Love this. I recognize doctors are often so pressed for time and burnt out themselves, and yet as a clinician myself.. I often struggle with the argument of “doctors don’t have time”. Answering the questions you end this piece with doesn’t require more time than the current consultation average. It’s simply a shift in your way of being. In my work within minutes of intentionally sitting and listening to someone I can have a good idea of what threads we need to follow and what questions to ask. Validation and active listening take no more time that checking boxes and ordering tests. I wonder what our medical system would be like if more doctors brought back those rituals!
Thank you! At least within the context of emergency medicine, it does take a lot more time than the “standard of care” and even more than that showing up emotionally for that volume of people takes a lot of energy in a system that does not do anything to replenish those who expend more energy. Does it take more than it takes other professionals, that I don't know. But people who are drawn to medicine often do so to prove their worth to someone, then long-term shame and fear based training further damages their self-worth so often we don't have the capacity to be present for negative emotions without becoming defensive, unfortunately.
I think there’s something to be said for finding a way of being even in emergency care that allows for healthy boundaries and energy maintenance for the provider while also a presence that doesn’t invalidate the patient. There’s always situations outside that ideal of course. Bad days happen, difficult clients are common, empathy gets blurred with burnout. I’m really glad to see this discussion happening more and more though. Interpersonal skills in the context of any practitioner context are so often not taught, and yet are so in demand.
Yes, I think letting go of money and efficiency as the ultimate priority in the system are key to that. Then you would have safe staffing and breaks, there's still that emotional healing that's needed, but that won't get anywhere until people feel safe and not overwhelmed.
Thank you for this! It's such a joy to read you columns. I greatly enjoyed reading about the effects of diagnosis and doctors' attitudes toward their patients and healing. I have an auto immune disease called lichen sclerosis that went misdiagnosed for years. Doctors thought I had herpes, overactive bladder, atrophic vulvo vaginitis. One kept throwing estrogen at me though the symptoms kept getting worse.. My pain and discomfort was dismissed as women's hysteria and all in my head and so on. Frankly, the doctors just didn't have a clue. I doubted myself and wondered if my hypochondria was in overdrive. But, I finally met a compassionate gyno who actually LISTENED to me and got a proper diagnosis.(Just recently she told me her mother has lichen sclerosis so, perhaps, this gives her extra knowledge and empathy). I was able to start treatment and get it under control and effectively treat the occasional flares. I've noticed that when I obsess and worry too much about it, and read up in chat groups about worst case scenarios I feel much worse and pretty hopeless about about having this incurable condition. Perspective is key. Anyway, great thanks for your words. So grateful to have found you.
Thank you Sarah! That sounds like a long road. It is a strange thing how we, as doctors, translate the tests are all normal to it's all in your head. Even though we know that's not the case. Maya Dusenberry talks in her book Doing Harm about the vicious cycle that happens where women's medical conditions aren't taken seriously so they aren't researched, so they aren't understood, so they aren't taken seriously. I think of endometriosis as a big example of that. Something that is incredibly painful, that only impacts women and remains very poorly understood despite how common it is.
Thank you for writing all of this, I loved how you said we often don’t know why or how disorders happen. I remember studying mental health diagnoses in school and for each one learning, it is unclear what the source is.
Thanks Emma, I think that’s one of the challenges for doctors is how to accurately convey how much is/isn’t known about a given disorder. As Mate said, through the proper lens, it often isn’t even a disorder, but a response that made a lot of sense in an earlier situation, even if it is maladaptive now.
Yes! It definitely goes against the ideal that doctors know all, when truth is there is so much unknown and like Mate talks about in his book, rooted into the past.
I love this, Amy! The Universe seems to be pushing me in the last few weeks to understand a set of symptoms with no easy handle on it.
Two of the most important observations to make are "What the F is this?" and "I just can't seem to understand what's going on!" The terrible opposite, of course, is the void - "It's nothing."
So many times, I have patients who say, "Oh, I went to the emergency room Saturday with stomach pains, and they did all the tests, and it was nothing." Sometimes, they don't even recall what the tests were.
No patient symptom is "nothing."
The medical Universe has been dragging me over the last few weeks to understand sclerosing panniculitis, a disease I've never heard of, and I've been practicing for 30 years. Beware the disease with too many names. Peritoneal Weber-Christian disease, sclerosing panniculitis, hypodermitis sclerodermaformis enterica, mesenteric panniculitis. It means that nobody has been able to get their hands around a cluster of symptoms and signs that they see, and give it a name out of desperation. If you go back in medical history, lots of things had multiple names, until people had clustered them under a diagnostic name.
I've always been fascinated by disease taxonomy, btw.
I'm working on someone who has this and am checking on another one who might. Now, your fine article comes up pointing the finger at this thingy. Having a name or pathology doesn't make something more or less real - it just gives a name to an apparent cluster of symptoms.
In philosophy, this is "nominalism." A name just means a name, the reality is in the individual examples.
I'm racing to go to work, but I just had to drop in my two cents.
Thank you, Steve! It is interesting how those lessons all pile up at one place and time. As an ER doc, I get so frustrated with the dismissive it's nothing. When all the tests come back good, my usual schpiel, goes something like, "We did not find a clear cause of x on the tests. That doesn't mean nothing is wrong, but it does mean it is unlikely to be dangerous over the next few days. It may take us more time to figure out what's going on or it may get better on its own." In order to make that statement in good faith, you have to have someone to refer to that is actually going to try to help them figure out what's going on, which sometimes works better than others. I also don't know about sclerosing panniculitis, but it sounds painful! Is there a treatment for it or does it fall into that category of just helping each individual do the best they can? Thanks for sharing your two cents, hope your work day goes smoothly.
Thank you very much for this excellent essay. For me, the key portion of this article was: "Declaring that a person has a certain condition gives doctors the confidence to discuss prognosis or what to expect going forward. This can be helpful for patients’ plans from when to return to work to ‘do I need to start making funeral arrangements?’" It gives a sense of closure. Patients, however, don't really care. They want resolution for the problem by the shortest, safest route. In situations where it is difficult to come to a diagnosis, our sense of uncertainty transfers to the patient. Patients don't like this. They prefer a physician who sounds and acts confident (even when wrong) to one who is dithering, albeit out of a desire to do the best for the patient. I admit that this challenge and pressure are the greatest in Emergency Medicine and Critical Care where "flying by the seat of your pants" is a necessary skill.
Thanks Arjun! I agree that confidence is part of the performative aspect of medicine. As you said, it's always a delicate balance in Emergency Medicine where we often have very little certainty. I tend to try to express show my confidence through the process, through conveying that whatever we find I know what to do next (which is almost always true), rather than a more blustery form of confidence. I do think that the anticipatory guidance is really important though, especially in conditions where the resolution is going to take a while. For example, my mom had a meningioma. The surgeon said, you'll be in the hospital for about a week, it will take you 6 months to get back to normal. What happened between one week and one month was a total black box. Luckily, she was retired, so she had time to recover, but if it had been me, with the guidance she received, I would have probably been planning to go back to work after a few weeks, which definitely would not have been realistic at all.
It's one of the hardest parts of being a responsible doctor, Amy. Patients and their families have to get on with their lives and we owe them a reasonable estimate of time frames for their problems. But, Medicine involves so many uncertainties; despite our best efforts and intentions, our projections go awry.
Love this. I recognize doctors are often so pressed for time and burnt out themselves, and yet as a clinician myself.. I often struggle with the argument of “doctors don’t have time”. Answering the questions you end this piece with doesn’t require more time than the current consultation average. It’s simply a shift in your way of being. In my work within minutes of intentionally sitting and listening to someone I can have a good idea of what threads we need to follow and what questions to ask. Validation and active listening take no more time that checking boxes and ordering tests. I wonder what our medical system would be like if more doctors brought back those rituals!
Thank you! At least within the context of emergency medicine, it does take a lot more time than the “standard of care” and even more than that showing up emotionally for that volume of people takes a lot of energy in a system that does not do anything to replenish those who expend more energy. Does it take more than it takes other professionals, that I don't know. But people who are drawn to medicine often do so to prove their worth to someone, then long-term shame and fear based training further damages their self-worth so often we don't have the capacity to be present for negative emotions without becoming defensive, unfortunately.
I think there’s something to be said for finding a way of being even in emergency care that allows for healthy boundaries and energy maintenance for the provider while also a presence that doesn’t invalidate the patient. There’s always situations outside that ideal of course. Bad days happen, difficult clients are common, empathy gets blurred with burnout. I’m really glad to see this discussion happening more and more though. Interpersonal skills in the context of any practitioner context are so often not taught, and yet are so in demand.
Yes, I think letting go of money and efficiency as the ultimate priority in the system are key to that. Then you would have safe staffing and breaks, there's still that emotional healing that's needed, but that won't get anywhere until people feel safe and not overwhelmed.
If patients are no longer numbers, humanity returns. And, if staff are also no longer numbers..
Thank you for this! It's such a joy to read you columns. I greatly enjoyed reading about the effects of diagnosis and doctors' attitudes toward their patients and healing. I have an auto immune disease called lichen sclerosis that went misdiagnosed for years. Doctors thought I had herpes, overactive bladder, atrophic vulvo vaginitis. One kept throwing estrogen at me though the symptoms kept getting worse.. My pain and discomfort was dismissed as women's hysteria and all in my head and so on. Frankly, the doctors just didn't have a clue. I doubted myself and wondered if my hypochondria was in overdrive. But, I finally met a compassionate gyno who actually LISTENED to me and got a proper diagnosis.(Just recently she told me her mother has lichen sclerosis so, perhaps, this gives her extra knowledge and empathy). I was able to start treatment and get it under control and effectively treat the occasional flares. I've noticed that when I obsess and worry too much about it, and read up in chat groups about worst case scenarios I feel much worse and pretty hopeless about about having this incurable condition. Perspective is key. Anyway, great thanks for your words. So grateful to have found you.
Thank you Sarah! That sounds like a long road. It is a strange thing how we, as doctors, translate the tests are all normal to it's all in your head. Even though we know that's not the case. Maya Dusenberry talks in her book Doing Harm about the vicious cycle that happens where women's medical conditions aren't taken seriously so they aren't researched, so they aren't understood, so they aren't taken seriously. I think of endometriosis as a big example of that. Something that is incredibly painful, that only impacts women and remains very poorly understood despite how common it is.
Thank you for writing all of this, I loved how you said we often don’t know why or how disorders happen. I remember studying mental health diagnoses in school and for each one learning, it is unclear what the source is.
Thanks Emma, I think that’s one of the challenges for doctors is how to accurately convey how much is/isn’t known about a given disorder. As Mate said, through the proper lens, it often isn’t even a disorder, but a response that made a lot of sense in an earlier situation, even if it is maladaptive now.
Yes! It definitely goes against the ideal that doctors know all, when truth is there is so much unknown and like Mate talks about in his book, rooted into the past.
I love this, Amy! The Universe seems to be pushing me in the last few weeks to understand a set of symptoms with no easy handle on it.
Two of the most important observations to make are "What the F is this?" and "I just can't seem to understand what's going on!" The terrible opposite, of course, is the void - "It's nothing."
So many times, I have patients who say, "Oh, I went to the emergency room Saturday with stomach pains, and they did all the tests, and it was nothing." Sometimes, they don't even recall what the tests were.
No patient symptom is "nothing."
The medical Universe has been dragging me over the last few weeks to understand sclerosing panniculitis, a disease I've never heard of, and I've been practicing for 30 years. Beware the disease with too many names. Peritoneal Weber-Christian disease, sclerosing panniculitis, hypodermitis sclerodermaformis enterica, mesenteric panniculitis. It means that nobody has been able to get their hands around a cluster of symptoms and signs that they see, and give it a name out of desperation. If you go back in medical history, lots of things had multiple names, until people had clustered them under a diagnostic name.
I've always been fascinated by disease taxonomy, btw.
I'm working on someone who has this and am checking on another one who might. Now, your fine article comes up pointing the finger at this thingy. Having a name or pathology doesn't make something more or less real - it just gives a name to an apparent cluster of symptoms.
In philosophy, this is "nominalism." A name just means a name, the reality is in the individual examples.
I'm racing to go to work, but I just had to drop in my two cents.
Thank you, Steve! It is interesting how those lessons all pile up at one place and time. As an ER doc, I get so frustrated with the dismissive it's nothing. When all the tests come back good, my usual schpiel, goes something like, "We did not find a clear cause of x on the tests. That doesn't mean nothing is wrong, but it does mean it is unlikely to be dangerous over the next few days. It may take us more time to figure out what's going on or it may get better on its own." In order to make that statement in good faith, you have to have someone to refer to that is actually going to try to help them figure out what's going on, which sometimes works better than others. I also don't know about sclerosing panniculitis, but it sounds painful! Is there a treatment for it or does it fall into that category of just helping each individual do the best they can? Thanks for sharing your two cents, hope your work day goes smoothly.
Thank you very much for this excellent essay. For me, the key portion of this article was: "Declaring that a person has a certain condition gives doctors the confidence to discuss prognosis or what to expect going forward. This can be helpful for patients’ plans from when to return to work to ‘do I need to start making funeral arrangements?’" It gives a sense of closure. Patients, however, don't really care. They want resolution for the problem by the shortest, safest route. In situations where it is difficult to come to a diagnosis, our sense of uncertainty transfers to the patient. Patients don't like this. They prefer a physician who sounds and acts confident (even when wrong) to one who is dithering, albeit out of a desire to do the best for the patient. I admit that this challenge and pressure are the greatest in Emergency Medicine and Critical Care where "flying by the seat of your pants" is a necessary skill.
Thanks Arjun! I agree that confidence is part of the performative aspect of medicine. As you said, it's always a delicate balance in Emergency Medicine where we often have very little certainty. I tend to try to express show my confidence through the process, through conveying that whatever we find I know what to do next (which is almost always true), rather than a more blustery form of confidence. I do think that the anticipatory guidance is really important though, especially in conditions where the resolution is going to take a while. For example, my mom had a meningioma. The surgeon said, you'll be in the hospital for about a week, it will take you 6 months to get back to normal. What happened between one week and one month was a total black box. Luckily, she was retired, so she had time to recover, but if it had been me, with the guidance she received, I would have probably been planning to go back to work after a few weeks, which definitely would not have been realistic at all.
It's one of the hardest parts of being a responsible doctor, Amy. Patients and their families have to get on with their lives and we owe them a reasonable estimate of time frames for their problems. But, Medicine involves so many uncertainties; despite our best efforts and intentions, our projections go awry.