May 26, 2010

Hurting My Patients

An email to Doctor D:

What does it feel like to cause pain or disfigurement to a patient? Is it troubling or do doctors not let it affect them?
Believe it or not, most doctors are not sadists.

Hurting patients is distasteful to those of us who went to medical school because we wanted to "help people."

But the fact is that the really cool gadget that Dr. McCoy waves over sick people to fix them hasn't been invented yet. "Dammit Jim, I'm a doctor not a butcher!" Unfortunately, for the foreseeable future even high-tech medicine will involve some butchering.

People come to Doctor D feeling rotten and I sometimes stick them with needles, electrodes, blades, and tubes which at least in the short run makes them feel worse.

Sorry, I know, it sucks.

Doctor D fully realized the cruelty of his profession as an intern when he was performing a lumbar puncture on a squirming, screaming 2 year old with meningitis. The terrified kid couldn't understand why sticking a needle into his spine was required. He just thought we were torturing him. It sucked. That day D wished he had chosen another profession.

But young Doctor D got over the trauma he caused. The fact was that the lumbar puncture helped save the kid's life. Many of the painful things we do save lives, so we grin and bear it.

After a while we get used to hurting you:
It doesn't help patients for doctors to get emotionally distraught every time we cause pain. You want me thinking clearly so I can do procedures quickly and efficiently, with as little pain as possible. The doctor who hesitates to do an urgent painful procedure can be dangerous to patients.

Empathy must kept in check by necessity.

But occasionally the doctor gets too hard... forgetting your pain altogether and focusing only on the job.

Or even worse, we enjoy hurting you. It's easy to feel for a helpless toddler we have to hurt, but a whiny grown up who asks to be "knocked out" just to get an IV and has more tattoos than skin is a lot harder to feel for. Patients who thrash around can be dangerous to work on because needles and scalpels get knocked all over the place. "STFU and be still!" We sometimes even fantasize about performing painful procedures on belligerent patients.

Our work in proximity to so much suffering has a natural hardening effect. Doctors must constantly be wary lest we become cruel.
I believe that we can find a middle ground in which we perform the difficult task of hurting to heal without losing our compassion.
If I must cause pain adding kindness and understanding can sometimes be more therapeutic than morphine.
Doctor D always enjoys hearing your stories and perspectives in the comments.

What are your experiences with doctors causing pain? What was done well? What was handled wrong? Have you ever felt a doctor was being intentionally cruel in a painful procedure?


Anonymous said...

Recently, I had to be treated for a dog bite that went septic and had to be cleaned out. The injections of lidocaine into the thin skin of my hand, around the wounds, were breathtakingly painful -- but fortunately, only for a short time as the numbing action of the drug worked mercifully fast. The young hand surgeon doing the work was calm, quiet, and very apologetic, telling me he understood that it was painful and that it wouldn't last very long. When my hand was numb, I watched in some fascination as he cut away mangled skin and dying tissue -- and I felt nothing. I can only imagine what it would have felt like without the lidocaine. Gives me the shudders, believe me. I was very grateful and thanked him for his empathy and care.

I can, actually, imagine being on the other end of that needle, knowing that the pain I'm causing is necessary for the well-being of the patient. I'm glad that doctors learn to harden themselves against too much empathy -- a lot of people would die without their self-discipline. I could have lost my hand -- or even my life.

Great post, Dr. D. Thanks. And welcome back! You're missed!

Anonymous said...

Hmmm. Well I got a pacemaker a few years ago, and it took about 3 1/2 hours to put it in because my anatomy is weird. I'm missing two veins in my left shoulder. I have a very high pain tolerance, so didn't realize how much pain I was in until later, while they were digging in my shoulder. Next time I will have to ask for more lidocaine.

That said, I think the part that has been the most painful is when I've been misdiagnosed and told that my symptoms are all in my head when they aren't. I just found out that my current doctors are thinking this way as well. This means I will have to go for a fifth opinion as I like to breath. And then I counted and realized it took five opinions to get the pacemaker. It's just painful. It was more painful because my lung doctor was trying to be kind, but he was so far off from my own experience of my symptoms that I was greatly discouraged. And I could even tell that upsetting me upset him which was really hard.


Anonymous said...

A friend had a procedure that was extremely painful - so painful the x-ray tech assisting cried because it was so awful for the patient. This procedure could have done under IV conscious sedation, but it is way quicker for the doctor and clinic staff to do it without. As an RN, I will certainly discuss thoroughly any painful procedures I might have. It will prevent an assault on a doctor.

Anonymous said...

I went to a surgeon who gave me multiple, very painful injections. As he did, he explained what he was doing & apologized for the pain he was causing.
When the injections didn't help, he referred me to his colleague who walked into the room, introduced himself, then grabbed the painful area. When I flinched and instinctively jerked my limb away, the second surgeon yelled at me for moving and spent the rest of the appt. talking to me through his gritted teeth. I asked a question and he snapped at me and answered derisively. I assume something had annoyed him before he came in my room because I'm pretty sure my flinching and asking a polite question about his instructions shouldn't have brought on that much drama but I was petrified and put off going back in to be treated for months. When the pain became greater than the fear, I finally went back in but made sure to stay still no matter how much it hurt.
Doctor One left to pursue another career but Doctor Two is still practicing medicine.


Anonymous said...

I once had several punch biopsies done on my cervix. This is not a painful procedure and I am usually stoic in a doctor's office, but for some reason the first biopsy hurt terribly and I yelped in pain and cried a little. I saw the doctor tighten his jaw as he wordlessly forged ahead with the remaining biopsies. Only the first one really hurt, but after that we were both on edge. He looked so tense and just kept on doing what he needed to do.

Later, during another procedure that WAS supposed to be painful (but, for me, somehow was not bad at all), this same doctor asked again and again so nicely if I felt okay. I realized he had probably been dreading doing this procedure on a "yelper." It was the first time I understood how a patient's pain could trouble a doctor even while they rely on their training and fortitude to continue the job at hand.

My favorite line in this post is the one about adding kindness. It really does help to know that your doctor is sorry to be hurting you.

tracy said...

If this includes emotional pain, yep, been there. With an ED doc who was so disgusted with my self inflicted cutting he barely uttered a word to me while suturing. i don't blame his attitude, but it hurt, alot.

tracy said...

.....annnnnnd, he seemed to find a bit of joy in beginging before the ladocaine took effect. O-kay, i deserved it.

Anonymous said...

I think that causing temporary pain might be a different sort of experience for doctors than doing something that permanently disfigures a patient. In my experience, doctors have sometimes been sympathetic about the effects of OTHER doctors' disfiguring surgeries on me but never about their own. Before surgery, the prospect of disfigurement has gone unmentioned or was referred to in an abstract, neutral way. (I once had a surgeon calmly mention the "small but real risk of limb loss" and then quickly move on to other topics---"Limb loss"? He meant that my entire leg might need to be amputated.)

One time when I politely asked if a surgery might be done in a certain way that would possibly be less mutilating, the surgeon did not answer my question. He attacked me for being so trivial when I was lucky to be alive. I felt ashamed even while I still felt my concern was legitimate.

These surgeons were all truly nice people. They were not cruel; my sense is that they were just deeply uncomfortable with the unfortunate, necessarily disfiguring side effects of their work and coped with their discomfort by ignoring the subject and discouraging me from raising it. It would be easier for me if they would speak openly and with a little sympathy about it. Nurses have been extremely kind and radiantly sympathetic in this regard.

Dragonfly said...

When you aren't able to communicate with your patient (language, age, cognition) about why something is being done it can be hard to explain why you are hurting them...

Old MD Girl said...

I probably shouldn't admit this, but I had a patient once who presented to the ED at 4AM with ankle pain. She claimed that the ankle was swollen and that she could not walk on it. Then she demanded percocet (a 3 day's supply was not good enough), a note to get her out of work for a WEEK, and screamed at everyone until she got what she wanted.

Truth? Her ankle was not swollen. At all. It was not tender to palpation. Plain films negative. All those ankle tests you do to check for a sprain (the names are alluding me right now) were negative as well.

I fantasized about tapping her ankle to determine the etiology of the pain.

The Bus Driver said...

Over the last 2 years, I've had to have two ingrown toenails removed (one in each big toe). The first one was so infected and i wasn't expecting the pain with the lidocaine injection that it caught me a bit off guard... but once it was numb, the doctor did a great job of removing the toenail. Fast forward to a year later (aug 2010) my other toe started acting up, and while i KNEW there was gonna be pain with the lidocaine injection, i also knew the relief of not having an ingrown toenail anymore. So despite the fact i knew the doc was gonna cause pain, i had the other toe taken care of.

I would do it again in a heartbeat too.

Anonymous said...

Just yesterday, I had an ingrown toenail surgically removed. I had previously had lidocaine injections into my leg (removal of a skin cancer), and although they weren't FUN, they were pretty tolerable. So, I wasn't expecting the extreme level of pain when they injected the lidocaine into my toe. The whole process seemed different, in that he must have stuck me at least 5-6 times, at least 2 of which were in the front of my toe where there's very little 'meat'. Unfortunately, because the toe was infected, they couldn't do the permanent removal, where they use acid to 'kill' the root of the nail; so I have to go back sometime in the next few months and do this again! I'm dreading it already, because of those breathtakingly painful injections. The rest of it (salt water soaks, bandaging, etc) hasn't been bad.

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