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

Wednesday, April 30, 2014

The grass is green

She looked at me, eyes pleading, telling me without needing to say a word: I am not lying to you. I am not crazy. I am not making this up.

I sighed. ”We’ve done the work-up and know this is not your heart. I don’t think there are a lot more tests that can be run.” I studied her expression, trying to discern what she wanted to hear from me.

I’ve come to understand that there are two questions my patients are looking for me to answer:
1. Is there anything serious?
2. Can you make me feel better?

Doctors don’t seem to know this list, instead either focusing on a third question What is wrong with me?, or failing to answer one of these two questions. I’ve heard countless tales of frustration over hours spent at the doctor’s office only to hear the final judgment of “nothing is wrong.” These doctors have answered question #1 without addressing #2, leaving the patient to feel like they aren’t believed by the doctor. In the best case, this is a well-minded doctor who simply doesn’t consider the patents’ perspective; in the worst case, the doctor questions the validity of the patient’s story.

Not knowing which question was weighing on my patient, I asked directly: “So, are you still concerned that this is a dangerous condition? I know it’s hard to have chest pain whenever you exercise and not be a little worried, but I think the risk of this being serious is pretty low.”

“It just hurts,” she told me flatly. ”I exercise through the pain, but it gets pretty bad at times.”

There. She clearly wanted question #2 answered. Yet I had already been trying different things to get rid of this pain, none of which were working. Part of me wanted to shrug and explain that I’d done all that I could do, sending her home only with the reassurance that she wasn’t going to die from it, it was just going to hurt and there was nothing I could do.

Attempting to remain disciplined in my approach, I thought through the list of possible causes: What lives in that zip code?
The heart does, but we’d pretty much ruled that out as the cause.
The lungs are there, but when does a person simply experience pain in the upper chest because of the lungs, especially without shortness of breath? I don’t think it’s that.
The esophagus takes a trip through that area, but again, what’s the chance of exertional esophageal pain? Not impossible, but quite unlikely. Besides, she’s already on Prilosec.
People with anxiety sometimes complain of chest pain, but it’s usually during emotional stress, not physical exercise.
That leaves only the chest wall as the best explanation, but I’d already gone after that with both systemic and topical medications with little improvement.

A small voice spoke out in the back of my consciousness: It makes no sense! She must not be telling the truth! Clearly I’ve done all I can do, and so there must not be an answer. There is nothing wrong with her really!

I hear that small voice whenever I am at a loss. The voice comes out of frustration at not being able to help patients, but mainly out of my own insecurity. I don’t want to fail. I want to be a superhero, swooping in with my cape to solve my patients’ problems and to make them all happy. I don’t want people to be disappointed in me. You don’t go into medicine without at least a small need for people to admire you. For me, that need is a 800-Lb gorilla. I want people to be proud, not disappointed. I want to look smart, not dumb.

Another part of this voice comes from the small group of people who want to use the doctor as a vending machine. They know if they say certain things and push the right buttons, the doc will give them what they want, whether it’s an antibiotic, a pain medication, or an order for a test. They hit me at a second insecurity: the fear of not being in control. It should come as no shock that most doctors have this insecurity. We hate being used or manipulated (do you hear that, payors?). I’ve concluded that, in my population at least, few of my patients are this way (and those who are, eventually leave disappointed).

Fortunately, I’ve learned to ignore that voice of my own insecurities.

Unfortunately, many docs out there haven’t been so successful, and some will actually openly question whether the patient is actually experiencing the symptoms they report. The skepticism with which patients are met as they tell their stories is most acute in the “quick fix” settings, like the ER or urgent care center, but it happens everywhere. Patients are on the defensive as they tell about their symptoms, trying to justify their visit to the doctor, and to “get the doctor to believe” what they are saying. It’s as if the patient is considered duplicitous until proven honest.

Here’s the problem I faced as I met with this patient: if I accepted her story as true, I had to accept my inability to help; but if I didn’t accept her story, I label her as a liar, someone who wastes my time, a cheat, or an incredibly mentally disturbed person. For what reason would she make this stuff up? I couldn’t come up with any. She was telling me her experience: that for her the pain goes like this, the medications I did helped like that. To her, the grass looks green. If I doubt her reality, I am essentially telling her that pain isn’t what she said, the medication didn’t have that action, and that the grass actually is blue, not green. I am telling her that her reality is not real.

Who am I to invalidate another person’s reality? I can question conclusions she draws, but not the reality itself. Our realities are all we’ve got, and we have to trust our own senses.

“I’m kind of stumped here,” I confessed to her, going through my list of possible causes. Together we discussed the possible options of diagnostic testing and treatment. While we talked, she continued showing a glimmer of fear in her eyes. It wasn’t that she thought she’d die from this, and I don’t even believe it was a fear that I couldn’t help her; it was a fear I would tell her the grass was not green. Maybe her reality isn’t real. Maybe she is crazy.

Doctor and patient. Insecurity meets insecurity. Weak helping weak.


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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Blog log

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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