Doctor D Crossed The Line!

Doctor D has been blogging about the Doctor-Patient relationship for a while now. It’s sort of the thing I’m known for. I’ve usually been on the doctor side of this equation. Most of my blogging, however, is to help patients figure out the weird world of medicine.

Well, guess what? Doctor D recently found himself on the patient side of a nasty injury!

Even as Doctor D looked down and realized his leg wasn’t supposed to be that shape he said to himself, “Self, take mental notes! The readers of Doctor D’s Clinic of Doctor-Patient Relational Awesomeness will want to know about this."

Here is what Doctor D discovered when he became Patient D:

1) Doctor D Is Mostly Right

Any reader of this knows that Dr. D’s insight is typically brilliant and totally useful. I found myself actually looking up posts I had written for the solid and useful advice.

But even D has a lot to learn, so from here on I shall delve into the dark secrets I could only discover when crossing the line to the patient side!

2) Being The Patient Is The Hardest Job In Medicine

We doctors think we have difficult work. We have to slave our asses off for years in school. We are expected to be perfect and heroic while working with huge uncertainty. We try to protect your health, comfort, and life, while you patients just lay back and get taken care of!

Lying here isn't as relaxing as overworked docs think it is.

Just a few days as a hospital patient cleared my mind of any misconceptions. Abject helplessness combined with severe pain trumps everything. And helplessness is far worse than pain. Dr. D had never done anything as a doctor that caused more stress than allowing myself to be put to sleep for a major operation with a surgeon I had only spoken to for 30 seconds.

3) There Is Much More To Pain Than A Number

Doctor D has written a lot on pain scoring, so I attempted to rate my own pain as a matter of curiosity. I have a good imagination for what 10 out of 10 pain would feel like, so I gave the feeling of multiple shattered bones crunching whenever my leg moved a 7, which made it the most intense pain I’ve ever felt, but I could totally handle the excruciating acute pain.

The real surprise was realizing that duration of pain was far worse than intensity. I had a throbbing pain during my recovery that I could rate as a 4 if I’m generous, but it lasted for weeks and nearly drove me insane. Low-intensity pain that won't leave can make a person much more miserable than 10 out of 10.

4) Narcotics suck

I’ve seen a lot of nice people get addicted to opiate pain medicines. So Doctor D was the dude in the ER with a bone sticking out of his leg begging not to be given morphine. When they finally convinced me to take the narcotics I was please to discover I didn’t get any high. But what I did discover is that they made me miserable in other ways. I was groggy, nauseated, itchy, constipated, and mushy-brained whenever I had to use them.

Their efficacy varies drastically from person to person. I can say with certainty that a 400 mg Ibuprofen was significantly better for pain for me than a 10 mg Percocet, but since my Ortho wouldn’t let me use ibuprofen I was stuck with narcotics. So I then had to deal with the suspicious look when I told the doc I needed more because I had run out.

I am so happy to be off those things! As a physician, it was a bit eye opening to experience how inconsistent and imperfect our best pain medicines are. Managing the pain of a fellow human being is about as frustrating a situation as an MD can experience. I doubt my prescribing patterns will change much, but I do have a deeper appreciation for how hard it is to correctly wield the double-edged sword of pain medicines.

5) Being Disabled Can Really Crush An Ego

Regular visitors to The Clinic of Doctor-Patient Relational Awesomeness are likely aware that Doctor D has a very healthy self-esteem. 3 weeks of lying on my back absolutely helpless and unable to do anything had me at the lowest place I’ve every been. One night I—a generally tough dude—cried myself to sleep. I’m up and moving better now, but I will likely have a limp the rest of my life. My whole life I’ve been able to do everything physical I wanted to do. Now I’m one of the broken people. It’s going to take some getting used to.

I know as physician I often see people with broken and damaged bodies. It kind of annoyed me when people whined about it. “Look, we can’t fix everything, so be a grown up, get over yourself, and quit complaining!” It’s easy to feel this way when you aren’t the one with the disability. I’ve given myself that same pep talk a lot in the last two months—It doesn't work as well when I’m the one with the gimp leg. A lot of my patients have far worse problems than my leg ever was. I’m manning up to fact that my leg’s gonna hurt for decades, but I think I’ll be much more patient towards patients with severe disabilities in the future.

You can't say you wouldn't complain about it if you've never been there—it's a good thing for docs to keep in mind.

6) There Isn’t A "Sort Of Person" These Things Happen To.

Okay, I have to admit something a bit embarrassing here: We doctors sometimes think of our patients as a completely alien form of human life. It isn’t intentional. We wouldn’t even admit it out loud. It’s a weird psychological quirk that happens like a reflex.

Doctor’s see so much suffering and misery on a daily basis, and we just can’t spend all our time worrying if it will happen to us too. So we develop this mental trick: "These things won’t happen to me, because I’m not that sort of person." What sort of person? Well, the sort of person who ends up the patient with a painful or horrible condition, of course!

Unfortunately, psychological defense mechanisms are useless when the cold, harsh laws of physics apply pressure to human bones. This shit happens to everybody—even doctors. No one is the sort of person that has a debilitating injury, until it happens.

7) Some Doctors Just Can’t Be Helped

Doctor D has spent a lot of time educating you on how to deal with difficult doctors. One of the worse maladies plaguing the medical field is piss-poor communication, and Dr. D’s orthopedist has about the communication skills of a mentally-retarded clam.

There's a lot that patients can do to improve their communication with difficult doctors. I had a lot of questions, and I found myself going and reading my own posts for advice on how to get answers out of a doc with weak bedside manner.

In the end I just gave up. This dude just couldn’t communicate like a normal human being with a patient (even a patient who had an MD). I hear he’s an excellent surgeon and the fact that my leg got put back together is proof of this, but his ability to converse was just dismal.

"I'm sorry, but I don't consider speaking with you to be part of my job description."

When faced with a doctor who simply will not or cannot communicate a patient has two options: Leave or trust blindly.

Dr. D had a FUBAR leg, there was only one Orthopedist available at 1:00 am, and the ER doc said this dude was a good surgeon. So I trusted him even though he seemed mentally incapable of explaining the operation he was going to do. The gamble paid off and the leg is improving, but generally I would have to advise that you hit the road when paired with doctors incapable of communicating—especially if your doctor will need to manage your problem longer than a 2 hour surgery.

Okay, that’s my story and I’m sticking to it!

Doctor D is back to limping around the exam room with patients, and so Doctor D’s Internet Clinic of Doctor-Patient Relational Awesomeness is back too. Send in those questions and I shall keep dropping knowledge on you!

What do you think?

Any of you medical folks have similar experiences and want to add some points?

Any of you with more experience as patients wish Dr. D had picked up more from his time on your side? If so, what did I miss?

Doctor D always loves to hear your thoughts in the comments!

The Purpose of Pain (Why the Painscale Doesn't Work)

Last week I answered a question by explaining the trouble with how doctors interpret your painscale. Doctor D confessed that he doesn't like the painscale at all. Today I will tell you why even if used perfectly the painscale still just won't work:

The 1 to 10 painscale ignores the way the human body uses pain in the first place. The scale assumes that we can observe the sensation of pain and then compare and contrast it to other pains we know or imagine. Your analysis of pain is supposed to produce a number that doctors and researchers can use to make calculations. There are a lot of things the human mind does a great job analyzing, but pain isn't one of them.

The purpose of pain is to get your attention. Pain is your body screaming, “Something is wrong!” It doesn't take much pain to completely capture your mind's focus. Pain functions as a useful warning system. It tells you to pull your hand out of the fire or not to walk on that broken ankle. Your brain pays close attention to pain and obeys its commands. So what if being burned at the stake is a 10 and your broken leg is only a 7? Trust me the broken leg will get and keep your attention till the bone is set.

Asking the mind to quantify pain is like asking it to assign a number to love or fear. It simply doesn't work that way. This is the reason that so many patient's say their pain is 10 of 10. No they aren't feeling the worst imaginable pain, but the pain does have their full attention.

Doctors want hard facts from painscales. We scoff at patients who say things like, “My pain is still a 10, but it's better than the 10 I felt before,” or “It's a 10, but not as bad as when I delivered my baby!” We demand hard facts and we get irritated when patients give us flawed and subjective data.

The worst pain Doctor D ever felt was probably about a 6, but subjectively it was miserable enough to get my attention and keep me from hitting my finger with the hammer ever again. We should listen to patients' descriptions of pain and seek to relieve it, but we shouldn't demand they to turn their pain into a number. The human experience of pain just doesn't work that way!

Doctor D is always talking about the natural purpose of things like hunger, laziness, anxiety, and pain. His theory is that understanding the natural functions of the feelings helps us respond when these feelings give us trouble. What do you think? Would understanding the useful warning function of pain help those of you that suffer from pain problems?

Never Say 10! (How Doctors Interpret the Painscale)

A question from a reader:

My doctors all use that 1 to 10 pain scale. Could you explain why? It seems so crude. Is a doctor equating my "6" to someone else's "6"? I always figure that "10" should be left for when a wolverine is gnawing off my face while my lower extremities are on fire, but other people may use "10" more casually.

The painscale is one of Doctor D's biggest pet peeves! The “powers that be” in medicine prefer looking at data rather than real people. And by data I mean numbers. Academics, researchers, and bureaucrats love numbers! They add them up to make treatment or policy recommendations. I often appreciate these bean counters that help clinical doctors, but it gets problematic when we try to pull hard numbers out of subjective human experience.

Medical people are now all commanded to record a numerical pain level on each patient. 0 means no pain at all and 10 means the greatest pain humanly possible (such as fiery wolverines.) They tell us to record this number like a vital sign, but while a fever of 102° F is the same temperature in every person, 8/10 pain may be a very different experience for different people. And lots of hospitals are making policies like "No one can be sent home from the ER until their pain is less than a 5."

Doctor D sees lots of people every day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale. Doctor D suspects that some people might be exaggerating a bit when they answer “Ten” while texting and complaining about the lack of pretzels in the waiting room vending machine. I've seen a few people I was certain had 10 of 10 pain and it seems like disrespect to those people to classify bruises and upset stomachs in the same category. But pain is subjective, so who is to say a mildly sprained ankle isn't more horrific to this individual than the fires of Hell?

Obviously there are some addicts who lie about pain to get drugs, but I think more commonly people say 10 because they lack the imagination to conceptualize greater pains or they hope that a 10 will cause doctors and nurses to take their discomfort more seriously.

While the painscale is supposed to empower patients to define their own pain, it ends up tricking people into an answer that gets them nowhere. Anyone who says 10, who doctors don't think looks like a 10, is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F.

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.” Your doctor will recognize that if you understand how bad 10 is then your 7 is really horrible, so your doctor will work hard to alleviate your misery.

But trust me, never say 10! Even if it you had to set your self on fire to get the wolverines to stop eating you say 9. Ten on the painscale is a Catch-22; answer “10” and the doctor immediately thinks you are about a level 4.

What is the worst pain you every felt? Doctor D's worst pain of his life was about a 6. Did a doctor believe you went you complained of the pain? Do you think the painscale was helpful for getting your pain treated?

Follow-up post: The Purpose Of Pain: Why the painscale doesn't work