It was the Patient's Fault

Doctor House was right. Everybody lies. Well, almost everybody.

She was a poorly controlled asthmatic.  Perfectly controlled asthmatics can often make do with one inhaler a year. She consistently used 200 puffs a month. She was not doing well.

I had quizzed her on her need for inhalers at multiple previous visits. Over and over that she was doing everything I had asked her to do. She had gotten rid of her cat and avoided triggers. She was taking her medications exactly as prescribed. Her recurrent asthma attacks were a mystery it took me months to solve out. In the end the answer was simple- She was lying to me.

Her secret was revealed to me as I drove the mile from my office to visit my grandmother in her assisted living facility. As I waited at a light I saw my patient standing on the corner waiting to cross the street. In her right hand was the smoking gun, a smoking cigarette. 

I drove through the intersection and pulled over, waiting for her to cross the intersection to where I was. As she approached I got out of my car. She did not look happy to see me. “You are so busted!” was my less than tactful greeting.

She was visibly embarrassed. She lowered the cigarette, trying to hide it from my view behind her leg.  “This is my first cigarette,” she proclaimed, “I have been under a lot of stress lately!”

“So throw it away then,” I replied. She did, apologizing profusely and telling me that she was not going to smoke anymore.

She was lying again.

I found out two days later when my nurse saw her at another intersection, again with a cigarette again in her hand. At her next visit I was finally able to address the real reason for her asthma problems. Sine then, her need for inhalers has decreased dramatically.

Her story reminds me of a basic truth in medicine. Doctors are only as good as the information we get from our patients. Patients who lie get poor care.

Doctor House was right.

Bart

Thanks for reading and thanks for liking and sharing with friends. Comments and questions are welcome.

Happy Easter! Or Not.

People hedge their bets.

I do this as a doctor. Often when I give a diagnosis, I give several alternatives, so that if the first diagnosis isn’t correct I don’t come across as a complete fool when I am proven wrong.

“Based on the location of the pain in your knee, the mechanism of injury, and the tenderness on exam, I believe you have torn your medical meniscus. Either that or it is a sprain. Or arthritis. Or a rare parasitic infection.”

I feel like someone who bets on every horse in the Kentucky Derby so when the race is over I can tell everyone that I picked the winner.

We are all like that. No one wants to be proven wrong, no one wants to be embarrassed, so we avoid all or none statements. We like to have options.

This may be comfortable, but it is not always possible. Some things in life are either true or they are not. Some questions have only one answer.

The question of Easter is a one answer question. Either Jesus of Nazareth rose from the dead, or he didn’t. The claims of the Christian faith are valid or they are not. There is no room in the middle. People have to pick a side.

No one understood this better than the Apostle Paul, the Jewish Rabbi who became the greatest missionary of the early Christian church.

Paul based his entire life on his belief that Jesus had risen from the dead. His commitment to Christianity cost him his faith, his career and ultimately his life. His investment was either incredibly wise or terribly foolish. There is no middle ground.

This dichotomy was not lost on Paul. He himself expressed this reality in a letter he wrote to fellow believers in the Ancient Grecian city of Corinth, saying, “If Christ has not been raised, our preaching is useless and so is your faith.”

Paul’s words are no less true today. Everything about the Christian faith hinges on a single event on a single day almost 2000 years ago. An event that either happened, or it didn't.

Christians proclaim that Jesus was not just a man, that he was actually God become man, that he lived a perfect life and then allowed himself to be put to death in a brutal fashion as payment for “sins”, rebellious acts against God, committed by every person who ever lived. As evidence for these remarkable claims Christians offer a single proof, Jesus’ resurrection from the dead. This is a risky position.

If Jesus did not rise from the dead then he is not the Son of God. His words are no more valuable or meaningful than any other moral teacher. People like Paul who make tremendous sacrifices for their faith are fools, complete, total and pathetically deluded fools.

If the resurrection of Jesus isdisproven, then all of Christianity comes crumbling down. Yet, if Jesus did rise from the dead, then He is everything Christians claim he is to be.

Given the profound implications, it seems that thoughtful, prudent people would take the time to explore the evidence put forth in support of the Christian teaching on the resurrection of Jesus. The matter is too important, the consequences too significant, to be dismissed out of hand. The question, “Did Jesus really live, die and rise again?” May be the most important any of us will ever answer.

Something to think about on Easter. 

- Bart

Thanks for reading and commenting. Questions are always welcomed.

A Question that Will define Your Life

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The patient presented for depression, an unexplainable feeling that things weren't as they should be. He came to me for help, unsure of what he could do to improve his situation. He had achieved every goal he had set for his in life but something was missing. He had a beautiful wife and well-behaved children, a good paying job, a nice car, and a comfortable home. He had arrived at the destination he had been working toward since he graduated high school, he had checked off every box on his list, but he wasn’t happy.

He came to see me wondering if he was depressed. He wasn’t. It took only a few minutes of conversation to identify the problem. He was unfulfilled. He had met his goals but failed to find his purpose. He had not addressed life’s most important question. He had not asked himself, “What happens next?”

He had fallen into the trap that has ensnared so many. He had lived his life thinking that once he checked off all of the items  on the list of attributes of a successful life that he would be happy. He believed the lie that if he could simply achieve his life’s goals that he would then be content. When he had achieved those goals and not found happiness he did not know what to do with himself.

His fate is the fate that awaits all who believe that earthly success can bring happiness. It is a pursuit that ends in despair. News reports and reality TV provide overwhelming evidence of the fact that the rich and famous are not fulfilled and happy people, yet our pursuit of wealth and fame continue unabated. For life to have meaning, more is required. For life to have meaning, there must be more to life than this life offers.

The question for our lives is “What happens next?” for it is eternity that matters. Living for eternity, with the awareness of what happens when this live is over, can keep us from empty pursuits.  When we die it will be the only question that matters. The most fulfilling and truly successful lives are lived by those for who the answer to the question is “I will spend eternity with God.”

-          Bart

Thanks for reading and sharing. The greatest reminder of why this question is significant is just a week away, when Christians all over the world celebrate the enduring evidence for life after this one, the resurrection of Jesus Christ.

A Death Defining Conversation

The visit was supposed to be brief, a quick assessment of a minor complaint. One look at the patient as he sat to have his blood pressure taken told me that his minor complaint was not the major issue of the day. The patient, a man in his early 70’s, was a shadow of his former self. Once heavy set and strong, he now seemed gaunt and frail. Once vibrant, he now had the look of a man fighting for his life. And losing.

His appearance should not have surprised me. He had been diagnosed with metastatic cancer a few months earlier and in that short time had undergone two surgeries and 3 courses of chemo therapy. 70 pounds had come off of his 250 pound frame in just a matter of months. He was a very sick man.

It took less than a minute to diagnose the cause of the man’s immediate complaint (swollen feet due to poor circulation) and plan a course of treatment. Thinking I had dealt with that issue I decided to address the greater concern, his cancer therapy. "How is the chemo going," I asked.

“It is going well,” he told me, “the blood tests show that the tumor markers are decreasing.” He spoke with hope, as if this was a sign of cure. I knew in my heart and head that it wasn’t. The tumor marker levels had dropped from incredibly terrible to really bad. He wasn’t being cured, he was postponing his death. It bothered me that he did know seem to understand this. I wondered if he knew the grimness of his prognosis, if the cancer doctor had told him that this was the illness that would eventually take his life. I had little confidence that he had, as in my experience oncologists are often the worst bearers of bad news.

I decided to take some extra time with him to see if I could help him understand the reality of his circumstances. As a way of introducing the topic I talked in general terms about the difficulty some doctors have discussing bad outcomes. I supported my contention by taking about previous patients who did not know they were dying until their last days of life and by pointing out doctors wait so long to talk about dying that the on average, patients die within 2 weeks of being placed on hospice. I expressed my belief that it was not fair to keep patients in the dark about the seriousness of their illness, that people deserved to have clear explanations so they could make appropriate plans.

With that said, I asked what his doctor had told him about his treatments and the likelihood of success. Not unexpectedly, the oncologist had said nearly nothing. The patient did not have any idea as to what the likelihood of success or failure was with the current treatments. I told the patient I would call the doctor and get the information on his behalf. The visit ended with me making a promise to call back later in the day.

The oncologist returned my call within the hour. After the usual exchange of pleasantries I asked the question. “If you had 100 people like Joe in front of you today, how many would you expect to still be around 6 months from now?”

“Five,” was his surprising reply.

“Five with treatment, or without treatment?” I asked.

“Without treatment,” he answered, “With treatment I would expect 50.”

“How many after 12 months?” I pressed, wanting to know how serious my patient’s prognosis really was.

“25,” he said, confirming my fears. I thanked him for his time and hung up the phone, shaken by the news. Knowing the tendency of many oncologists to overestimate survival rates, and factoring in Joe’s weakened condition, I concluded that the 25% survival rate at one year was the best case scenario. It was highly unlikely he would make it to Christmas.

I paused and pondered how to communicate this information to my patient. As I did I opened the chart and saw that I had a phone message from Joe’s son. I was caught off guard by the words on the screen. “Please call daughter, Joe was very depressed and angry when he left the office.”

I called Joe instead. Joe was indeed angry with me. He told me that he did not want to hear bad news and that I should not have said the things that I did. He told me that I had not been kind, and that he liked his cancer doctor. “He gives me hope,” he said, “It may be false hope, but I like it.” I apologized for the hurt, telling him that determining the best moment to address life and death issues is difficult, and that I am often left dealing with the issue the only time I can, which is when the patient is in the office. As the conversation ended he pointedly instructed me to be more sensitive in the future.

His words stung. My desire to educate and enlighten, to allow him to make informed decisions about his care and to intelligently plan for his limited future had instead offended and shaken him. While I was correct in my assessment that he had not been well-informed by his oncologist and was in the dark about the gravity of his situation I had been seemingly equally ignorant in where he was emotionally.

I ruminated on our conversation for the next 24 hours, internally debating on how I could have done better. My thoughts went back and forth. I found myself arguing that patients cannot make informed decisions about their health care without accurate information, and then countering that patients should be able to choose when and how to receive that information. Hours of thought and prayer did not resolve the dilemma. The only certain conclusion I reached was that I wanted to do better.

I ultimately decided that I would be more cautious in the future. I would still ask people if they knew their prognosis but when they didn’t know ask, “Do you want to know?” before going further. It is not a perfect approach, but it may be better than how I approached Joe.

A few day’s later a patient who is a friend of Joe’s came in to see me. The first thing he said to me was, “I heard you saw Joe a few days ago. He wasn’t happy,”

“So I heard,” I sheepishly replied.

“Don’t worry about it,” said Joe’s friend, “everyone knows Joe is dying. He just doesn’t want to admit it.”

I held back a smile, grateful for the comforting information that Joe’s anger was at least in part due to the fact that he wanted to deny the seriousness of his disease. I may have messed up, but I hadn’t totally messed up.

In the aftermath of the difficult discussion, I am left pondering the challenges faces by doctors who find themselves having to discuss end of life issues with their patients. There is so much emotion, fear, and denial involved that effective communication is incredibly difficult and perilous. Doctors and patients need to realize this and extend grace, kindness and understanding to one another. As difficult as these discussions are we cannot fail to have them.

- Bart

Update- 2 weeks after my visit with Joe he was hospitalized with severe pain. His oncologist finally admitted the truth, that there was nothing further he could do. Joe went home on hospice.

Thanks for reading and sharing posts with others. You can subscribe to the blog to receive posts via email. I can be followed on twitter @bartbarrettmd. I am beginning to video blog as well, and my vlog posts will be available here and on my vimeo page www.vimeo.com/bartbarrett