“They haven’t found what’s wrong with me yet.”
“Well, that’s what I’m telling you, Y. These doctors don’t know what they’re doing.”
Catching the end of the conversation as I entered the hospital room, I took in a deep stabilizing breath.
This was not going to go well.
Punctuating the air with air quotes, Y greeted me.
“Well hello, Dr. M. Did the cardiologist tell you his ‘good news’?”
“They can’t find anything on the heart cath to explain my chest pain. 2 days in the hospital and nobody can tell me what the problem is and how they’re going to fix it!”
“Are you still having chest pain, Y?”
“Well, no, but I still want to know what it was! The cardiologist said it wasn’t my heart and left.”
Great. And left me this mess to clean up.
I looked up at the 7 pairs of hostile eyes staring me down in this shrinking patient room. How was it possible to contain this much tension in such a confined space? Looking beyond them through the window, I could see the cherry blossoms blooming outside, gently swaying with the breeze.
5 more hours, M. You just need to make it 5 more hours, then you can walk out of the hospital and not come back to this glorified prison for another 6 days. Spring will still be waiting for you.
“So what are YOU going to do now?”
“Y, from my standpoint, I think it’s great news that your heart cath didn’t show any heart blockages that needed intervening. You’ve already had a quadruple bypass and needed stents in those bypass grafts last year. These cath results tell me the meds you’re on are helping to prevent any new blockages from happening.”
“No, they’re not doing jack shit! And you know why? Because I haven’t been taking them. The lipitor the so-called doctor put me on made my joints hurt and raised my blood sugars, so I stopped that poison on my own. And metformin keeps giving me the runs, so I had to stop that too. You’re supposed to be helping me, but all you do is keep putting me on things that make me worse!”
6 heads nodding in my peripheral vision distracted my attention to the table at the other side of the room.
Is that a cheesecake? And 2 bags of Doritos?? And a 6 pack of Coke??? Did I walk into a “Yay, you’re not dying!” party with celebration food or is this her every day diet? Or maybe they just wanted to display the starter pack to her next stent failure.
“You know, my wife has been through a lot in the last year. And every time we get the same run around from her doctors and we’re sick of it. We are paying you to help her, and she only gets worse and worse! You’re just wasting our time here.
So we ask you again, WHAT ARE YOU GOING TO DO ABOUT THIS?!”
Y’s husband’s bulging eyes held mine as his voice crescendoed into a passionate outburst. Daring me to look away and crumble into an apology.
This is what they were gearing up for, yes? How long had they sat in that hospital room, collecting lifetimes of frustration against the medical system for this ultimate moment in which they could finally confront the big bad doctor and make him/her feel as horrible as they did? It didn’t matter that this was only the 2nd time I had met them – I was here in my long white coat and as such, I was going to pay for all of medicine’s transgressions.
How many times had I already been in this situation in my short medical career? Enough to have my scripts ready to recite from memory:
“Yes, this last year must have been very difficult for you. Reading through your chart, I can see why of course you’re frustrated with how things have gone.”
“I’m sorry you’ve had so much difficulty with your medications. You’re right, it makes it very hard to trust your doctors if we’re giving you things that make you miserable. If I can ask for your trust again, we can work together to get you on something that works for you.”
“Thank you for sharing your frustration with me. It helps me understand where you’re coming from. What things need to happen so we can move forward with working together in the future?”
Searching through my rehearsed responses as I held his gaze, a cloak of utter exhaustion suddenly fell upon me.
How many times are you going to play this game, M? You know how this is going to end.
You diffuse the situation with one of your scripts, flash a smile and absolve the patient of all of their responsibility to take care of their own damn selves.
You don’t mention that medications can only do so much against a lifetime of shitty choices. You don’t mention that gaining 20 pounds in 6 months is probably the thing that’s causing Y’s joint pain and high blood sugars, not the medications her “so-called” doctor put her on. You don’t mention that she’s sabotaging her own life and refuses to take ownership, instead shifting the blame on doctors.
On you.
And yet again you become the warehouse of guilt others refuse to bear.
Returning to the room, I could sense the tension being replaced by anxiety. My silence certainly wasn’t the response they were expecting. Was I going to play this game or not??
We could move forward and argue about who’s more right, escalating until we’re all satisfied the other parties are idiots, secure in our initial presumptions.
Or, I could diffuse the situation and leave everyone in a more comfortable place – inertia. We could just keep doing what we’re doing, but at least they’d all feel better about it.
Stretching out the silence just a while longer, I searched for the compassion I used to have in spades to give me strength, but came up empty.
Where had it gone? Logically I understood they were coming from a place of fear, vulnerability and a sense of powerlessness. But this wasn’t enough to turn them from just another item on my to do list to wanting to connect to their humanity.
This is why you have scripts, M. Do you really think this one conversation in time is going to change up their entire lifestyle and start making healthier choices? How many second chances has she turned down – if she didn’t make changes after her first stents, heart surgery and 2nd round of stents, what makes you so arrogant to think you’re going to make a difference?
Do you really think it even matters anymore? She’s probably got what, 5 more years in the trajectory of her life, if that? Let her have her damn cheesecake.
Cross out your to do list and go home. Survive so you can come back to “save lives” another day.
Imagining the sound of leaves rustling with the floral spring breeze, I set aside the sense of futility washing over me in preparation for what came next.
Let’s get this show on the road.
“Thank you for sharing your frustration with me…”
30 minutes down, 4 hrs and 30 minutes left to go.
***
Photo taken of the sun rising over a New Zealand mountain range.
To be honest, I’m amazed at the number of people I have admitted for chest pain, kept overnight, drawn blood x 3, gotten a stress test and then offered no explanation whatsoever for why they are having chest pain. Then they leave without questions.
But conversations like yours happen all the time. This is one of my big frustrations with medicine. You apply to medical school thinking you will be armed with this knowledge to help people and solve problems. When in reality there isn’t much you can do. I probably started to really realize this toward the end of residency. Residency was really a time to perfect your “scripts” for why you are doing nothing or can’t explain the cause of symptoms. Patients don’t want to hear about how the real answer is prevention, quitting smoking, losing weight, or doing something that requires significant effort and lifestyle change on their part.
This post reminds me of an old quote of why Michael Crichton (writer of Jurassic Park) left medicine.
“Reflecting on his career in medicine years later, Crichton concluded that patients too often shunned responsibility for their own health, relying on doctors as miracle workers rather than advisors.”
https://en.wikipedia.org/wiki/Michael_Crichton
4 years after graduating from residency and now working in the hospital where essentially all I see is the accumulation of poor lifestyle choices, patient after patient, the realization that I’m only practicing futility medicine has hit me hard.
But, this is what we worked so hard to get to.
To bear the responsibility of other people’s actions/inactions.
I often wonder if I would’ve made the same choices if it had been laid out for me in this way or if I would have been too bullheaded to listen.
The other day I must have accidentally ordered sliding scale on a non-diabetic and the nurse called saying the patient is wondering why we are doing fingersticks.
I must have thought it was not possible to be admitted to the hospital and NOT have type 2 DM
Ugh! I wish that they could read the thought bubble, instead of listening to the glib scripted performance. I was rooting for you to really let them have it. Maybe next time? 👺
And thanks for the mention in the intro. 😍
M, I think you are the next Michael Crichton! Your writing just so perfectly captures the everyday frustration. I too was on the edge of my seat to see if you would “snap” and have a Dr. House moment (god, love watching him tell patients what he’s really thinking, such a great fantasy!)
Today a patient was borderline enraged with me when I told her she was GBS positive (after reassuring her that 20% of pregnant patients are, and that it was easily treated). She looked at me like I had snuck into her house and secretly inserted an infected Petri dish in her vagina. And so, I went over the “script” again, while I internally self congratulated on my decision to give up now even office OB as of Jan (solely gyne and IUC clinic now). 😊🎉
Hope you are in the midst of your days off and enjoying spring!
-Kristina
People are so interesting. I used to tell myself that I was just “educating” my patients when I’d diffuse situations like that, but even that euphemism doesn’t give me much traction anymore. Not sure what my decision is going to be, but I am considering giving up internal medicine entirely and just seeing kids. Or maybe giving up medicine in general. We shall see!
Nothing prepares you for reality.
The witty Corey Slovis, program director in EM at Vanderbilt, once wrote about how exactly none of his board exams offered the answer, “I’m not sure what this is, but I’m going to prescribe some pain pills for a couple of days and see if it gets better,” despite this being the management decision in 80% of his cases.
My cardiology fun story when I was senior resident running the CCU: scion of a beloved deli in LA came in for a STEMI, had someone bringing him pastrami sandwiches from the restaurant during his recovery after getting stented because he couldn’t stand hospital food. I stopped trying to make my case after he sent sandwiches to feed the entire night shift out of gratitude.
For some battles, you simply don’t deploy troops.
Fondly,
CD
“For some battles, you simply don’t deploy troops.”
Haha.. that sounds like a great long term strategy, but I hate to think of this career as a long term war I’ll be battling until I finally retire as general. It does feel that way at times though.
The script that comes to mind would be something like what you observed. “I understand that you’re afraid and that may be why you are angry and are demanding quick solutions and answers as to why these things are happening to you. I wonder if you have worked closely with your primary care doctor to let him know that the medications he offered you were having side effects and that you discontinued them. That way you could have worked together to find the best choices that you can live with. As I am only the hospitalist caring for you in this brief encounter, it is very difficult for me to solve the riddle of a lifetime of poor health choices that you may have made. Even if you have family risk factors for these types of diseases, the right choices that you make with food and fitness can promise you a longer and better quality of life. From what I can see laid here before you at this table, I can only take a guess at the food choices that have contributed to your heart problems and it would not make sense for you to continue demanding quick cures and magic pills until you have corrected these poor choices that you are still making. I hope this might be a day to consider that just maybe you are the central cause and solution to your own health problems, and maybe you can motivate yourself to discover better choices. Thank you for sharing your fears and concerns with me and I really wish you do make changes for a longer prosperous life ahead of you.” Yeah, something like that and think it up on the fly. People always want to kill the messenger but it is our duty to help them clear the haze and empower them to correct their own mistakes, whether they like it or not. This would be the seed and it is is up to them to lay fertile ground for that seed to propagate and bear fruit. Our job is to toss the seeds of hope and possibility that help them clarify their choices. Stay hopeful don’t let negativity kill your spirit just touch luces and spread good seeds and move on rinse and repeat.
Typo ..just touch lives and spread good seeds.. Doctor’s are mostly just teachers, the body heals what the mind believes is possible. We toss good intentions at it and let time do the rest.
I wonder if we did a poll between doctors vs the general public what the percentages would be in agreement with the statement: “Doctors are mostly just teachers.”
I agree with this, but based on my interactions with patients in the hospital, they think we’re miracle workers and can clean up 40 years of bad habits in a single hospitalization. Perhaps if this mentality changed we could actually move forward to helping them help themselves.
Rough, walking into that kind of environment when all you want to do is help is terrible. It feels awful.
How many of those types of encounters does it take to sour a perfectly good type of job?
How do we combat our negativity bias and make it easier to see the good we do rather than let the bad encounters take center stage?
(I have no idea)
You and me both.
I’d say it took about 4 years for me to get to the point where I’m almost done with this. And that’s not a long time at all.
It’s stories like this that make me glad I’m a radiologist. It is much nicer to be in my own little dark confines and be able to do the majority of my work without much outside intervention.
I’m still searching for a little place in the hospital where I can hole up and work without being interrupted about a thousand times. But then I realize my pager will still continue to beep, so that effort is largely futile.
M,
I know that conversation all too well. In the end, I use the scripts all the time. It becomes this mental game for me to see if I can diffuse people and redirect their attention. I feel like a mental Jedi sometimes.
I try to start hospitalizations explaining that people are in the hospital to make sure it ISN’T CAD, PE, PNA, etc. Not that we are going to find a miraculous answer. A frustrating thing about shift work is that you are often starting in the middle of someone else’s work, so they might not have managed expectations well.
In the end, if a person’s narrative is that doctors and medicines make them sick, you are stuck with it. Argue with their narrative invalidates their whole experience and they will decide you are part of the problem. You can only redirect the anger and punt to the primary.
The system is broken. The system doesn’t want engaged proactive patients, it wants inert bodies to do procedures to. When people ask questions, the assembly line slows down and makes less money.
It also isn’t fair to blame people for all of their choices(thought in general people should take more responsibility for them). Society is set up to encourage working class and poor people to make shitty choices.
This is why shift work has exploded. We break the care of a human being down into smaller and smaller pieces because people have to high of expectations and the system won’t empower us or them to do the things that actually need being done.
Agree with all of this, so much so that I can’t even think of anything to add.
I think I know the problem. You don’t believe your scripts. They could also come across as condescending.
I think a far more powerful script might have been : “ouch, that sucks.” … “Yeah he explained nothing to me so what are YOU gonna do about it??” … “Nothing…” And then tell the truth to whatever comes up next.
I think there is an unspoken dynamic where the doctor is above the patient and knows everything. If you don’t know, then you don’t know. If you feel powerless to help, then you are powerless to help. I have had resounding success with this method. I plan on patenting either “Truth Therapy” or “Empathy without Bullshit”.
In this situation, I don’t think that tactic would’ve gone over well. I’m all for telling people things straight, but only if they are in a place where they can handle it. For people who are itching for a fight, giving it to them is an even surer way to ruin everyone’s day.
Disease has a natural history and a prognosis. Chronic disease has a long history and typically a prognosis leading to more not less chaos. Implicit in your narrative is the notion by you and your patient, you possess some power to heal. You possess no such power. The disease process owns that power. All you possess is some uncertain knowledge making a given choice will impeded or promote the impending relentless chaos. You live in a place where death by Dorrito is allowed. You live in a place of rampant metabolic syndrome. You live in a place where metabolic disease is purposely mis-catagorized. You live in a place of “experts” each hawking his own cure each cure diametrically opposed. Go down to the B&N and see 100 books published this month hawking the latest cure.
Metabolic syndrome is a constellation of subservient diseases. It is best characterized by insulin resistance and that is the lynch pin of the chaos. incorrectly cycling insulin production is constantly signaling anabolism, inflammation and hypertrophy due to the steady state consumption of Dorritos. You were taught to make the wrong moves. If insulin resistance is the issue and your pancreas peters out because its ball to the wall pumping out every molecule in can make 24/7 stimulated by Dorritos 24/7, you oblige the dorrotio by giving exogenous insulin exacerbating the hyperinsulinemmia and anabolism and inflammation. Inflammation shows up as kidney disease, CAD etc Hypertrophy shows up as HTN, muscle wall thickening. In addition the insulin CAUSES the accumulation of fat especially centripetal and internally around organs for that is what insulin does, turns glucose into fat storage.
The body also has glucagon. In the absence of insulin hyperproduction, Glucagon is catabolic and catabolism is just what is needed. The phrase “loose weight” is catabolism in action. You promote catabolism by eating moderate protein and fat. Protein has some small insulin spike but in the face no carbohydrate stimulation insulin resistance reverts to normal. Calories are provided by fat. Fat metabolism under glucagon provides all the acetyl groups needed to power the mitochondria. Fat metabolism under the catabolic glucagon signal also promotes gluconeogensis in the liver more than enough self generated glucose to live. 2 sources of neogenesis, the glycerol backbone of fat and some amino acids like glycine and serine.
People are their specific expression of their phenotypes. All of the sub expression of metabolic disease (obesity CAD HTN Renal PVD) depends on the specific phenotype which accounts for the variability in the expression of the “diseases” of metabolic syndrome. The cardiologist was right, it wasn’t her heart. It IS her insulin resistance manifest this day in her particular phenotypic manner. There is treatment but its mention will horrify you. It’s the elimination of all carbs from the diet and allowing the body to migrate to a ketgenic or acetyl basis for its energy of moderate protein and fat consumption. In a catabolic state the body over time reverts to normal cycling of insulin/glucagon. And some balance will be restored, weight will be lost, edema will be lost, the excesses of insulin induced hypertrophy (HTN for example) will be lost and eventually many of the drugs you use to treat that will be lost. Pump function not permanently destroyed will be restored. This suggestion will kick off a fire storm of controversy since diet is the MOST political of all decisions and everybody considers themselves experts. That doesn’t matter to me. What matters is a systematic understanding of a very complex problem and then once understood doing what is necessary to stand against the advancing chaos. There is plenty to learn and plenty to know. A lot of it sounds quacky but clearly what we are doing is not working.
This situation reminds me of a quote that author Danielle Steel keeps on her desk:
“There are no miracles. There is only discipline.”
For Steel, of course, this refers to the writing process (and, apparently, it does the trick, as she is prolific).
But I think it could also apply to the recalcitrant patient you described.
She and her husband want miracles; they fail to recognize, or choose to deny, that health requires discipline.
Much like everything, people want things to be easy. To not have to expend any effort on their part. That’s the beautiful thing about miracles – they just happen serendipitously.
With that being said, the struggle sucks.. haha. Those who go through it only do so because we believe the payoff will be there. Perhaps for these people the long term payoff wasn’t worth putting off the short term gratification. Maybe it wasn’t even something they had considered.
I am not a Doctor but I have been a patient and I would prefer the Dr to give it to me straight rather than some BS script. I am someone who does everything in my power to be healthy. Good diet, exercise 6 days a week, no smoking, no drinking, no drugs. So when I am sick I go to the Dr for help, not a script.