RSS Feeds
The Patient as Physician
- American College of Physicians, Philadelphia, PA 19106 Requests for Reprints: Herbert S. Waxman, MD, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106. Requests for Reprints: Herbert S. Waxman, MD, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106.
The physician who becomes a patient has a chance to become a better doctor. In 1985, I developed sudden chest pain, which led to cardiac catheterization. My physicians found a type I acute aortic dissection, and emergency surgery quickly followed. The cardiopulmonary bypass time was very long, and I received hundreds of units of blood products to maintain hemostasis. After surgery, I sustained extensive lower-extremity necrosis of muscle and nerve, probable deep venous thrombosis, cardiac arrhythmias, total global amnesia, painful peripheral neuropathy, and severe depression. It took me 3 months after the surgery to begin the transition back to my responsibilities as a department chairman and clinician-educator. And I still worry about the longer-term consequences.
Dedicated physicians from many specialities saved my life, for which I have the most profound gratitude. Yet, I learned hard lessons from my experience. Three aspects of my own care are particularly instructive.
Time
After the first 10 days or so, it seemed that my short-term survival was no longer in doubt. As a consequence, my physicians did not have to spend as much time attending to the many details of my medical care. But at the same time, I became preoccupied with questions, concerns, and anxieties. Yet, like most patients, I was hesitant to impose upon my busy physicians. And so, like those of most patients, my anxieties persisted and my questions went unanswered. Later, it came to me: how vital it is that the physician should be sensitive to the possibility that such patient concerns are lying beneath the surface and should fulfill all of his or her patient's needs. Because being a patient means being dependent and vulnerable, the physician needs to take the initiative in asking the patient about unanswered questions or unresolved issues.
Honesty
Later in my course, the dominant clinical issues shifted from the vascular to the neurologic. A painful peripheral neuropathy, probably a consequence of earlier ischemic nerve damage, led to my increasing dependence on analgesics and my diminished capacity for rehabilitation. Consultants were everywhere. There were no ready solutions. Each physician communicated to me the expected natural history of this distressing, if not life-threatening, problem. However, as reassuring as each physician was individually, the information being transmitted differed from physician to physician. As a patient, I could only conclude that lack of knowledge was being masked by communication that probably went beyond the facts. I began to trust my physicians less. Only when another consultant told me that no good information about long-term prognosis was available but that therapeutic options existed that might help did I find myself in the hands of someone whose honesty I could trust. All my physicians were caring and well-intentioned, yet their reluctance to say “I don't know” shook my trust in them.
Recognition of Depression
Several months after the surgery, I developed the most distressing symptoms of all: dysphoria, early morning awakening, joylessness, and a profound sense of unworthiness. I had developed major depression. Yet my physicians did not recognize it and advised me to keep busy and not dwell on the symptoms. Their advice was well-intentioned but, not surprisingly, ineffective. Finally a consultant (and friend) recognized the correct diagnosis. Antidepressants and psychiatric care helped immensely. I could sleep again, make decisions, feel confident, and find a sense of purpose. I learned firsthand that there are two characteristics of depression: It is very painful, and it is treatable. Failure to diagnose it results in failure to institute therapy; as a consequence, the patient continues to suffer. My case was not uncommon. The literature abounds with documentation of the lack of sensitivity of usual primary care to the diagnosis of depression.
As I returned to work and to the care of my patients, I found myself dealing with their problems in the context of the illness from which I was recovering. More often than before, I would ask myself three questions, which I was thoroughly convinced were important: Am I allowing enough time to talk to each patient and assess whether there has been an adequate opportunity for questions to have been addressed and concerns relieved? Am I being honest in communicating to each patient what I know but also what I don't know in response to his or her questions and concerns? Am I sufficiently sensitive to symptoms of depression (or other treatable psychological and psychiatric conditions) and thereby losing no opportunity to diminish the patient's suffering?
Sadly, I realize that my own sensitivity as a physician differed between the 17 years of practice before my illness and the period thereafter. Unquestionably, my experiences as a patient changed my behavior as a physician. Although I had always thought of myself as a capable, caring internist and hematologist, my medical education had not prepared me to care for patients as well as did the added experience of having myself been a patient. How might it have been otherwise? It is hardly practical to require that every physician have a serious illness as part of the process of preparing to care for patients. (However, many schools now offer opportunities for students to participate in experiences as simulated patients in a real medical environment.) It may prove helpful, however, to listen carefully to physicians who have been patients.
Herbert S. Waxman, MD
American College of Physicians; Philadelphia, PA 19106
- Copyright ©2004 by the American College of Physicians
