only time will tell

 

 

 

As a physician, and at times as a patient, I enjoy the advantage of knowing, before I see a doctor, what questions he will (or should) ask concerning the reason for my visit. This saves time and effort because he doesn’t have to tease out the diagnostic clues that are part of the “history of the present illness.” I hand them to him in perfect order.

 

“It is much more important

to know what sort of patient

has a disease

than what sort of disease

a patient has.”

~William Osler~

 

Likewise, I already know what the physical exam should include and how it should be performed. I can predict what tests he will order, and he doesn’t have to go into detail about the treatment he is recommending. I know what he is going to say before he says a word.

 

Unfortunately, this means I pick right up on it when my own physician slacks off. When he fails to ask the right questions. When he neglects parts of the physical examination. When he fails to follow-up on X-ray findings or blood tests.

 

This is how mistakes are made…and I know why it happens. Not because he lacks expertise in his field. Not because he is uncaring. Not because he is lazy or unmotivated. (I know him better than that…).

 

No, there are other forces at work. He is seeing a patient every 10-15 minutes, so he is usually running behind schedule. The history and physical exam must focus solely on what he suspects is wrong. There simply isn’t time to be as thorough as he would like to be.

 

“It’s not about having enough time.

It’s about making enough time.”

~Racheal Bermingham~

 

Perhaps he's falling behind on his “productivity quotient” and risks losing his job if he doesn’t pick up the pace.

 

Or maybe the EMR he is using doesn’t have a bullet for the information he wants to include, so it goes unrecorded.

 

All the health care mandates and initiatives in the world will not solve the problem of TIME. Time spent with the patient. Time to reflect on his illness. Time to help him heal.

 

Now is the time for change.

 

“Lack of time

is actually

lack of priorities.”

~Tim Ferriss~

 

jan

 

 

 





true story

 

True story:

A friend of mine has been in terrible pain for over a year. She has orthopedic problems and degenerative disc disease in her back resulting in unrelenting sciatica. She also has a rare autoimmune disorder that requires her to be on chronic steroid treatment. Her initial workup, several years ago, found nothing operable so she has been taking substantial doses of opiates daily since then in a futile effort to control her pain. She can’t drive. She can barely make it up the stairs to her bedroom. She is experiencing a deepening depression because of it.

“You can avoid reality

but you can’t avoid the consequences

of avoiding reality.”

~Ann Rand~

 

Why hasn’t she gone back for re-evaluation?

 

Because, as she puts it, “They’ll think I’m a whiner.” She doesn’t want to take up the doctor’s precious time when other patients are worse off. She doesn’t have the language to describe her pain…not the nature of it, not the severity of it, not the timing of it. She tells herself she’s a sissy, that other people wouldn’t complain about it so she shouldn’t, either. She is convinced the doctor won’t find anything wrong and he’ll laugh her out of the office, or worse, he’ll assume she’s seeking drugs. Or, worse yet, he’ll decide she needs surgery after all, and she definitely doesn’t want that.

 

Her situation illustrates some of the obstacles patients encounter when trying to tell their story--the chief complaint and the history of the present illness.

 

What happens in situations like this is that the patient lies. He minimizes the severity of his symptoms because he doesn’t want to sound like a complainer or weakling. He may be embarrassed to admit that he can’t keep up with things anymore because he’s afraid he’ll lose his job. Even if he suspects the gravity of the problem, he may be reluctant to learn the truth. For example, the patient with chest discomfort may describe it as indigestion or heartburn in an attempt to dissuade the doctor who is sure he has CAD.

 

“You’d be surprised

what lengths people will go to

not to face what’s real and painful inside them.”

~unknown~

 

These are some of the obstacles that serve to confound the patient’s narrative: denial, shame, fear, ignorance, and dread.

 

To make a long story short, at my insistence my friend scheduled an appointment to see her pain management specialist. I’ll be going with her that day because, as a physician, I know what she's up against. As a writer, I think I can help her tell her story.

 

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

 

jan