American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, February 24, 2014

My turning point

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:
• What makes people choose things which cause themselves harm?
• Are some people better people than others, or are they just more skilled at hiding their problems?
• Is pain really a bad thing, or is our aversion to it a sign of human weakness?
• Does God ever wear a hat?
• Do dogs watch Oprah?
• Why did I put “big ideas” in quotes?

Tough questions.

Lately I’ve been contemplating the nature of human awareness:
• Is self-awareness (the ability to think of ourselves in the third person) a uniquely human trait, and is lack of self-awareness the essence of mental illness?
• Is empathy, or other-awareness the highest of human traits? Is this what the biblical idea of being “made in the image of God” really means?

Yeah, that’s a lot deeper than about dogs watching Oprah. The second of these questions seems to be a very important dividing point in people’s ability to have good relationships with others. Our ability to put ourselves into the place of others, pondering their motives, thoughts, and emotions, goes a very long way in helping us develop deep relationships and avoiding causing inadvertent pain.

It also seems to be a trait that is in short supply in our health care system. I am amazed and deeply disturbed by how callously many my patients have been treated by some of my colleagues. Patients are seemingly treated as a commodity, a necessary evil required for billing of services.

I do understand that doctors and nurses are drained of their ability to show compassion by a system that puts them in an adversarial relationship with patients, hospital administrators, insurance companies, lawyers, and their fellow doctors and nurses. That feeling of burn-out in me was one of the big reasons I left my old practice. Either I had to change my compassion, or my situation.

Still, I am appalled at how many times patients’ worries are not addressed, their pain is questioned, and their truth is doubted. More and more, patients are assumed to be manipulating, exaggerating, or making things up, and so must disprove these assumptions to get any kind of good care. Seeing this in the people I worked with was the other big reason I left my practice to do things differently.

While I think it’s probably part of my DNA to be more compassionate than most, there is 1 event that affected me more than any other, a moment where I suddenly saw things so differently that it dramatically changed my approach to my patients.

Ironically, my turning point was on a trip sponsored by a drug company to Puerto Rico. Yes, I know, I know, this kind of thing is now viewed as an act of evil avarice. They were trying to buy my prescribing habits by offering me all sorts of nice things. In my defense, I was young, not very rich, had 4 kids, and had never been able to afford a real family vacation. These kinds of perks were very common at that time, and I did still have to pay for my family to go with me.

Plus, as you will soon see, things didn’t quite turn out all that well. Karma, I guess.

The drug company sponsored event was at the end of the week, and we arrived in Puerto Rico early in the week so we could go to different parts of the island and see the sights. After enjoying the beaches on the east coast and the rain forest in central Puerto Rico, we arrived on the west coast city of Rincon, the surfing capital of the island.

On the second day in Rincon, I got the delusion that I was: a) younger than I was, and b) far more coordinated than I am. I tried body-surfing. The 6-foot surf unfortunately broke quite close to the beach, which turns untrained body-surfer into a projectile launched at great speed into 6 inches of water. As my face was about to be planted into the sand, I put my arm up to protect my face and (more importantly) my neck. The result: a fractured surgical neck of my right humerus.

While I immediately knew something was seriously wrong, I didn’t know it was a fracture. In my pain-induced confusion, I allowed myself to be convinced that the people on the beach (in various stages of inebriation) knew something about first aid for shoulder injuries. After a few attempts to locate my “dislocated shoulder” (and several offers of alcoholic anesthesia), I was still in really bad pain, and decided that perhaps I should seek the opinion of a real doctor.

I will skip my adventures in the Puerto Rican health care system (now a blur of oxycodone-clouded memories of Spanish-speaking soap operas, paper linens over my wet, sandy body, and my cries of “mucho dolor” to the radiology tech as she tried to twist my arm to get a better picture). I will also skip my time at the drug-company conference (also experienced in an oxycodone-induced blur).

Not long after I came home, I met up with a surgeon who also recently had broken the same ironically-named bone a few months earlier. He got a smug look on his face as he bragged, “I was back doing surgery after 4 weeks.” Four weeks seemed like a long time to be out of work, but it gave me some idea of what to expect.

But after 4 weeks of healing, with the first 2 devoted to immobilization and oxycodone, and the second 2 to the cruelty of physical therapists seemingly unaware that I had FRACTURED MY FRIGGIN’ SHOULDER, I was not anywhere near to being functional. I couldn’t lie down in bed, and I could barely move my arm without significant pain.

The words of my surgeon colleague echoed in my head as I walked into the orthopedists office for another X-ray, exam, and opportunity to satiate the sadistic needs of my physical therapist. Chris was doing surgery at 4 weeks? I could barely scratch my nose. What is wrong with me? Am I a wimp? Am I really feeling this much pain? I asked my orthopedist why our surgeon friend had such an easier go of this same fracture. Was he different? I was desperately trying to escape the obvious proof of my membership in the brotherhood of whooses. He told me he didn’t know, and said he’d get back to me.

After a few weeks of doubting my pain and my manhood, my orthopedist happily informed me that Chris had a mid-shaft fracture, which is far quicker to heal than my fracture of surgical neck of that bone. I was off the hook! I wasn’t the king of the whiners! My pain was real!

It took nearly 4 months before I could lie flat in bed, and almost a year before I was mostly pain-free. But as I pondered my incredible self-doubt and shame over my pain, I realized something: many of my patients have that same fear. Here I was, with as good of a reason to feel pain as anyone could have, and I was doubting my own experience as being valid. How much more of these feelings of doubt and shame do people with fibromyalgia, chronic back pain, or chronic fatigue feel?

This idea changed forever how my approach to my patients. Instead of judging whether a person’s symptoms were “real or not,” I try to reassure them that I believe them and didn’t doubt their reality. Over time, I’ve come to believe that my patients almost always tell me the truth about their experiences. The problem comes when they do one of 2 things: either try to self-diagnose, mixing up their theories with their symptoms; or they exaggerate their symptoms to get medical people to believe them. People are so used to being doubted that they feel they have to make the story more dramatic (resulting usually in decreasing their credibility).

This brings me back to the idea of other-awareness, or empathy. My experience of self-doubt about my experience of pain taught me one of the most important aspects of my patients’ psyches. They are afraid. They feel vulnerable. They desperately want to be heard, understood, and believed.

Fortunately for me and my patients, my new office is centered on communication, not documentation. As opposed to the rest of the health care system that seems driven to de-personalize doctors, nurses, and patients, my office is all about relationship. I used to have to offer compassionate and empathetic care despite the system we lived in, but now I am rewarded for it.

I like to think that at least some of my colleagues who have lost the emotional energy to care about patients’ needs would gain it back if given the opportunity in my environment. My degree of emotional burn-out last year was, in large part, due to my refusal to stop caring. It’s sad when a system built to care for people squeezes compassion out of those whose job it is to give that care. The need for reform is more than just a financial one, it is a human, personal, and spiritual one.

Once we solve that problem, we can turn our thoughts to the harder questions, like whether dogs watch Oprah.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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