A Pain Filled Deposition

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We were seated around the dining table in my office break room, two attorneys, a court reporter and I. A patient of mine was suing someone for injuries sustained in a car accident and that someone’s attorney had subpoenaed me regarding the case. It was a relatively straightforward disagreement. The patient said he had been injured and was experiencing ongoing pain, the defense was arguing there was no way he could have been hurt that badly in the accident.

The defense attorney showed me photos of the cars (there was almost no visible damage) and asked me about my findings and diagnoses for each patient visit after the accident. The patient had no physical findings consistent with an injury at any of the visits, did not consistently follow up with a physical therapist as requested, and had ultimately undergone an MRI of his spine that was perfectly normal. It was clear from his questions he believed this meant that there was no way the patient could be having pain. Brimming with confidence, he proceeded to ask me a stupid question.

“The normal MRI means the patient does not have a radiculopathic pain, correct?”

“No,” I replied.

“But doesn’t a radiculopathy mean that there is something compressing a nerve?”

“No, it means that the patient is experiencing pain in the area supplied by a specific branch of a spinal nerve. There are other causes of such pain.”

“What else could cause the pain?”

“I can give you an answer, but it is going to be a long one,” I replied. As i did I saw the confidence drain from his face.

I went on to give him the long answer. I explained there are many causes of pain that do not show up on an MRI or other imaging scans. I summarized the nature of pain fibers and how they could be activated without physical trauma, how once triggered even normal stimuli could lead to these nerve fibers firing and a patient experiencing severe pain.

In a resigned tone he verbalized the realization that he would have been better off not asking me that question. “I opened a can of worms,” he said.

The mistake he made is a common one. Most people do not understand pain. They understand pain after surgery, when a kidney stone gets stuck, or when a bone gets broken, but when there is no visible cause, they doubt it. If it can’t be seen it with the eyes or in a medical image it can’t be real.

This was the teaching I received when I was in medical school and residency. Patients who complained of pain in the absence of physical findings were filed into one of two categories. They were either crazy or they were “drug-seeking.” They were often treated with scorn instead of compassion.

It took years for me to understand how wrong this teaching was. My first inkling that there was more to pain than I had been told came after I had a knee operation in 1992. Several weeks after the surgery I was standing in the clinic when I had the sensation of something like a hot drop of oil running down my leg. So intense and real was the feeling that I turned and looked to see what was on my leg. The only thing touching my skin was the fabric of my pants. There was nothing there. The sensation was the result of a rogue nerve misfiring and sending inaccurate signals to my brain. There was “nothing” there, but the sensation was real.

My understanding expanded further 17 years ago when I suddenly began to have excruciating, burning pain in my right shoulder and arm. Over a period of weeks I saw 5 different doctors in search of an explanation. MRI scans and nerve tests were all normal. It was the fifth doctor who finally gave me the diagnosis of an inflamed spinal nerve, possibly from a virus. He gave me a diagnosis but could not promise a cure. The pain gradually faded to a persistent tingling but never passed. The pain returned a few years ago, this time deciding to stay, but MRI scans and nerve tests were again normal. The only evidence I can give others for the pain is a description of how it feels. It is “undetectable” but it is definitely real.

Pain of this nature is more common that many realize. Fibromyalgia, a pain condition that impacts as many as 10 million Americans, falls into this category. No visible damage can be detected and no blood tests are abnormal, but the pain can be debilitating. Many patients suffer for years while being told by doctors and others that they shouldn’t have pain. They shouldn’t, but they do.

The current theory is that these unfortunate patients have pain nerves that are overly sensitive. In the same way that some people are always cold, even on a warm day, fibromyalgia patients always hurt. Unlike those who feel cold, fibromyalgia can’t be helped by putting on a sweater. Medications can sometimes lessen the pain but there is no cure.

I cannot cure many of my pain patients, but that does not mean that I do not, or cannot care. I can listen to them and pray for them. Most importantly I have learned to avoid the mistake made by the attorney. When someone says they hurt, I believe them.

- Bart

Empty Promises and Feel Good Intentions

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“How can I get people to believe we are committed to quality?”  The question was posed to me by the newly hired Vice President for Quality Management at the hospital. I was surprised by the question, not because the answer wasn’t important, but because I thought the VP of Quality for a large institution should already know it. I was further surprised that he was asking me. Although I had the fancy title of “Executive Director of the Primary Care Institute” I had only been in that part-time position for a few months and had no experience at all in quality management.

In spite of my lack of experience, the answer came to me in just a few moments. He wasn’t asking me how to manage quality, he was asking me how to get people to believe that quality was a high value for organization. With that realization the answer sprang forth from my lips almost without thinking. “Easy,” I said, “Do something to improve quality of care that is against your financial interest.”

He looked puzzled, so I explained. “When the goals of quality and profitability come into conflict, the one that wins is the one you are most committed to. People I talk to say the hospital is committed to profit, and that quality takes a back seat. If they see you do something that promotes quality, even though it hurts the bottom line, then they will believe you are committed to it.”

I do not think my answer was the one he was looking for, as the expression on his face in response was not encouraging. While my answer may not have impacted him that day, it had an effect on me. My answer taught me that the value of a thing is always measured relative to the value of other things. As people of limited resources, both in time and finances, it is inevitable that we will find ourselves having to choose where to invest our time and money. We cannot do everything so we have to make choices. Our choices reveal our values.

In the last few weeks I have heard many stories of choices made by others. I heard a minister share how a commitment to ministry had taken time away from his son, with heart-breaking consequences later in life. I dealt with a recently hospitalized patient with multiple serious problems who had been rushed into and out of the hospital by her doctors before her condition had been adequately treated. I ended my relationship with two separate hospice agencies who both promised attentive care and consistent communication, who both talked extensively about a commitment to service but neither of whom had bothered to update me on my patients for several weeks.

The minister had said he was committed to quality parenting, the hospital doctors would say they were committed to quality medical care, and the hospice agencies had repeatedly assured me of their commitments to compassionate personalized care, but they all fell short. They did not fall short because they despised the quality to which they expressed allegiance, they fell short because had a higher allegiance to something else. For the minister it was the demands of his ministry, for the hospital doctors is was the desire to get the patient out of the hospital, and for the hospice agencies it was a desire to save time by only communicating when absolutely necessary.

As it easy as it is for me to criticize the minister, doctors and hospice agencies (and criticize them I did), I do so at my peril. I am not immune to the trap into which they fell. Like them, it is not always bad things that get in the way of doing what I should. Sometimes it is a case of good things pulling me away from better things, other times it is forgetting what the best things in life are.

I share with all of them another reality. The world is watching to see what I am most committed to. Their judgment will not be based on the words I speak. It will be based on the choices I make.

-          Bart

 

God and Blood Pressure

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His blood pressure was higher than it had ever been. There had been no changes in his medications nor any changes in his overall health, so I asked him if there were any life situations that might be impacting his stress levels.

“I am under a lot of stress right now,” he said. “I am going to be retiring next month and I am really worried about it.”

He was 70 years old and his career as a salesman had been successful. As his retirement seemed both earned and due, I asked what about his exit from the workforce he was worried about. The main source of stress for him was a common one for men in his circumstances. He did not know what he was going to do with himself. He had always lived a life of purpose, but his purpose had always been work-centric. Without work he had no goals, no objectives, no goal for which he could strive.

“Are you a religious person?” I asked, “are you a part of a faith community?” I explained that many people find purpose in serving others. As a man of character and integrity it seemed that mentoring others might be something he could do.

To my surprise he seemed less interested in my mentoring suggestion than he did in my question about faith, for this was what he addressed in his response. “I have never been into organized religion,” he explained, “but I am a very spiritual person.” He shared that he had been raised Jewish but that he was “very interested in Jesus of Nazareth” and that he had been to the Holy Land several times. He spoke of being in Galilee and on the mount where Jesus’ gave the Sermon on the Mount and other meaningful moments from his travels.

I wish he had not arrived late for his appointment that day, for this was one of those “non-medical” conversational detours that I wish I could have followed further. I could not continue the conversation further, but this did not keep me from later wondering if there wasn’t a connection between his fear of retirement and his non-specific faith. When he spoke of “God” he spoke of a “being”, but not of a person, of someone who was “there” but not of someone who was near. His faith was a hope for something but did not include a belief in a specific something or someone. It seemed his faith lacked definition and as a result lacked purpose. He did not have a specific “who” or “what” kind of faith and as a result he did not have a “why” for the rest of his life.

His blood pressure revealed that lack of purpose and meaning is not without consequences. His readings had previously been normal, it was only when retirement became real that they started to rise. There is comfort in having an understanding of our place in life, and of our place in the next one, and unease and stress associated with lacking a sense of who we are and where we are going.

His concerns reminded  me of a common Christian saying, “I do not know what the future holds, but I know who holds the future.” There is peace in knowing that God has a purpose, even when his purposes are not known. Peace it seems, and for some perhaps, lower blood pressure!

-          Bart

Thanks for reading and for sharing with others. Comments and questions are always welcomed. 

Men Need Men

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We meet every Wednesday morning. We are of different ages, different backgrounds and different socioeconomic classes. Some of us are devout, others are still unsure about their faith. We are a diverse group, not all of us are married and our ages range from 28 to 64. We do not have much in common yet we come together each week with a shared agenda. We want to be better men.

We want to be better because we know we can be and we know we should be. We recognize that we are all messed up, all have problems, all have hang ups and issues. Most importantly we understand that we cannot become the men we need to be on our own. We have blind spots, prejudices and preconceptions, broken thinking that gets in the way, and keeps us from being the men we want to be. We need other men to help us.

We rise early once a week, drink coffee and discuss the struggles common to all men. We spent a month discussing anger, why we get mad, when we get mad and how we can learn to control our tempers. We have talked about women, but not in the way men often do. We talk about how we can be the type of men who respect women in our personal and professional lives. We talk about morality, honesty and integrity, and all of the barriers that make it hard to be good.

We laugh together, tease each other, challenge each other and encourage each other, week after week. As we do, a remarkable thing is happening. We are changing. Tempers are coming under control, goals are being adjusted, and definitions of manhood are changing. Friendships have developed and are growing. 

Also growing is the realization of how much men need other men. Many of us did not have strong fathers, most of us have not had many deep male friendships. All of us are seeing that we need each other and that we are better because we meet.

It is one of the most significant things I have ever done. I have been a doctor for 28 years and been actively involved in church ministry for nearly as long. I cannot think of a single thing I have done that has been as consistently powerful and meaningful. Men need men, and it is a privilege to bring men together.

Bart

If you are a man interested in meeting with other men, send me a message. If you know a man who might be interested, send them a message. We weren't meant to fight these battles alone.

Dogs, Squirrels, and a Wasted Life

 Sadie on Squirrel Guard Duty

Sadie on Squirrel Guard Duty

My dog is obsessed with squirrels. I realize all dogs are, but she has taken things to a different level. She has dialed her squirrel intensity up to 11. Her walks are less about exercise and more about squirrel hunting. Her eyes continuously scan the environment looking for the flicking tail or bounding scamper of her prey. So intent is she that she remembers the location of every previous squirrel sighting so she can return to it on following days. As she approaches the sites of previous encounters her body tenses and quivers and she strains against her leash, muscles taut, ready to launch into the chase should the animal reappear.

Lately her squirrel problem has become our problem. There seems to be a somnambulatory one that likes to traverse our back fence in the middle of the night. Our sleep is often interrupted by the sound of our dogs jumping to their feet, sprinting down the hall, and bursting through the doggy door in response to the sound of the squirrel invader.

Things have escalated. We are now at SquirrelCon 4. It seems that this squirrely night walker has now taken up residence in our neighbor’s yard. As far as Sadie is concerned this is an evil that cannot stand. She is perpetually on the lookout for it, spending hours on guard duty staring through a crack in the fence. She will not rest until her furry enemy enters its final rest. The squirrel’s death is now her primary reason for living.

As I watched her watching the fence this morning I laughed at the absurdity of her doggy behavior. The squirrel was impossibly out of her reach. There was nothing she could do to get to it, yet she gave it all of her attention.

This behavior is funny in a dog, but it is tragic for people. Looking at her I thought about the hours, days and years I have similarly wasted focusing on things that were unobtainable and out of reach. I thought of the time I spent wishing my father would realize disowning me was a mistake and hoping my mom would become sober. I recalled patient behavior I could not change, professional recognition I could not gain, and relationship problems I could not solve. I had so many thoughts about so many things I couldn’t change.  It seems that wasted attention is not merely a canine problem.

What is sad about futile attention is that it always has a cost. When we focus on the unobtainable we turn away from blessings that are within our reach. Time spent trying to change patients who were set in their ways is time I could have spent helping others who would have benefitted from my attention. Hours of thinking and planning on how I could get people to appreciate me are hours I could have spent in quality moments with the family and friends who already loved me and appreciated me.

How much better would all of our lives be if we learned this lesson. It is time to focus on the good we can do, the love we can share and the lives we can touch, and not on those things beyond our reach.

It is time to be smarter than my dog.

Bart

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