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Friday Reflection 29: The Totally Predictable Doctor as Patient Essay
AC is a 56-year-old man brought to the emergency room by ambulance for a trauma evaluation after a bicycle crash.
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I’ve tried to stay away from the reflections that end up being part of the “doctor-as-patient” genre.[i] Books, TV shows, and movies are filled with these stories.[ii] A doctor gets sick or injured, spends time as a patient, and then authors a piece with a predictable message:
• The experience made me more empathic and a better doctor.
• I learned something about life.
• I discovered new insights about healthcare while I was in the bed rather than next to it.
• What I learned while I was a patient will help you when you inevitably become one.
But I write one of these reflections every other week and I need to satisfy my brother-in-law who texted the day after I got home from the hospital, “Well, it should give you plenty of future Sensible Medicine content…”
First, because it’s kind of a good one, the story of the crash itself.
On the Sunday of Memorial Day Weekend my wife, daughter, and I went for a bike ride on the Chicago Lakefront path. We biked from Hyde Park on the Southside to Andersonville on the north. Our destination was a great coffee shop for coffee and Mexican chocolate cookies. After a good rest, we headed south with the wind definitively at our back. With about five miles to go, we decided we would sprint the rest of the way. My daughter got out ahead of me and, as we approached the end of our ride, I remember thinking, “these damn kids, you teach them to ride a bicycle, and then they turn 18 and you can’t keep up with them.”
I’m going as fast as I can on my one speed, with about 200 feet left to go. As I ride through a congested area,[iii] another rider cuts across the path. I don’t think I hit him but my breaking and swerving sent me airborne. I opened my eyes lying in the grass, staring up at the sky, four strangers looking down at me. I did my own primary survey, recognizing that my left clavicle was broken, my spleen was fine, a few ribs were broken, but, thankfully, my head and neck seemed OK.
The 24 hours in the hospital were blessedly uneventful. I learned that I had broken my clavicle, six ribs, and my scapula. I had an occult pneumothorax (not previously part of my lexicon) and subcutaneous emphysema. I was discharged after 24 hours on the trauma cocktail of acetaminophen, lidocaine patches, gabapentin, and (as needed) oxycodone.
Although you should never take credit for your own health, I have a hard time not taking credit for my health.
Given the eight fractures, I was in remarkably little pain. The clavicle was painful, debilitating, and unstable, but if I remained in a sling, I was OK. The reason for this: luck. I frequently remark on how people take a lot of the credit for their good health – credit they don’t deserve. Just as often, people are blamed for their poor health – blame that they rarely deserve. But with people telling me that I was doing well because I exercise regularly, that my rib fractures caused only mild pain because of my core strength, or because Capricorns have a high pain tolerance, I was prone to believe that it reflected well on me that I was not suffering more.
I’m not that important.
As a primary care physician, I sometimes think my patients would be lost without me. They call me daily to ask about symptoms. They message me on MyChart to ask about the results of tests ordered by other physicians. I get asked to help with issues that can’t remotely be considered medical in nature. What would happen to these people if I were just to disappear for two or three weeks? The answer: nothing. Everybody did just fine. I came back to a smattering of messages that went something like this:
Nurse: “Your doctor will be out for a couple of weeks. Do you want me to forward your message to the doctor covering or can it wait for his return?”
Patient: “It can definitely wait.” Or, “Never mind, it’s not that important.”
Providing equitable care is hard.
Ten days after the crash, and three days before a week of previously scheduled vacation, I was feeling well enough to return for a couple of abbreviated clinic sessions. I asked the nurse I work with to fill the 4 or so hours I’d be in clinic with people whose appointments had been canceled and seemed like they needed to be seen. Every one of the openings was filled with entitled, very connected people. I have written about all the forces that work against people having truly equitable access, so it is a topic certainly on my mind, but these schedules presented the stark reality of the problem.
Time as a patient can lessen your empathy.
Most of the doctor-as-patient genre deals with an experience that increases the doctor’s empathy (see footnotes 1 and 2). I have spent a career doing my best to be empathic to people with rib fractures. “They hurt so much.” “You can’t rest the ribs because you need to breath.” “They take so long to heal.” “Whatever you do, try not to sneeze.” For whatever reason, my rib fractures weren’t that bad. I only sneezed twice. Will I be less empathic in the future?
When a patient knows that the doctor seeing him or her is unwell, the tenor of the visit changes.
For the first couple weeks that I was back in clinic, I wore a sling. As I have always told people, “A sling will help your pain, allow you to heal, and will signal to others to be a little more careful around you.” What I didn’t expect was how obviously the sling’s presence changed my interactions with people I’ve been seeing for years. Some people seemed more relaxed, freed from their patient role, and happy to express their care for, and concern about, me. Other people were uncomfortable. I imagined them thinking, “Wait, you’re supposed to be the healthy person.” Some people managed to appear completely unaware. I am not sure if this meant they were unobservant or just respectful of my privacy (and extraordinary actors). Fellow cyclists were morbidly interested and could not help but tell me about their accidents and have me (re)examine their healed clavicle fractures.
Even an illness can make you feel lucky.
Repeatedly since the crash, I have thought about how ridiculously lucky I was. My helmet had barely a scratch.[iv] My neck was not even sore. My teeth were fine. Even some of my chronic low back pain improved with the weeks of enforced rest. As I sat at my daughter’s high school graduation I teared up. Yes, this was because my youngest was graduating from high school[v] but the tears were also because I thought of how close I’d come to missing this.
Personal experience can trump clinical experience.
I never thought gabapentin did much. Sure I have some patients whose neuropathic pain truly responded to this drug. I have also had a couple of inpatients whose cannabis hyperemesis seems to have responded terrifically, but mostly I think it is a drug that doctors prescribe when we don’t have much to offer. I have probably deprescribed pounds of it in my career. On post-crash day 2, I said to my wife, “I can’t believe I am taking gabapentin. I am stopping this.” I weaned myself from 300 mg three times a day to none in 3 days. The following day, our conversation went something like this:
Me: “I don’t know why I am in so much more pain today?”
Her: “Could it be that it is because you stopped the gabapentin?”
Me: “Come on, no way.”
Her: “Why don’t you try getting back on it for a couple of days.”
Yes, I was better the next day. Placebo, maybe; N of one, sure. But I do expect to look at this drug a little differently going forward.
One good story.
The story that I will probably tell for years concerned the opiates I was given in the emergency room. After being triaged, I was left waiting in an ER room alone. After 30 minutes (exactly 30 minutes, I had nothing to do but watch the clock) lying in pain, I called the nurse. I told her, “I’m clearly stable, I’m sure the doctors have sicker people to see, but I really would appreciate something for pain. I first received a dose of IV morphine, then two doses of IV fentanyl, then a dose of IV hydromorphone. My inappropriate, opiate, trauma humor? I thought I might write a TripAdvisor rating of the drugs.
I couldn’t hold back from the doctor-as-patient narrative.
I’m not sure anything I learned will make me a better doctor.
[i] I have gone there a couple of times with Friday Reflection 6: Abrogating our Responsibility to Use Placebos and Friday Reflection 13: Empathy Earned and Learned.
[ii] I gave a talk on this genre once and this is the list I came up with:
• A Taste of My Own Medicine (Rosenbaum)
• When Breath Becomes Air (Kalanithi)
• In Shock (Awdish)
• Being Mortal (Gawande)
• Diary of our Fatal Illness (Bardes)
• In Sickness: A Memoir (Rollins)
• And Finally (Marsh)
• The Doctor (1991)
• House: Three Stories
• Doctors, Revolt! (Rich Joseph, NYT)
• How to Give Bad News (Marjorie Rosenthal, NYT)
• On Breaking One’s Neck (Arnold Relman, NY Review)
• Resident Report (Brooke Gabster, JAMA)
[iii] FTITK, the west side of Promontory Point. Yes, I should have slowed down.
[iv] But, I bought a new helmet because that is what you’re supposed to do after a crash.
[v] As every parent has said, “how the hell did that happen?”