A Pain Filled Deposition

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

“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

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. 

A Parent's Joy

 “I have no greater joy than to hear that my children are walking in the truth.” The Apostle John wrote these words to his friend Gaius almost two thousand years ago. The same words were written to me 25 years ago when my mother-in-law wrote the verse in a Bible she gave me. It seems she and the Apostle John had something in common. Their greatest desire was  that their children would continue in the faith.

As my children have reached adulthood, the power of this sentiment has grown on me. There are many things I wish for my children. I wish them physical and emotional health, lives free from pain and anxiety, happiness, as well as joyful relationships with their spouses and their children. I wish them success, recognition in their careers and freedom from financial worry. All of these things are important but they all pale in comparison to my desire for them to know God and walk with Him.

As much as my chidren’s lives of faith bring joy, I can imagine no greater sorrow than watching them walk away from God. It has been my greatest fear since their were born. This hope for faith and fear of falling led me to pray for them ceaselessly, carefully teach them the bith the what and the why of Christian faith, and tried to be a role model. I have worked hard to pass on my faith but that does not take away my fear.

I am not alone in these feelings. In recent years I have witnessed firsthand the heartache of godly parents whose children no longer believe. I know a man who is a church elder who has a son living with his girlfriend. For his son, church no longer matters. A missionary couple who has spent over 30 years working to bring the Christian message to strangers across the globe has shared with me their grief over their atheist son. I have recently been praying for a pastor friend whose son who has angrily rejected the message his father had taught him since childhood. The pain of these parents is real.

While each of our children are in different places in their faith we have one thing in common. We are neither in control of, nor responsible for, the choices our children make. Each person must personally respond to the call of God. No parent can do it for them. As hard as we try, there is no secret recipe or magic formula for passing faith on to our children. No one can take credit for the faith of their children, nor can anyone take the blame for the lack of faith in their children. 

Our children choose for themselves. Which may be why their correct choices bring so much joy.

- Bart

What Forgiveness Looks Like

I knew before she said a word that something was wrong. As my front office employee hurried down the hall in my direction the look of concern on her face was unnerving. She was clearly upset. “Dr. Barrett there is a patient at the desk yelling at Alisa. He is very angry and mean and I think we need your help. He is telling us we don’t know what we are doing, that we are lying to him, and demanding that we take care of his problem right now. He says we have been refusing to fill his prescriptions, but we never received the request. He won’t listen to anything we say. I think we need you.” She turned and walked away, confident I would follow her.

I did, and as I turned the corner into the front office I saw the patient at the front desk, visibly upset and annoyed. He saw me as well, and his body language instantly softened, as if he realized he had been caught acting poorly and that I was there to deal with his behavior. He softened, but he was still frustrated and angry.

He proceeded to tell me that he had a problem with my office and office staff. He told me that his pharmacy had contacted our office four times about a refill request and that we had not responded. I calmly told him that this was not possible, because all requests come in electronically and are never ignored. In fact, I told him, our policy is to address every refill request on the day that it is received, so I did not think the problem was with us.

In a stern tone he made it clear that he did not believe me. The pharmacy had repeatedly assured him that our office was to blame. He told me that he did not know where the mess up was but that he wanted us to fix it. I told him that we would.

I then went on to tell him something about our office. “We provide outstanding service here. If there is an issue, all you have to do is let us know. You do not need to yell, or demand, or threaten. We take care of people here.” He remained unpersuaded. I told him I would call his pharmacy and get to the bottom of the matter and call him with an answer. Still perturbed, he turned and left the office.

After he left the staff filled me in on some of what the man had said. He had been rude and demeaning and loud. They were clearly shaken. Because we work so hard to provide service, we don’t get very many complaints and even fewer angry patients. They were not accustomed to being treated in such a fashion.

I went to my desk and immediately called his pharmacy. When the technician came on the phone I gave her the patient’s name and told her that we had not received any of the refill requests. “Our records show that we sent them four times,” she said.

I asked her if they had been sent electronically, and she said they had. Confused as to how they had not appeared in our electronic record, I asked her to check and see how and where they were sent. She came back on the line and said, “We sent them to Dr. Somer’s office.”

Problem solved. He had changed doctors a few months earlier, and the refill requests were being to the wrong office! I ended the call and immediately dialed the patient’s number. I told him what had happened and that we had approved his medications. I then explained that our office had done nothing wrong. I also told him that his actions had been inappropriate, that his anger with my staff was not deserved. I explained that his words had been hurtful and that if he wished to remain a patient in my office that he needed to treat my staff with respect. I said that they deserved an apology, but that they were very forgiving people, and would be willing to serve him in the future.

There was a moment of silence on the phone. “Are you telling me I need to find another doctor?” he said, with a tone that implied defensiveness and offense. “No,” I said, “I think the best outcome would be for you to apologize and for us to go on to have a long and beneficial relationship.” He was non-committal in his response and ended the call.

That was almost 5 months ago. Not once in those 5 months did I see him in the office or hear from him. I assumed that he had indeed changed doctors and that I would never see him again, which made his appointment this week very surprising.

He was extremely pleasant when I walked through the door and greeted me warmly. He was in the “baseball room”, the exam room decorated with baseball art and Angels souvenirs. He asked me if I was an Angels fan, and for a few moments we exchanged stories about ballgames we had seen. I went on to address his medical condition, doing a brief exam and refilling his medications. As I finished up the visit I looked up from my computer and said, “I cannot tell you how delighted I am that you decided to stay with us!”

He smiled and said, “I told myself I should be happy if I was allowed to stay!” I gave him a reply that I have shared with many patients, “I am a man of faith, and my faith teaches me that God is far more concerned with where I am and where I am going than He is with where I have been. I am looking forward to taking care of you.” And that was that. The past was forgotten, and a new relationship was started.

After he was gone, I went to the front office and asked the staff how their interaction with the patient had been. “He was so nice!” was the unanimous reply. They were all happy that he was back, and especially happy that he seemed to appreciate them and their work.

As they shared their feelings a thought came to my mind. This is what forgiveness looks like.

 - Bart