Below the Surface

Stuff is always there under the surface – stuff you don\’t hear about.  Patients come to see you and talk about their medical problems, stressors, and their pain; but they often leave out big issues.

My partner encountered that recently when working up someone with elevated liver tests.  He did a thorough exam and a good history and had no good reason for these tests to be abnormal.  After the lab work came back without a clear reason, my partner decided upon a CT scan.  He called the patient to tell about the results and the planned test, and instead got his wife on the phone.

\”Has he ever told you about his drinking?\” she asked.

\”We talked about his habits, but he didn\’t tell me about anything excessive.\”

She paused and sighed, \”Well, he drinks fairly heavily at times.  He thinks we don\’t know about it, but ever since the economy started going bad and his business started struggling….\”

My partner listened as she went on to describe the obvious reason for the test abnormalities.  Wanting to get more direct information but not wanting to reveal the conversation with the wife, he called back when he could speak directly to the patient.  \”Is there anything else that could explain the test abnormalities?  Do you drink much?\” he asked him after explaining the further testing needed.

\”No.  I just drink a little bit from time to time.\” the patient answered, keeping his voice level and confident.

People do this a lot.  There is a lot under the surface that nobody knows about.  Most of the time it isn\’t directly relevant, but other times it is.  Yet either out of embarrassment or because they simply don\’t think it is relevant, they hide their lives.

It makes sense that people do this.  We have people saying \”how are you doing?\” to us all day long.  These people don\’t really want to know how we are doing; they just are being polite.  They wouldn\’t really appreciate it if we did share how we were doing.  So when the doctor says \”how are you doing?\” the first impulse is to answer in the normal way.  We don\’t want to burden others with our big problems.  We don\’t want someone to make a big deal out of things.  We don\’t share who we really are because it feels very uncomfortable to do so.

Doctors need to remember this.  There is always stuff that is not being told.  I have uncovered this when people came in for inexplicable reasons or with perplexingly vague symptoms.  Nobody comes to the office without reason.  If it seems that way, it should be a clue that there are bigger things under the surface.

We also need to remember this with the people around us.  We think we know our friends and family, but there is a whole lot we don\’t know.  If you doubt this, think about how much you keep hidden in your own life.  Think about what would happen if you were really transparent about things.

Sometimes it\’s much easier to keep things quiet.

Don\’t forget that.

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22 thoughts on “Below the Surface”

  1. Dr. Rob,
    As an adult child of a lifetime alcoholic, I am way too familiar with the denial, excuses and such. (That’s not to imply that your patient has a chronic problem with chemical abuse, but…)

    I watched my father completely self-destruct, but it took 30+ years to get there. To be fair, I’m sure that Viet Nam was no picnic, but he came home with the weight of the war on his shoulders. Substance abuse and PTSD, along with chronic depression and a side of alarming work ethic which alienated him from my mom and us kids. He was always working. Always. Many years later I realized it was a cover for his drinking. My dad didn’t go to bars and come home sloppy drunk. Instead, he drank in his “shop” where he ran two side businesses in addition to his full time job. See the good provider for his family, constantly working? He drinks beer because he likes beer. True drunks drink hard liquor and cheap wine. He wasn’t an abusive parent (though our Catholic school disagreed), he was simply keeping everyone in line. The school threatening to call Children’s Services was the motivation my mom needed to leave and divorce him.

    Fast forward about 10 years and dad crushed his heel when a ladder rung broke and he fell 12 feet – most likely drunk. The Orthos did everything they could, but the damage was beyond repair, so dad’s leg was amputated below the knee. It was at the point of his injury that pain meds were introduced to the mix. Pain meds + antidepressants + sleeping pills + alcohol. Oh goodie.

    You can paint the train wreck, can’t you? I could and I didn’t WANT to see it, it was too painful. The docs would put him in 3-day detox and he’d manage to get beer on his way home. At one point, he had a young man at the beer store delivering it to the house. He carried a sheet of paper listing all the Rx drugs he was taking. I spoke up and asked if the docs were communicating because some of it HAD to interact. I was shut down and told that he needed every one of those drugs while continuing to drink. The biggest part of the problem was that there WAS no communication. He sought treatment from private docs as well as the VA.

    My father died in 2004 from acute liver failure, in hospice with pallative care. He was 59. At least I can say that he finally slayed his biggest dragon – himself – and is at peace.

    As an aside, I was made sick to my stomach when the VA hospital “prescribed” a certain number of beers per day to offset detox while he was IN the detox unit. WTF? Clearly they had given him up for lost. I later learned that this isn’t unusal, nor is it considered controversial. His body simply couldn’t handle the stress of full detox.

  2. Dr. Rob,
    As an adult child of a lifetime alcoholic, I am way too familiar with the denial, excuses and such. (That’s not to imply that your patient has a chronic problem with chemical abuse, but…)

    I watched my father completely self-destruct, but it took 30+ years to get there. To be fair, I’m sure that Viet Nam was no picnic, but he came home with the weight of the war on his shoulders. Substance abuse and PTSD, along with chronic depression and a side of alarming work ethic which alienated him from my mom and us kids. He was always working. Always. Many years later I realized it was a cover for his drinking. My dad didn’t go to bars and come home sloppy drunk. Instead, he drank in his “shop” where he ran two side businesses in addition to his full time job. See the good provider for his family, constantly working? He drinks beer because he likes beer. True drunks drink hard liquor and cheap wine. He wasn’t an abusive parent (though our Catholic school disagreed), he was simply keeping everyone in line. The school threatening to call Children’s Services was the motivation my mom needed to leave and divorce him.

    Fast forward about 10 years and dad crushed his heel when a ladder rung broke and he fell 12 feet – most likely drunk. The Orthos did everything they could, but the damage was beyond repair, so dad’s leg was amputated below the knee. It was at the point of his injury that pain meds were introduced to the mix. Pain meds + antidepressants + sleeping pills + alcohol. Oh goodie.

    You can paint the train wreck, can’t you? I could and I didn’t WANT to see it, it was too painful. The docs would put him in 3-day detox and he’d manage to get beer on his way home. At one point, he had a young man at the beer store delivering it to the house. He carried a sheet of paper listing all the Rx drugs he was taking. I spoke up and asked if the docs were communicating because some of it HAD to interact. I was shut down and told that he needed every one of those drugs while continuing to drink. The biggest part of the problem was that there WAS no communication. He sought treatment from private docs as well as the VA.

    My father died in 2004 from acute liver failure, in hospice with pallative care. He was 59. At least I can say that he finally slayed his biggest dragon – himself – and is at peace.

    As an aside, I was made sick to my stomach when the VA hospital “prescribed” a certain number of beers per day to offset detox while he was IN the detox unit. WTF? Clearly they had given him up for lost. I later learned that this isn’t unusal, nor is it considered controversial. His body simply couldn’t handle the stress of full detox.

  3. “Sometimes it’s much easier to keep things quiet”, you said. Yes, indeed! I come to complete agreement with that based upon many experiences I’ve had as a patient over the years, and most of the time the thing I’m trying to leave out of the conversation isn’t something harmful like a history of drinking or drugs, a potentially problematic sexual history, or anything like that; it’s only a history that started just a few weeks after I was born and involves a now extraneous hydrocephalus shunt. I try to not mention it because it caused me some horrendous upheavals when the powers that be pulled one of those “we’re only doing this for your own good” sort of deals (when really it was all about a giant case of “CYA” on their part) and basically turned my life inside out, upside down, and every which way. I don’t, of course, blame the docs (who are still, 30-some years later, quite curious, no matter what specialty they practice), but sometimes leaving out a detail can save a ton of hassle, aggravation, and wasted time. So I can totally understand why people might do it, even to the detriment of their own health and well being.

  4. “Sometimes it’s much easier to keep things quiet”, you said. Yes, indeed! I come to complete agreement with that based upon many experiences I’ve had as a patient over the years, and most of the time the thing I’m trying to leave out of the conversation isn’t something harmful like a history of drinking or drugs, a potentially problematic sexual history, or anything like that; it’s only a history that started just a few weeks after I was born and involves a now extraneous hydrocephalus shunt. I try to not mention it because it caused me some horrendous upheavals when the powers that be pulled one of those “we’re only doing this for your own good” sort of deals (when really it was all about a giant case of “CYA” on their part) and basically turned my life inside out, upside down, and every which way. I don’t, of course, blame the docs (who are still, 30-some years later, quite curious, no matter what specialty they practice), but sometimes leaving out a detail can save a ton of hassle, aggravation, and wasted time. So I can totally understand why people might do it, even to the detriment of their own health and well being.

  5. The lesson from your hard story is that keeping things to ourselves comes with a cost. Your father paid his own price and made you pay it as well. We can tell ourselves that it is “our problem” but we don’t live in isolation.
    Thanks for sharing that.

  6. The lesson from your hard story is that keeping things to ourselves comes with a cost. Your father paid his own price and made you pay it as well. We can tell ourselves that it is “our problem” but we don’t live in isolation.
    Thanks for sharing that.

  7. I think that knowing where to draw the line with openness is one of the hardest choices. Being too open can hurt people and cause trouble (as Medrecgal states clearly) but being to private can also hurt people and cause trouble (as Shell illustrates). The bottom line is that we are not dealing with predictable things. There is a Heisenberg Uncertainty Principle for dealing with people. Our interaction is not objective and without its own effect.
    Again, I think we are far too quick to judge others for doing what we do all the time.

  8. I think that knowing where to draw the line with openness is one of the hardest choices. Being too open can hurt people and cause trouble (as Medrecgal states clearly) but being to private can also hurt people and cause trouble (as Shell illustrates). The bottom line is that we are not dealing with predictable things. There is a Heisenberg Uncertainty Principle for dealing with people. Our interaction is not objective and without its own effect.
    Again, I think we are far too quick to judge others for doing what we do all the time.

  9. Years ago, I was visiting a patient in the hospital as he was unconscious and dying, and his wife said it was probably all his drinking that was doing him in. I was surprised, and I told her that when I asked him how much he drank, he consistently admitted to drinking only one glass of scotch a day. She laughed and said: “One glass? Sure, he had one glass, but he kept drinking some and then refilling it again and again throughout the evening!” Since he only got to the bottom one time at the end of the evening, he would total his drinking for the day as “one glass.” And this was a patient that I had a good rapport with. That is when I knew it was hopeless to expect many of my patients to be truly honest about their drinking. In order to be honest with us, they have to be honest with themselves first.

  10. Years ago, I was visiting a patient in the hospital as he was unconscious and dying, and his wife said it was probably all his drinking that was doing him in. I was surprised, and I told her that when I asked him how much he drank, he consistently admitted to drinking only one glass of scotch a day. She laughed and said: “One glass? Sure, he had one glass, but he kept drinking some and then refilling it again and again throughout the evening!” Since he only got to the bottom one time at the end of the evening, he would total his drinking for the day as “one glass.” And this was a patient that I had a good rapport with. That is when I knew it was hopeless to expect many of my patients to be truly honest about their drinking. In order to be honest with us, they have to be honest with themselves first.

  11. I think that Dr House is right: “Everybody lies”. Mostly, we lie to ourselves via denial and then it seems to us that we’re telling the world the truth. Extremely few people are exempt from this pattern. Sometimes it makes for great stories, but mostly for a lot of pain that gets shared in an inequitable manner. Good post- a lot to think about.

  12. I think that Dr House is right: “Everybody lies”. Mostly, we lie to ourselves via denial and then it seems to us that we’re telling the world the truth. Extremely few people are exempt from this pattern. Sometimes it makes for great stories, but mostly for a lot of pain that gets shared in an inequitable manner. Good post- a lot to think about.

  13. This makes me wonder – when I was a patient with elevated amylase and was asked by both my GP and the Gastroenterologist how much I drink, did they think I was lying when I said I don’t drink much – maybe only one or two per month? Sorry, but that’s the honest answer. Hopefully doctors don’t believe that all answers are lies.

  14. This makes me wonder – when I was a patient with elevated amylase and was asked by both my GP and the Gastroenterologist how much I drink, did they think I was lying when I said I don’t drink much – maybe only one or two per month? Sorry, but that’s the honest answer. Hopefully doctors don’t believe that all answers are lies.

  15. No, most of the time we trust our patients in this regard. It’s just that we don’t always see the truth and that makes a hard job even harder.

  16. No, most of the time we trust our patients in this regard. It’s just that we don’t always see the truth and that makes a hard job even harder.

  17. Patients often hide domestic violence for the usual reasons, and don’t disclose histories of childhood sexual abuse or of sexual assault easily to anyone. Numerous studies have demonstrated that childhood sexual abuse and later sexual assault have long-term affects on physical health (for instance, see the ACE study funded by the CDC). Physicians who directly ask, or use screening questions on a form, have more success getting this information from a patient.

  18. Patients often hide domestic violence for the usual reasons, and don’t disclose histories of childhood sexual abuse or of sexual assault easily to anyone. Numerous studies have demonstrated that childhood sexual abuse and later sexual assault have long-term affects on physical health (for instance, see the ACE study funded by the CDC). Physicians who directly ask, or use screening questions on a form, have more success getting this information from a patient.

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