\”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 two 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 ten 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 ten 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.
12 thoughts on “Simply Difficult”
Beautifully written, after 50 years in nursing, I too have seen the evolution of what the "system" has done and is continuing to do to the practice of medicine. Cudos to you Dr Lamberts for your humble and caring attitude, it’s becoming a rarity in medicine. God Bless you.
Great piece, Rob. With doctor burnout and dissatisfaction at record high levels, do you think that a grassroots uprising that is a partnership of clinicians and individual citizens (aka "patients") is possible? I don’t think one without the other would make a dent. Clinicians or regular citizens can’t do it on their own. Are there enough doctors who’d say "enough is enough" and demand something better? I’m not saying it would be easy…just whether it’s possible in your opinion. Curious your thoughts.
Good question, Dave. I do think that what physicians like me are doing is potentially quite subversive. We give such an attractive alternative to the rest of the system to both patients and providers that this could be the trickle before the torrent. We could be the tip of the spear that causes the system to come down. What it will take is a clear proof of concept and a roadmap for other docs to follow. After doing this for two years (with great thanks to you, I might add), I am more optimistic about the eventual success than ever. Still, it’s hard to predict the future (otherwise I’d be awash in money from buying stock in Apple, Google, and Microsoft). Time will tell.
I’d rather have the human doctor (you) that I have who is willing to admit they don’t know or there is nothing more than the one who acts like they are God and you should never question them. I’ve had those doctors. I can honestly say you are among a very few doctors I’ve had who are tops in your field. Why? Because you’re willing to admit your limits and be human. Medicine is personal and human. How can you really treat people if you’re not willing to listen? If you don’t listen, why should your patients. This piece is well written and right on point! Thank you so much for working with me!
I appreciate all the care and understanding you bring to us as your patients. Also the knowledge and the courage to say there’s nothing can be done. Not over medicating and giving us false hope that it will be cured but how to make these things not damage our quality of life…..probably drive you nuts with all our questions and concerns but I want you to know we feel blessed to have you, Jenn and Jamie in our life. It has made us realize there are doctors that really care. Thank the lord for you Dr Rob. You are a godsend to our troublesome life! All the best to you 🙂
Wow Rob! Exquisite. One question, why hasn’t direct practice exploded if this reality is so prevalent? Still a trickle. Will it ever consume a meaningful share or physician practices?
I would say that it needs to reach a critical mass for there to be enough awareness with both doctors and patients. People need to get used to the idea and see it as a viable alternative. I also think longevity of practice makes it more than just a flight of fancy or a fad. Me being around for 2 years makes it much easier to attract new patients. Additionally, docs need to have an easier road than I had to take, and many of us blazing the trail will hopefully make it easier to transition. I think it’s just a matter of time.
Exactly. You sound like someone practicing in my field… Chinese medicine… How refreshing to hear someone on your allopathic side having such human insight. I pray daily for this healing in our collective medical systems.
Many years ago, I lived in a very small town in southwestern Oklahoma. Doctors were pretty scarce around there. There were 3 doctors for about a 90 mile radius. I lived in the same neighborhood as two of them and I was best friends with the third’s wife. In that area, you either saw a doctor that you were friends with or you traveled a long way to go to the doctor. These were the people that I went to church with. But when both of my boys came down with epiglottis at the same time, they weren’t there to be my friend. The jumped in with full professional doctor mode and had my boys intubated and on a helicopter to Oklahoma City before I could catch my breath. The experience changed the "Doctor as demigod" attitude that I had been taught previously in my life. Since I have moved back to Atlanta, not all my doctors have appreciated my attitude. But when I had to deal with doctors on an almost daily basis, like when I had cancer the experience was a godsend. It has fostered an atmosphere of openness where I feel free to be bluntly honest with my doctors. " Actually, I’ve gained more than a bit of weight. This has been quite disturbing to me." type of honesty. But also when my doctor made a mistake that could have been serious, I was able to shrug my shoulders and say "maybe we shouldn’t try that again." Trust is a two way street. But you can’t build that kind of trust without an open relationship.
I loved your post Rob and have greatly appreciated the huge risks you’ve taken to follow what is so meaningful to you in the practice of medicine. I was a family doc too and one of the things I liked most was the privilege of being there to share and hear and support people with their most intimate, painful and difficult experiences. I ended up leaving medicine in part because I wanted more connection and time with people. After taking a year off to think about other options I ended up retraining as a psychotherapist. Being heard and listened to with care and compassion really does make a huge difference in people’s lives. I’ve focused on working with people with chronic illness and it’s been the great fit for me that combines my two backgrounds in health care. I’m so glad to hear how you are finding the way to make it happen while staying in the field!
Very insightful post here. I think you really hit the nail on the head here – there’s a lot to be said about the doctor who shows you they’re human and listen to you over the one who tries to stay out of it. Thanks for sharing your thoughts.
This should happen with all human interaction and not just with Drs. If we are learned to be more compassionate life would be so much better for everyone. This reminds me of an older lady who lived in the same apartment complex I lived in years ago. She was as salty as they come. most people would not even try to talk to her. But, many times i would see her out front, or getting mail and I would always smile and speak to her. She almost always ignored me and most times gave me a dirty look as well. After a while I pretty much gave up even trying to be nice to her and I began to ignore her like everyone else. Then one day I saw her in the commons room having a snack. I got myself a cup of coffee and sat down at the same table she was at. I spoke to her and she spoke back, for the first time ever. It took awhile but eventually I found out her back story. Her only child, a daughter, and all 3 of her grandchildren had burned up in a home fire many years ago. Just six months later she also lost her husband. So yes, everyone has a story that accounts for the person they become. society, as a whole, should just be more tolerant.