I did not smile when I saw his name on the schedule. His previous visits had been difficult for me as he had presented with symptoms that defied physiologic explanation. He had vague abdominal pains that came at sporadic intervals and had no relationship to meals or activity. The pains were brief and mild and there were no changes in his bowel function, appetite, weight or ability to exercise. Making the diagnosis even more challenging, he had not experienced the symptoms in the last several weeks before his office visit.
In spite of these facts he was intensely concerned about his pain and almost demanded that I do something about it. I dutifully reviewed his symptoms, performed a physical exam and explained why his symptoms did not mesh with gall bladder disease, liver disease, ulcers, reflux, pancreatitis, cancer or irritable bowel disease. I told him we could be confident that he did not have a serious condition.
He thanked me for my opinion and demanded to see a specialist anyway. I did not think it was necessary or that the specialist would find anything, but I referred him anyway, hoping that his fears would be put to rest. As expected the specialist did multiple tests and found nothing. Predictably, the patient’s fears remained.
While months had passed since I had seen him last he communicated these persistent fears to me soon after I entered the exam room. They weren’t the reason he had given the receptionist when he scheduled the appointment, but they were clearly the reason he was there. He was certain something was wrong with him and that we were missing it.
I reviewed the notes from the specialist and saw that she had been incredibly thorough in her approach. She had left no stone unturned and had gone as far as possible in insuring that the patient did not have any significant illness or disease. Reading her notes the thought went through my mind, “What am I supposed to do now?”
What I wanted to do was scream, to grab the patient by the shoulders and shake him and tell him to get over it, that he was being foolish and he needed to let go of his worry. We had done our jobs and evaluated him thoroughly. There was nothing physically wrong with him. He needed to understand that the problem was in his head and not in his abdomen.
That’s what I wanted to say, but I didn’t say it. I wish I could say it was because I was moved with compassion, that I understood that his sensations were real to him and that his fears were genuine but that would be lying. I didn’t say it because I was afraid he would be offended and complain about me to the insurance or leave a negative review online. It was fear of negative consequences that caused me to take a different approach.
Having failed at a strictly medical approach I turned my attention to his fears and his feelings. I asked him what he was worried about. I listened. I then explained to him the limits of modern medicine, that oftentimes we do a better job telling patients what they don’t have then we do at explaining the cause for their symptoms. I told him that I wanted to help, that I wanted to give him an answer, but that I did not know if I could.
As I focused on him as a person I sensed a change in our interaction. It seemed that by expressing concern about what he was feeling he felt less of a need to get me to believe his complaints. As I made his feelings my focus he became more accepting of my words.
Something changed in me as well. As I focused on his feelings my perceptions were altered. He became a real person with real fears and concerns instead of a complaining intrusion on my day. He became real to me. His discomfort and fears began to matter.
Out of concern for his feelings I sent him to a second specialist. He accepted my warning that we might not find a cause and was grateful that I cared enough to pursue his diagnosis further. He left the office on a positive note.
He left me humbled. I am ashamed to admit it but there was a time, in the old days before the age of online reviews, when I would have dismissed his concerns without fear of repercussions or worry for his feelings. Confident in my diagnosis and the irrationality of his fears I would have sent him on his way. I would have been a jerk, but for the most part I would have gotten away with it.
Our encounter has led me to reflect on a harsh a human nature. We can do bad things and be bad people when we think we can get away with it. While the desire to avoid negative consequences can occasionally lead to good behavior this is not the way I want to live my life. I want to be a person who loves and serves first from my heart.
I want to be the type of person for whom “getting away with it” doesn’t matter because I have no desire to do “it” in the first place.
Bart
Note- as with many posts, some details have been changed to mask the identity of the patient so neither he/she or my office staff can know who it is.
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