“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 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.
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We docs have to bring some testosterone back. First of all, we need to get together. Anti-trust can have nothing to say if we get together only for patients. The most important things to patients are our time and their bills. We should announce that we are not going to spend more than 15% of our time looking at computer screens. You managers have to figure out how to do this. Handle it. We should insist that patient insurance forms and hospital and provider paperwork be understandable to the average high school level student. Not our problem. Ypu managers handle it.
Good idea. You’re a smart dude.
Great post. Filled with empathy, compassion, listening … all the qualities we would hope for in our doctors. Unfortunately these skills are the first to go out the window when the doctor is over stressed and burned out. Even more tragic is the evidence that 30-50% of all doctors are suffering from burnout on any given office day.
I often see initiatives aimed at patient centered care and patient satisfaction simply stacking additional work responsibilities and demands on physicians who are hopelessly over loaded. The organization either has no awareness of the physicians stress and burnout levels or, worse yet, does not care. When the doc is unable to handle the additional tasks their “engagement” is questioned. Some are labeled disruptive and marginalized.
To reintroduce humanity into the patient relationships at the point of care … what is acutely needed is the creative destruction of burnout. If doctors have the bandwidth and some energy reserves they naturally are better listeners and can muster buckets of empathy. If we fail to notice their stress levels … and keep piling on mandates aimed at goosing your Press Ganey scores … it simply adds to the problem.
And everyone has a back story … if we are capable of listening.
Dike
Dike Drummond MD
http://www.thehappymd.com
It might not be a bad idea to give people the ability to write a personal history to help guide the interaction, something that plugs into the patient record somehow. Make the information completely confidential and explain why it’s helpful. A blog like interface that allowed people to post updates to their file might even work. People could list things that they might be unwilling to reveal in a one on one conversation, alcoholism, work-related problems, marriage, job related stress, military service, other things that may be relevant (weird hobbies, killed husbands, etc. etc) …
I tried to get backstories in my old practice and was increasingly overwhelmed with the time requirement for all the other nonsense, eventually becoming strongly tempted to spend each evening in exercises of escape using copious amounts of adult beverages.
I do refer these patients if I can. Many, however, don’t have the resources to go to pain specialists and many pain specialists are not good at peeling back the emotional status of patients. They tend to be very cynical about people and their motivations. The truth is, many docs out there inappropriately prescribe chronic pain meds for problems for which they are not indicated. Obviously, pain control is extremely important and should be taken extremely seriously, but having folks on chronic narcotics as the only treatment for chronic pain should be done far less frequently than it is done. Having a frank talk with people about this is very valuable. Obviously, you are an outlier on this, not the normal patient wanting regular pain/anxiety meds.
The point of the piece was that relationship between two human beings begats far better care than formulaic care between doctor and patient. I can’t imagine you’d disagree with that.
Exactly. Everybody has a backstory.
If you want to understand WHY your patient is acting in the ways they are, rejecting your advice, asking question after question, engaging in seemingly self-destructive behavior ..
People say there isn’t time to get to back story, I am not sure I agree with that … although I know it feels that way …
The good ones know the power of a few well asked questions ..
Started out well — then landed on your face! As a chronic pain victim I write w the authority of experience. Rather than cajoling your patients – why not refer them to someone who can actually help!?! & if it’s the laws preventing you from prescribing adequate meds – get together w your fellow frustrated medical professionals & fight the lawmakers. For the same reason that “doubt” keeps some guilty from prison, compassion should get you to prescribe more than you “think” is adequate — of course you stay on top of it – check back in a week or month & confirm either way – it helped or it didn’t. Different people respond differently. I have been treated by pain specialists who found a dose that allowd me some semblance of life – a “high” dose as it turns out according to the healthcare professionals (HP) I’ve seen since. The HP I’ve seen since my move have both refused to increase their dosing (1/3 what helped) & to obtain (or look at once I obtained) my records. 2.5 yrs, 8 different Docs – all inexcusably biased “humans”. Of course they all know better than I & are rigid in their determination to NOT “give me what I want”. WANT!?!?! The foundation of all their flawed assumptions. That so many can so completely delude themselves that they “know”. Here’s a new thing to know: the # of deaths of chronic pain sufferers will always be high – & a great many “accidental” ODs will have been brought on by the sad truth that life is, for many, not worth living — loopy is only marginally better than agony for some & not at all for others — but it should always be our choice not yours. You making our life harder in NO way makes it better. Listen to your pain patients – to their fears & concerns. Keep trying to help them find some relief. When you stop trying you have no right to judge them for whatever further decisions they make in their search to improve their condition.