AskAnMD is Hibernating

Okay, it's time for the standard apology:

Doctor D has been remiss in his blogging duties. 

Yes, I over-committed himself to multiple projects and AskAnMD faltered just as it was achieving greatness. I see no point in the near future in which I can invest the time in this blog that I once did.  I enjoyed blogging as "Doctor D" but for now I have to put this thing on ice:

AskAnMD is going into hibernation.  

 I may post a 3 or 4 answers a year, but I'm not sure when or if it will ever return to regular posting.  

"No blogging today.  Tomorrow doesn't look good either."

I'm still checking email and still getting a ton of it, but I can't guarantee an answer.  (PS: Although you should already know better than to email your symptoms to an anonymous blogger asking for a diagnosis, let me remind you again: Don't go there!)

The archives still getting hundreds of hits a day and lots of comments.  If you haven't looked around the AskAnMD Archives you may find a lot of useful and fun stuff. 

I'm also still tweeting since it requires zero time commitment.  You can always drop by Doctor D's Twitter and we'll have a 140 character conversation. 

Thanks for making this blog such an awesome conversation.  See you around.

   -Doctor D

Welcome NYT Readers!

Welcome to everyone who came from the link in New York Times Health section!

Feel free to look around The Clinic of Doctor-Patient Relational Awesomeness.

You can subscribe to the feed or email Dr. D, but Doctor D has been a bit slow of late on posting new content and answering emails so don't hold your breath.

The best way to enjoy the delicious goodness of AskAnMD would be to check out Dr. D's Best Answers page.

Have fun!

The Greatest Medical Myth

A reader asked her specialist a question that befuddled him, so she wrote Doctor D this question:

How is a doctor allowed to mess around with body parts he doesn't understand?

If doctors were required to understand everything we touched we wouldn’t be able to touch you at all!

The human body is still a deep mystery. Doctors understand more than most people, but what we know is still a vague approximation. Just because our educated guesses often work out well doesn’t mean we have any idea what’s actually going on.

The Myth of Physician Omniscience:

It is a popular myth that doctors know exactly what your body is doing. The myth assumes the human body is a machine that is even understandable in the first place. Doctors learn a ton of stuff in medical school so they must understand everything the body does or can do, right? TV medical dramas have reenforced this myth without you even realizing it. If you fart or have a rash a doctor should be able to explain exactly why your body is doing that.

"Nope, nothing about your body could ever surprise me!"

I hate to kill your Santa Claus, but MD’s don’t understand with any real depth what is going on in your body most of the time.

We are still be useful, but we don’t always know what’s going on behind the scenes anymore than you need to understand the internal combustion in order to press the gas pedal. Human bodies are exponentially more complex and varied than engines so when what we do doesn’t work, we can be at a loss to know why, although we can often make up some bullshit that sounds convincing.

Mythbusting

Doctor D has tried to disabuse people of this impossible myth, but nobody’s listening.

Patients either don’t believe me, “How nice of you to be so humble, doc, but I know you know what’s going on,” or they assume the lack of knowledge is some default in my training, “Okay Dr. D if you’re incompetent then refer me to someone who does understand!”

People just refuse to believe that there could be things that no doctor understands. The body is just too complex! Every human body is different and is constantly interacting with your mind, soul, other humans, and the environment. Not only is there a lot we don’t know. There is a lot that will always be impossible to know.

So, why is the myth of Physician Omniscience so deeply ingrained? When a wrong idea won’t budge it’s usually because it satisfies a deep psychological need.

No Thanks, We Prefer Myth To Reality!

Being ill is terrifying. When your body begins to betray you it is natural to want to know why. Patients need to believe that somewhere out there is a doctor who understands this. In their imagination patients replace doctors’ vague, tentative understanding with a mythic understanding that is complete and without doubt. “It’s okay that I feel out of control, because my doctor is on top of it!” This is why mystery illnesses are so unsettling. It feels like like being in speeding car with no one at the wheel.

"Don't worry! Doctor Zeus has this under control."

Doctors are also responsible for this myth. We perpetrate this falsehood for 2 reasons:

• First, we want you to trust us. It takes a lot of trust for you to ingest the chemicals we give you or let us cut you open. We fear that if you knew how little we understand the bodies we work on you wouldn’t let us near you.

• Secondly, we lie to ourselves. Medicine works. This is a good thing, but it allows us to mislead ourselves about how deeply we actually understand what’s going on. It also takes a lot of self-confidence to take on the care an ill person. Imagining we have god-like knowledge of the body helps us banish self-doubt. Unfortunately, banishing self-doubt is a double-edged sword: It can give us the confidence we need to pull of some incredible healing, and it can blind us to the humility and insight needed to acknowledge when we don’t understand.

One thing you can take as gospel: If any physician tells you they totally understand your body they are either lying or deluded.

How To Live Without The Myth

This is good and bad news for you. The good news is that having and MD doesn’t make your doctor the final authority on you. Understanding this can allow you and your doc to have frank discussions on what we do and don’t know about your body. The bad news, of course, is that full understanding of your body is impossible.

But realizing that the body is a fearful and wonderful thing isn’t such a bad discovery. Appreciate your body for the mystery it is!

Doctor D always loves to read your thoughts in the comments.


Do you think that Dr. D is over-stating the uncertainty of medical science?


Patients and Heathcare People: How has this Myth affected you?

Psychotic Medical Students

Doctor D gets lots of emails from students considering medical school.

Hey, if the practice of medicine is your dream then you should go for it, but be forewarned it isn't sexy or glamorous like on Grey's Anatomy. It is years of drudgery in which helping patients and feeling awesome about yourself will be the exception rather than the rule.

But I pray to God you never go totally off your rocker and spend your precious days off making videos like these:






Doctor D has more relevant material than silly parodies of parodies of parodies, but unfortunately not the time to post it right now.

He's also about 2 months behind on answering AskAnMD emails. Feel free to chastise him the comments!

What To Do If You're A "Bad Patient"

Last post Doctor D explained the sad phenomenon of "Bad Patient Syndrome" to a reader who had been branded by doctors as bad. Today in the Clinic of Dr-Patient-Relational-Awesomeness we shall teach you proven therapies for curing Bad Patient Syndrome:

The Super Simple Solution:

Find another doctor. If one doctor-patient relationship didn't work there are lots of other fish in the sea. Move on!

Knowing there are lots of fish in the sea isn't always comforting!

When the 'Super Simple Solution' doesn't work:

Some people seem to get labeled as a "bad patient" wherever they end up. Within a minute of entering the exam room the doc seems to decide that that you are gonna be trouble. Of course, some patients get this label because they really are irredeemable assholes, but most aren't. Many "Chronically Bad Patients" are just people with difficult or undiagnosable illnesses or a personality that for some reason triggers the suspicion of people with MD behind their name.

So if you are one of the unlucky innocent victims of Bad Patient Syndrome, I am sorry. It really does suck. When the simple answer doesn't work the therapy is going to be longer and harder, but it still can work...

How To Overcome Bad Patient Syndrome:

Don't confront!

If medical professionals' totally wrong impression of you is not grounded in objective reality, then you would think that exposing the falsehood would make it go away. After reading the last post you probably wanted to storm into your doctor's office and yell, "I'm not bad! In fact, I'm a great person. It's YOU who are wrong! Your own fucked-up physician brain that has unjustly labeled me! Dr. D said so on his blog!"

While I'm sure it would feel great to tell off your doctors it wouldn't help. It would likely make things worse.

Confrontation: It won't always have positive results.

Bad Patient Syndrome is a prejudice, and like most delusions prejudice is most dangerous when you try and expose it. Prejudice is subconscious. Docs don't recognize we think this way. Your confrontation or insisting on your innocence only confirms our suspicions that you must be a manipulative asshole.

If you directly attack a delusion it will only entrench itself. You have to work on it subtly until it is the prejudiced person who realizes they were wrong. Your doctor must think they discovered you aren't a bad patient on their own, without any confrontation from you at all.

Dr. D only realized he was labeling people as bad patients after he "discovered" that a few "bad patients" were amazing amazing people after all. In retrospect, I think they were quietly working against my prejudice all along.

Don't act suspicious

Okay, I admit this one is hard. Once you're labeled a bad patient everything you do is suspicious. Doctor's prejudice against you seems to find confirmation in everything you do, but this doesn't mean you have to give us ammunition.

The best way to approach this is to imagine yourself in the doctor's shoes. Ask yourself, "If I suspected someone was manipulative, dishonest, or crazy would this behavior seem to confirm my suspicion?" If the answer is YES or even MAYBE then don't do it!

When a patient suspect they're being unjustly labeled as being a bad patient the instinct is to resist. Patient's get angry or argumentative. They beg and plead. They lose control of their mouths and emotions. They accuse their doctors of incompetence or malpractice. They behave erratically and refuse to work with their doctors. These desperate attempts to resist only confirm the doctors' prejudice toward them.

Instead your strategy must be to come across as calm and above suspicion. Try to act as normal and well-adjusted with your doctor as you do with your friends and family.

If your doc seems frustrated with you say in the most genuine way you can, "I know I'm a difficult case, and I realize I'm in the wrong on this. (Take the blame even if you weren't wrong) I'm still new to needing medical help. How can I do this in a way that help you, doc?"

I realize this feels like giving in to an asshole bully who has mistreated you—and in some ways it is—but if you have an illness that needs medical help and the entire medical system is against you then you might have to play along with our delusion for a while. Sorry!

Knowledge is Power

If you have been unjustly labeled as a bad patient this may be the most important blog post you ever read. Understanding the bizarre psychology of the medical mind is of the utmost importance for you:

• First, you can finally realize it isn't your fault: You really aren't a bad person. It really is a false label that has been attached to you by delusional physicians.

• Second, you can understand WHY the doctor's mind becomes this way: While our prejudice against you is totally indefensible, you may realize that it is a warped product of our desire to do our jobs right and help people. Perhaps this will allow you feel sorry for us instead of angry with us.

• Third, you can make peace with the fact doctors are out of touch with reality: It's hard to take a totally reasonable person calling you bad, but you don't mind if a crazy person calls you names because he doesn't know what he's doing. Don't assume doctors are sane just because we have letters after our names! We are subject to psychological trauma just like anyone else--and we get a lot of it in this job. It is quite possible that you are the most emotionally mature person in your doctor-patient relationship. Treat us like your grandfather with Alzheimers and play along. "Sure Jimmy Carter's the President and the KGB is trying to break into your tool shed each night."

"Don't let the white coat fool you. I'm absolutely bat-shit crazy!"

This knowledge will give you the patience and peace of mind to gradually undo the damage of Bad Patient Syndrome:

Your Long-Term Strategy

If you are stuck as the bad patient no mater where you go then stop switching MDs before you get labeled a "doctor shopper." Pick one doctor and stick with him or her. Pick a doc who seems at least slightly reasonable despite their totally misjudging you. This should usually be a primary care doctor, but if you have a chronic illness you may want a doc who specializes in your condition.

Work patiently with your doctor. Don't try to change you doctor's idea that you are a bad patient anytime soon. Your goal is to let his or her mind change on it's own. Your long-term campaign of patience, kindness, and consistency will eventually wear down your doc's prejudice.

I'm not saying this is easy. Changing anyone's misinterpretation of you is hard, and it's doubly hard when it's your doctor and you feel sick and are worried about your health.

As you work with this one doctor you will learn a lot about doctors in general. We are an odd bunch, but we are also predictable. You'll start to learn how we think: what sets off our prejudices, and also what lowers our defenses and makes us humane.

Chances are if you are getting repeatedly labeled a Bad Patient there is something about your style of interaction that sets off alarms in the medical psyche. Work patiently with one doctor to cure your "Bad Patient Syndrome" and you'll likely find the doctor-handling skills you learned will work with every other MD you encounter.

This Therapy Might Just Save Your MD Too:

Yes, you the "difficult patient" could be the one who saves an MD from becoming and eternal asshole!

Dr. D was once near burn out and lost within the delusion that patients who didn't act the way I thought they should were bad. It only took one patient who I had previously written off as a hopeless bad patient to turn me around. He was so damn genuinely nice to me that I suddenly realized I had been calling one of the most amazing human beings I would ever meet a "hopeless trainwreck."

In many ways a "bad patient" has the opportunity to transform a physician and positively affect thousands of other patients in a way a "good patient" never could.

What do you think?

Have any of you who have been labeled a bad patient every tried this?

Do you think heathcare workers are open-minded enough to reexamine their prejudice about a "bad" patient?

Dr. D always looks forward to reading your stories!

How Could You Think I'm A Bad Patient?

Dr. D recently got an interesting letter from a young woman who got along well with doctors and never had significant health problems …then she got sick. She developed problematic symptoms that required that she seek a lot of medical attention.

What really shocked her, though, was the distinct feeling of hostility she felt from her doctors.

I could totally smother you with this pillow!

Her complaints were suddenly greeted with suspicion. Her report of odd pains resulted in a lecture on drug seeking. She was subtlety accused of being a lying hypochondriac and manipulating the system. When she broke down and cried at this treatment she was diagnosed with "anxiety problems." She had suddenly gone from normal healthy person to the bad patient.

In desperation, she wrote Dr. D to ask, "WTF just happened?"

I wish I could say that situations like this are rare, but they aren't. I've written before about Nice Patient Syndrome. Unfortunately there is also Bad Patient Syndrome, and it claims a lot more victims than the former.

While there some despicable patients out there, many of the victims of Bad Patient Syndrome are really nice folks who are getting the run around. The true illness is a mental one in the mind of medical people:

"The fault dear Brutus, lies not in our patients, but in ourselves!"

Why would doctors label you as being a Bad Patient?

1) We Suspect Everyone

MD's are a naturally suspicious bunch.

"But why would doctors who chose this profession because they want to help people be suspicious?"

Doctors have control over work excuses, narcotic pain medicines, and the exams that determine disability. This makes us popular targets of sleazy folks who want to get things they shouldn't. Docs get told more lies middle school teachers and probation officers. After getting burned a few times we learn to be suspicious. We even find ourselves being suspicious of patients who have nothing to gain from fooling us.

Suspicion becomes a habit of mind. Your docs are like the grizzled old detective walking out of an interrogation muttering, "His story doesn't add up. He's lying!"
Sometimes stories don't add up because people are lying, but sometimes they don't add up because the human body occasionally does strange things.

2) Pattern Recognition

It is often the patients with weird or atypical symptoms that get labeled as the bad ones. Diseases are typically diagnosed by identifying patterns of signs and symptoms. Doctors get pretty good at recognizing common patterns. It gets problematic when your symptoms don't fit any known pattern. We might look up your pattern in the books and run some tests and still come up empty handed. This is frustrating!

Learning the patterns of diseases is very useful. A majority of medical education is dedicated to learning these patterns, but sometimes the doctor's mind begins to slavishly adhere to patterns without exception. We start to think that symptoms that don't fit our patterns aren't "real" problem at all.

If your symptoms don't fit into any known patterns then you must be full of shit!

The human body, of course, is extremely complex and each person's body is unique and acts slightly differently from all others. The number of patients with signs and symptoms that don't fit known patterns shouldn't surprise us at all, but if you bring us a pattern we've never seen before we might just blame you.

3) Impotence

Doctor's hate to feel helpless. Our work gives us an incredible (almost superhuman) power to identify dieases and save lives. Like all superheros we are expected to use our powers for the good of mankind. Our patients expect us to be all-powerful and we like to feel powerful and needed.

Then you come along and we can't help. Heck, we sometimes can't even figure out what's wrong with you! Suddenly we go from feeling like superheros to pathetic loosers. Not only are you kryptonite to our superpowers, but you still expect us save you when we find all of our medical powers useless. We hate feeling this way!

What we should do is admit that we aren't superheroes after all and confess that your situation has confounded our ability to help. From personal experience I can tell you this is really hard to do.

Feeling powerless is a huge narcissistic injury to our superhero ego. It is a lot easier to accuse you of being a villainous bad patient who is unworthy of our heroics, that admit that we aren't as super as we would like to be.

4) Of Maybe You Are Just A Manipulative Asshole?

It does happen sometimes, but I believe many of our bad patients are just getting a bad rap. So if you are one of the unlucky innocent victims of Bad Patient Syndrome I am very sorry. It really does suck!

How do you overcome Bad Patient Syndrome? Well, it isn't easy, but Doctor D has some suggestions coming up in next week's post.

What do you think?

Have you ever been the "bad patient" or been the heathcare provider who misjudged a patient?

Doctor D always loves to hear your stories and opinions in comments.

Healthcare Should NEVER Be Free

Is Healthcare A Right?

Yes, Healthcare probably is a right, but it should never, ever be free

Now Dr. D is a Socialist (I’m not talking little ‘s’ Palin-calling-Obama-names socialist, but big ‘S’ from-each-according-to-means-to-each-according-to-needs Socialist) but he still believes medicine should never be free if we want to keep it.

So what’s a nice Socialist boy like Dr. D doing defending the financial exploitation of sick people?

Okay, now that I have your attention…

Rights and Responsibilities

If something is a Right then it must be someone’s Responsibility too.

We have the right to vote. This means someone is responsible to run a fair election and count the votes. We have the right to a fair trial. This means someone is responsible for maintaining an impartial court and providing a public defender. Make sense?

If Healthcare is a Right then someone is Responsible for funding and running an efficient healthcare system that cares for everybody... and that someone is Dr. D.

Dr. just paid about $60,000 to the US treasury and as a bleeding-heart he also did a lot of volunteering and giving to healthcare for the poor. (Dr. D puts his money where his Socialist mouth is!) Like most people with well-paying work, D contributes large percentage his resources toward the general welfare.

Dr. D is also the dude that gives away the free healthcare.

WTF, free healthcare in the USA?

Yep, if you are broke ER care is free by law.

News Flash to Republicans: Socialist Medicine has been here for decades! Doesn’t it just make you feel dirty?

If Healthcare is a right then Dr. D is the dude responsible, because over half my waking hours and dollars earned are spent providing that right. Actually, we are all responsible for it.

We're already providing free care—we’re just doing a piss-poor job of it:

Bad enough that Republicans are right to complain that our kids already owe China trillions of dollars we’ve wasted on healthcare.

Also bad enough that Democrats are right to point out that millions of uninsured are sick and dying without the care they need.

The current state of the healthcare system

So let’s think responsibly about this...

Human Nature Is a Bitch

We Socialists are big picture dreamers. We like to feel we do some good, without get bogged down in the details. Young D used to give a $10 to every homeless dude that asked. It felt good and kept me restricted to a diet of mostly ramen during school. Then I started working at homeless shelters and realized that the bills I gave usually ended up spent on crack. Giving a crackhead money isn’t responsible. Responsibility is a lot harder.

Are you comparing sick patients to crackheads? Yep!

We are all subject to the same rules of human nature. The problems of human nature affect everyone and always fuck up our brilliant plans. (This blog has spent considerable time dissecting how the foibles of human nature make doctors one of the most screwed up and difficult types of people you'll meet.)

Humans are naturally self-serving and take the path of least resistance.

We occasionally rise above our natures, but when we create a system we should expect people to generally act like typical human beings—and by ‘typical’ I mean jerks.

We guarantee the Right to vote and to justice, but because we recognize that human nature people lust for power we have to make a Responsible electoral and jury system that isn’t easy to cheat.

I’m in favor of giving free food to people that need it, but if I laid out a buffet of delicious food on the corner with a note that said, “Just take one plate, and only if you’re hungry.” It would likely all end in the trunk of the first person that drove by—even if that person already had a million in the bank.

Sorry, but human nature sucks! Why do we expect free medical care to be any different?

But people wouldn’t do that with medical care would they?

Dr. D sees it every single day: People call ambulances to bring them to the ER for runny noses and dry hands. People getting a free $1000 emergency room visit demand antibiotics for viral and then don’t fill what is prescribed. People come to the ER to get “checked out” just because there’s nothing good on TV.

Most people will treat anything that’s free like it’s worthless and waste it without even thinking. Just look what we did with this planet God freely gave us!

Free Stuff Has Consequences

Medical care actually isn’t free. It is really expensive. It takes a lot of resources and work to create even the simplest doctor’s visit. Somebody is responsible to pay the bills for free care, and even though Dr. D chipped in $60K this year, our kids are still in the hole for 14 trillion bucks.

A responsible system must be sustainable, and free-for-alls just aren’t sustainable.

The freeloaders also screw up system so it can't work for the people who actually need it. Dr. D gets to deal with a microcosm of this every time we don’t have space for real emergency patient because the ER is full with people who checked in because they were bored or lonely. It happens a lot.

Rationing Healthcare

Healthcare is a right. We owe it to our fellow human beings. We would be some sorry bastards if we just sat by and watched poor people die preventable deaths. We owe it to our kids to create a responsible and stable system to guarantee these rights. The only way I see that you could possibly have free medical care is if it is heavily rationed.

OMG, did Dr. D just say rationing? Get the pitchforks and torches! (BTW, I love how my Conservative friends get so worked up about rationing something they don’t want people to have at all.)

Human beings will frequently use their freedom to go all apeshit. We need to have someone responsible enough to prevent us from exercising our rights to the extent that we harm others.

We have the right to be free but we also have the police to arrest those who use their freedom wrongly.

But nobody wants a police state and nobody wants a free medical system that is constantly saying NO.

Totally free healthcare might not be as nice as you hoped.

What we really want is for people to restrain themselves. Some saintly folks may do this, but most of us will follow our baser natures to disastrous results.

Valuing Healthcare

Yeah Dr. D, but if human nature is really that shitty why doesn't everybody misuse their freedom and end up in handcuffs?

Sorry to bruise your college-educated ego, but it isn’t because you’re such a better person. You just have a whole lot of incentives to stop you before the handcuffs. Some are social incentives—you’d be ashamed to act out—but many are financial. Misbehaving will hurt you in the pocketbook.

Everyone has different values and motivations, but we all accept that money has some value. If we want universal access to medical care then it has to cost money.

It doesn’t have to cost much money. In fact healthcare is best if kept inexpensive. The “free market" cost of healthcare is a huge barrier to most people’s access. But there has to be some barrier. Drop the cost to $0 and you get a tidal wave of people wasting very costly care.

I guarantee that if every person who came to the ER had to pay $2 up front the number of frivolous visits would drop by 80%.


I’m not saying that no rationing will ever be a necessary, but if we insure healthcare has value to everyone rationing care will be the exception rather than the norm.

You want everyone to have healthcare? Never give it away for free!

Okay, Dr. D has managed to piss off both the Left and the Right!

The floor is now open to your comments. Just try and be civil with each other.

Next post Dr. D will studiously avoid politics and return to the regularly-scheduled programing on Doctor-Patient Relationships.