Wednesday, June 3, 2015
“I want to tell you my story now,” a patient recently told me, a woman who suffers from many physical and emotional ailments. She had the diagnosis of PTSD on her problem list, along with hospitalizations for “stress,” but I never asked beyond that.
“OK,” I answered, not knowing what to expect. ”Tell me your story.”
She paused for about 30 seconds, but I knew not to interrupt the silence. ”I killed my husband,” she finally said.
She went on to explain a horrible set of circumstances involving alcoholism and physical violence, that resulted in her shooting her husband in self-defense. She spent the 2 following years on trial for murder, eventually being cleared on all accounts. Despite this, the rifts in her family continue, and she (obviously) still relives this terrible moment.
Deep breath. How can I ever hold any emotional instability against this woman? Who wouldn't struggle? It brings me back to my oft-repeated mantra: Everyone has a backstory.
Not all backstories are so dramatic. One woman, who is very lovely and vibrant from first meeting, revealed that it had been 10 years since she was intimate with her husband. She does her best to hide the pain, but the toll of feeling unloved and rejected over 10 years has taken a heavy toll. In some ways, her skill at hiding the pain inside causes even more pain, as she faces the daily need to screw up happy emotions she doesn't have. In her own way, this pernicious pain of rejection has made her walk through life feeling distant from everyone. She smiles to everyone, but the pain doesn't leave.
How can I know what this is like?
But in a way, I do know, as backstories are not limited to the patient side of the equation. I know physicians and nurses dealing with empty marriages, the demons of addiction, rebellious children, and deaths of parents and children. As professional as I try to act, there is no way I cannot bring my own pain to my relationships with patients. Perhaps there's a mention of something by a patient that triggers memories, or perhaps the pain in my life drives me to seek emotional harvest from the praise I get from my patients.
As hard as we all try to do otherwise, our encounters between doctors and patient are human to human, frail to frail, broken to broken. We strive for objectivity, but are always looking up from our own valleys of circumstance.
So is this a bad thing? Is the ultimate ideal one of objectivity and clinical impassivity? Does it hurt me to feel deep compassion for those people in such pain? Does it hurt my patients to have me bring my own pain into the patient encounter? As always, the answer is probably “yes and no.”
Clinicians often don't know how to handle when patients don't act predictably. Noncompliance with medication, diet, or other advice often elicit complaints, frustration, and even dismissal from the practice. Just as my emotions toward that idiot who cuts me off on the street jump to the conclusion that the he is either mentally deficient or is out to get me, the doctor often assumes the noncompliant patient is either stupid, apathetic, lazy, or out to waste the doctor's time. I'd probably be less mad at the guy who cut me off if I knew that his wife had just died. In the same way, compassion gives slack to the rope when dealing with our patients.
The very word ”compassion” suggests feeling emotion alongside another person. It's not an emotionless understanding, but an acceptance that the person got the way they are for a reason. I can only truly understand that through the lens of my own pain. In this way, our bringing our own pain to the exam room can be a great asset.
Obviously, there is a limit to this. This is a job for which I am being paid. I must always strive to give the best care possible. My emotions, negative or positive, should not cloud my clinical judgment. Regardless of the severity of my bad day, I must try to hear what the patient is saying and try to understand it. This doesn't mean I always give in to their demands or to protect them from pain. Sometimes the confession of “I can't do anything more” hurts to say, but it is better than giving false hope. I believe that many of the worst over-prescribers of pain and anxiety medications do so because they hate for people to be mad at them, and so can't refuse people's inappropriate requests for these medications. This not only puts the patient at risk, it legally and professionally puts the physician's career in jeopardy.
But even when I rebuff requests for unnecessary treatments, testing, or inappropriate medications, I must be aware of the patient's emotional state. It sucks to have pain. It hurts to be anxious. Loneliness makes us look for escape. I find that, more than anything, people want understanding. People accept my answers much better when I show that I understand their pain, and hence their desire to get rid of it.
Which brings me to the most important issue: relationship. Our system has stripped care of its heart. We are judged by the codes and data we submit, not the care we give. We follow the recipe for treating a condition or avoiding certain meds, not paying attention to the huge underlying issues. We fragment care between providers, and have ripped away any opportunity to hear and be heard by requiring obtuse documentation and profuse data submission. So how can we ever expect good care to happen?
My patients listen to me because I listen to them. My patients believe me because I know them. I can tell the person they don't need more narcotics because they know I care about their pain (even if I can't do anything about it). This takes time. It can't be measured. It is not a computerized task; it is a human relationship.
That's what good care is: human to human, frail to frail, broken to broken. If my patients know I am human, they don't ask for me to be superhuman.
It's that simple.
It's that difficult.
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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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.
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