The Intimacy Gap

I used to think that there was a communication gulf between doctors and patients.  Somewhere in the hub-bub of of the harried office visit some secret sauce was missing.  A divide that was so fundamental that both parties often left the room feeling disjointed and uneasy.  Patients wondered if doctors truly heard them.  Physicians wondered if any one was listening to what they were saying.  The tension ebbed and flowed but never disappeared.  This has been the state of health care over the last decade.  This has been the environment in which I have built my clinical career.

I now believe that the term "communication" is imperfect and lacks the specificity that I am looking for.  I think what we truly have is an intimacy gap.  What separates doctors and patients is a disjointed and unnatural version of intimacy that in no way mirrors the important bonds that we form in real life non-medical relationships.

Let me explain.

A patient walks into the exam room and unloads the most intimate, embarrassing, and frightening secrets to their doctor.  Unlike close friends or loved ones, the physician has in no way earned this privilege.  They had not gained this right through hours of conversation, years of support, or acts of selflessness.  There is no shared struggle or trust.  It is given too freely.

The doctor listens patiently and kindheartedly.  But the interaction can only be so rewarding.  There is no mutual disclosure of secrets.  No bidirectional sharing of intimacy.  The physician remains stone faced, objectively detached.  This is what we learned in training.

The practitioner, conversely, is bombarded day in and day out with urgent and emergent situations.  There often is no normal period to engage and form stronger bonds.  They are shuttled from exam room to exam room trying to put out fires without any of the nicety of experiencing their patients during non turbulent times.

When disaster hits, physicians become immersed in someone else's pain and tragedy.  But when they die, or get better, or move away, we are plucked out of their lives and rarely are present for any sense of closure.  By then we have moved on to the next case, the next emergency.

Disjointed, unnatural intimacy.

I don't know how to solve this problem.

For my part, I have decided the only solution is to strive for mutual disclosure.  Maybe we, as physicians, can tell our stories.

We can tell our stories to those we care for,

so that they may also care for us.


My Book: I Am Your Doctor And This Is My Humble Opinion

 

Behind Every Doctor Is A Patient

Behind every doctor is a little boy or girl who once watched helplessly. Maybe it was her father or grandfather who suffered under the weight of a disease that was deemed all but incurable. Perhaps her own skin was battered and bruised by the repeated trauma of an unrelenting tourniquet.  She swore that when (if) she got older she would protect the innocent from such things.  Her vow was the light that guided her through arduous years of study and apprenticeship.  Her promise was etched into the depths of her psyche like those two dangling letters she worked so hard to get placed uncomfortably after her name on her hospital ID.

Behind every doctor is a medical student or resident.  A young man at first, his innocence was the first casualty of a mostly unexpected war.  At some point that boy saw something, felt something, that was far beyond his repertoire.  The shattered remnants were collected and placed back together into a facsimile of what had been before.  But the sum of the parts never quite amounted to the whole.  Those who looked closely enough could see how porous his nature had become.

Behind every doctor is just a person.  Haunted by the weight of her decisions. Baffled by the foibles of our legal system.  And asked to trade in his most sacred skills for a degree in data entry.  She is tired at the end of the day because she was on call the night before.  He is a husband, father, or son and languishes under the weight of such responsibilities as would be expected.

Behind every doctor is a patient.  Who suffers from time to time just as you do.  Who has good and bad days similar to yours.   Who may be a son of a bitch one visit, and a prince the next.  Don't let the artificial barriers of rank and title confuse you.  Don't let the complicated jargon and technological blockade distract you.

There is so much more in common than could ever pull us apart.

The only difference is that we have always had the privilege of hearing your most pressing stories.

Maybe it's time for you to hear ours.

I'll start by telling you mine.

I Am Your Doctor And This Is My Humble Opinion.

What's Happening To Health Care, A Damn Shame?

I understand that there is a difference between perception and reality.  I also get that the kind of people one meets on a tropical vacation in the middle of March are of a certain economic and sociopolitical status.

Nonetheless, I am amazed at how history seems to repeat itself.  Year after year, while sitting in the shade and relaxing by the pool, I strike up a conversation with the vacationers sitting on either side of me.  The conversation starts innocently enough.  We talk of the details of our trips and about the kids.  More times than not, they are from Canada.  We bristle at the cold we left behind, and lament that these trips can only last so long.

Maybe we talk of politics or economics.  Eventually, however, they ask what I do for a living.  After a knowing glance, the litany of questions begins.  They inquire about my speciality, and other assorted details of my day to day life.  We chat for awhile before I get embarrassed at all the attention, and try to steer the conversation in a different direction.

But here's the kicker.  Just when I am about to successfully move to another subject, they go out of their way to stop me and say how great the American medical system is.  They declare Canadian health care to be horrible.  They deplore the hospitals.  They claim that getting into the doctors office takes months for routine visits, and weeks for emergencies.

And they all have these stories.  I can't tell you how many harrowing recollections I have heard of racing some child, parent, or loved one over the border to the US when they couldn't receive adequate care at home.  Upon crossing country lines, they checked into the nearest hospital mecca, and were lavished with top ranked medical care that literally solved all their problems.

I was as incredulous as you the first time I heard this kind of story.  By now, three or four times later, I can almost say the words before they are uttered out of my new friend's mouth.   Is there some hyperbole?  Probably.

The fact remains, though, that a healthy part of the population is unhappy with the care they are receiving.  In fact, many of them are paying extra concierge like fees for services that are expected as bare minimum in the United States.

When I tell these Canadians that the political winds are changing and that the goal is for our system to eventually be a lot more like theirs, they shake their heads.

It's a shame they say.

A damn shame.  



Now available on Amazon, I Am Your Doctor And This Is My Humble Opinion.

Does Medicare Allow For Agility and Innovation?

The call came around 10 pm on Saturday night. Helen was concerned by her mother’s cough and lethargy. I checked my schedule, and we agreed to meet at the house first thing in the morning. 

I awoke before the sun rose. My car rustled through the half-melted snow as I sped down the freeway. Thirty minutes later, I pulled up to the small bungalow at the end of the street. Helen and her husband greeted me at the door. The look of concern was apparent on both their faces.

We chatted for a few minutes before I went to the bedroom to do my exam. Helen felt her mother was generally doing well at home by herself, but the last few days had been rough. She caught a cough from one of the grandchildren and was slow to recover.  

I knelt at the bedside and examined my patient. She was alert and coherent.  There was a deep rattling sound coming from her left lower lung. Her mucous membranes were moist, but she was weak and resistant to getting out of bed. 

She had pneumonia.

See the rest of my post at The Medical Bag.

The Wise Man, His Son, and the Camel

There is an ancient parable about a wise man who travels with is son and a camel through the desert on a long journey.  Being wise and kind, he estimates the sweltering heat will take a toll on his steadfast animal and so decides to unburden the beast for a short period.

My daughter is screaming.  She has planted herself on the ground in the middle of a shopping center, and dug her heals in.  She will not move.  After a day of disappointments she has reached her breaking point.  Overwhelmed by the helplessness of being a seven year old, she has decided to take control over the only thing she has left: her body.

My wife and I approach the situation cautiously.  Although our blood is starting to boil, we recognize a pattern of behavior that signals fatigue and probably hunger.  Our compassion is blunted by a repeated pattern that both of us know needs to be broken.  Even if her behavior has an explanation, at some point maladaptive actions need to be redirected into more mature coping skills.

People are starting to stare.

As with any journey of consequence, the wise man and his son encounter fellow travelers from time to time.   The first is a set of merchants, leading a caravan of pack animals lugging their wears from one port of commerce to the next.  They are men of few words but distinct opinions.  They shake their heads at the site of the two humans walking side by side with the camel unhindered by cargo.

"Such a hot day and these fools choose to walk instead of mount their animal"

We sit quietly next to our daughter and whisper calmly into her ears.  Our assuaging words are not having the desired effect.  She disagrees vociferously.  An older couple walking past looks down at us with disgust.  They don't speak, but their eyes say volumes.  They think it is unconscionable that we let our daughter treat us in this way.  In their day, a child only spoke when spoken to.  Adults these days have become so indulgent and have lost control.

My wife and I are all too aware of their opinions.  We feel the disapproval pitter-patter onto our backs like the first drops of what will become a torrential rain.  We try to tune the world out and redirect our attention to our daughter.

The wise man feeling the sting of disapproval  turns to his son and offers him a boost up onto the camel.  His son, already tired from the arduous journey, takes the reigns happily. 

Until they come upon a traveling gaggle of performers.  They are making the journey from one kingdom to the next to perform for some important prince or another.  They are clowns and acrobats, actors and comedians.  

Upon noticing the wise man accompanying his son perched atop the camel they shake their heads disapprovingly.  

"What of respect for one's elders?  The old man wears out his tired legs as his majesty, the spoiled child rides in luxury."

My anger is staring to grow.  We decide to change approaches.  We demand that my daughter get up immediately using our most stern and forceful voices.  She looks up at us and her crying gets even louder. She now is completely unhinged.

A small crowd has started to gather adjacent to one of the store fronts.  We can hear their whispers.  A  growing chorus of voices using distinct words but in hushed tones.  They feel bad for the poor child who is being harangued by her parents.  She needs patience and understanding, not anger.

Again embarrassed by the attention, the wise man switches places with his son and continues the monotonous expedition.  It is many more days before they encounter a group of smugglers brandishing weapons and overfilled casks of wine.

The smugglers appraise the wise man and his son and quickly realize that there is little to plunder or pillage.  They laugh as they pass at the ancient one.  Frail and old, he must rely on his poor son to lead him around on a camel.  

"Old man, old man, one step from the grave, use those wobbly knees while you still can!" they croon as they race by on their trusted steeds.

My wife finally gives up on negotiations and picks up my screaming daughter, and we walk quickly towards the exit.  Young and old see my daughters tears and make sweet comforting faces and wave in her direction.

The wise man jumps off the camel.  He stands beneath the animal, and with a great groan heaves it onto his shoulders.  And they finish their journey in this manner.  

They still encounter other people on the road, from time to time, who have a plethora of opinions.  

But now the passersby are too stunned to open their mouths.

The Wolves Are Licking Their Lips

There is much sacred in the hallowed halls of medicine. As any other secret society, this fraternal order of health care professionals has its own language, costumes, and humor. The pathway from pre-medical student, medical student, resident, and finally to attending is heavily marked with ritual and ever-expanding responsibilities. The world opens and unfolds before the eyes of the novice.

There is no more enduring symbol of membership in this group than the modern-day hospital. For those who don’t belong, only fear and wonder lie behind the sliding glass doors of the entry to the emergency room. For the initiated, however, a highly classified world expands and defines our existence.  

It was in the hospital where I diagnosed my first disease. I led my first team. I saved my first life.

Read the rest of my post at The Medical Bag.

Burned Out

Walter was far older than his chronological age.  A mere thirteen years, he kept company with a much older crew.  Doctors, nurses, and CNA's were his constant companions.  The other kids on his floor were either too sick to interact, or came and left within a matter of days.  But not Walter.  His heart was too weak to allow his departure, but too strong to be first in line for a transplant.

So he passed his spare time with the staff.  He often duped me and the other medical students out of our pocket change with some confidence game or another.  He was like a younger sibling, or maybe the hospital mascot.  Everybody knew him, and everybody loved him.  Unlike friends and neighbors, however, we knew the most intimate details of his medical history.  We examined his body and ordered blood tests.  We were in charge of his well being.

Walter was the patient I spent the most time with during my medical school career.  He was a constant presence throughout my three months of pediatrics.  The last day of my rotation, the nursing staff got the unexpected call.  Walter was prepped and taken to the operating room.  A child had died tragically, and Walter was given a second chance at life.  Around midnight my team snuck into the ICU and peeled back the curtain.

Walter was alive and well.  A breathing tube snaked from his mouth and chest tubes hung from his bedside.  The grayish pallor of his face had been replaced by a pink glow.  I took one last look back and left the ICU.  And left my pediatrics rotation.

And stepped out of Walter's life forever.

Years later, I am struck by how many times I have repeated this cycle in my medical career.  Patients come and go.  Doctor is inserted at most intense moment.  The patient dies, or leaves the hospital, or exits the nursing home, or moves away.  We live a life of transience.

I used to think of this as intimacy.  As I get older, I question this belief more and more.  For true intimacy, confidence is earned, not given forthright. It is the product of shared struggle and trust.  And when someone you are intimate with dies or leaves your life, there is a period of mourning, a time for closure.

What physicians experience today is feigned intimacy.  We swoop into people's lives during their most intense moments and leave abruptly.

It's no wonder most of us walk the hospital floors with gaping holes in our sides that only we are unable to see.

Wounded.

Gasping for air amongst the charred remains.

Burned out.


(If you liked this post, please check out my newly released book: I Am Your Doctor And This Is My Humble Opinion).