days. Upon my
colleague’s return, I spoke with him about the confidentiality. He elected to
continue to respect the mother’s wishes.
Discussion Questions
1. What would you have done in the situation? Would you have told the
patient about her leukemia? Why or why not?
2. Can you think of at least two reasons why the mother may not want to
share the news of the diagnosis with her daughter?
3. What would you have said to the mother when she told you not to tell her
daughter?
4. Would the case be any different if the daughter was 18 years old? Why or
why not?
5. What right does the patient have at the age of 17 to know her own
diagnosis?
6. Imagine if the daughter accidentally found out about her diagnosis --
perhaps she sees a chart or another clinician who wasn't part of the
original conversation lets it slip. What impact might that have on the
daughter? How much might it affect the trust she has in her mother or in
future health care providers?
7. Have you ever witnessed a similar situation? What was the end result?
Commentary from Dr. Griner:

I was disappointed that my colleague had been a participant in keeping the patient
in the dark about her disease. I elected not to tell the patient about her disease
during the two days of my care only because I was a “substitute” physician.
Having never seen her before, I had not established a doctor/patient relationship.
As mentioned, and to my disappointment, when my partner returned, he elected to
continue this approach.
Study after study shows that patients are better able to handle bad news than either
relatives or doctors may think. In fact, some patients may even be concerned about
the person who delivers the news. Sometimes, I’ve heard people say, “It must have
been hard for you to tell me this.”

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The Protective Parent by Dr.

During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of

Griner, now Professor Emeritus of Medicine at the University of Rochester School

Recently, she had relapsed and was again under treatment.

Commentary from Dr. Griner:

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