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

Wednesday, June 3, 2015

Simply difficult

“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.

OK. Unexpected.

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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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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