There’s always more floaters than time to anchor them to words. This, as with many posts, has been brewing (on cold drip?) for many months now. But I’ve marked it with a priority flag. Barely a month out and I’m already struggling to picture life in mainstream general practice or remember the stories that triggered this thought in the first place.
(On a side note, I suppose when you move clinics you wonder how the patients are doing. I haven’t much, except with the antenatals; many whom I’ve been seeing since their very first visit. I hope the little ones have hatched successfully. On my last day one patient gave me a hug and said, “aww, you mean, you’re not going to meet my baby?!” I recounted the story at home, then mum made the snide remark that I should just hatch my own, but that’s a scary thought.)
Is that medical
Many people demand medical certificates for work or welfare, without a medical condition, sometimes blatantly gaming the system for financial gain. But this occasion was memorable because it was the only time I’ve opened the door and informed a patient that we could not continue with the consultation.
The woman arrived more than half an hour late for a fifteen minute appointment. She was “fed up with working” and went on a one week holiday out of town. Now she was back and wanted a medical certificate to be paid sick leave for her days away. This was her first time seeing me, and she wasn’t interested to explore or manage any underlying issues. “The other doctor just writes a week off when I want some time off.” I gave her some options (me writing this certificate wasn’t one) and she started raising her voice. “What are you going to do for me? Nothing?! It’s a waste of time seeing you, you’re just adding to my problems. I’ll never come back to you again, YOU LOST ME AS A PATIENT.” Then she added, “I came late but had to wait. I shouldn’t have come on time anyway!”
To what extent (start of an essay question) is the employer-employee relationship, or a person’s unwillingness to contribute meaningfully to society, a medical issue?
The palliative care patient in his mid fifties with motor neurone disease. He always arrives in a fancy motorised wheelchair, skilfully navigating the width of the door by just a few nudges of his finger. Accompanied by the wife, who is ever impeccably dressed, positive and respectful of her husband’s independence (giving him plenty of time and space to talk for himself, and make decisions about his care). His mind was crystal clear, but his only functioning limb, the left arm, was becoming progressively weak. It shook too much for him to feed himself properly or hold anything. His breathing was increasingly weak as well. “Which state has voluntary euthanasia? I feel like a useless piece of meat.”
What hope can we offer in the face of protracted suffering and incurable disease?
The girl was about my sister’s age. She presented with numerous episodes of abdominal pain throughout the year. Nothing concrete on examination or investigations. So far she’s had visits to various doctors at my clinic and the hospital, including two inpatient admissions under surgery and paediatrics, with a variety of diagnoses including recurrent cystitis and pyelonephritis (negative cultures), appendicitis (had an appendicectomy), mittelschmerz, and possible dysmenorrhoea (started on the contraceptive pill). Later, it seemed like the episodes were related to school refusal and psychosocial issues. There was high tension between her and her mum, and between her parents who were separated. Out of nowhere she also mentioned being excited about her confirmation ceremony but complained that kids at her (Lutheran!) school were teasing her about being a “goody two shoes” Christian and going to church.
For a moment I wondered whether I’d have had more to offer if she was a girl in my youth group, rather than a patient at this clinic.
An elderly woman presented for a routine 75+ health check. She lived alone and independently – the closest family member was a sister halfway around the world. She was as well as could be. When we got to the part about her mood she says she didn’t feel down or depressed but wondered about life. “At this age I know more people dead than alive. I know it’s silly but I’m angry at them for leaving me.”
We certify deaths. Does that mean we are more able to grasp life and ageing, death and afterlife?
A woman came in for just a repeat script. But just a script is never as it seems. On tidying up the “issues” list on her file , she started talking about her pregnancy last year which ended in a termination. She was actually trying for a baby with IVF and went through the emotional rollercoaster, and financial cost, of several failed cycles. Soon after giving up, she fell pregnant spontaneously. Her husband was delighted but she was ambivalent because she had already given up by then. Then, during pregnancy she had severe hyperemesis gravidarum (nausea and vomiting) that wouldn’t go away or respond to treatment. She was waking up every one or two hours to vomit or dry retch, morning and night, and there was no relief from the nausea between the vomits. She was crying constantly. “I couldn’t handle it anymore,” she recalled, now with tears in her eyes, “people say you make the best decision for you at the time. But I don’t know. I feel guilty. I’m not sure I did the right thing.”
Can we acquit someone of their guilt?
Last one, and a strange one too – the patient turned the tables and started asking me all sorts of questions (which I largely refrained from answering). She presented under the guise of being up and down with her mood. After going through the standard questions, she didn’t have any symptoms of depression or anxiety. Then she jumped into her story, which was what she really wanted to talk about, given she was new to town and had no close friends to confide in.
She moved with her husband, who recently started a new job here. They had been married for over a decade and had several beautiful children. The couple had a fantastic relationship – “we’re soulmates”. He encouraged her to get out and about, and so she’s been hitting the gym. There she fell in love with her hot personal trainer, who was “the one” and everything she ever dreamed of. Alas, he felt the same way. She was even having “X-rated thoughts” about him (this information was definitely not from my history taking). “I feel terrible! What do you think I should do?” Not a rhetorical question. Then it got more personal – “what would you do if you were me? Are you married or in a relationship?”
Confessions. I’ve never been behind (or in front of) one, but I imagine this is the sort of thing that take place at a confessional. Does medicine offer moral and spiritual guidance?
Doctors are laypersons
“It is in reality the priest or the clergyman, rather than the doctor, who should be most concerned with the problem of spiritual suffering. But in most cases the sufferer consults the doctor in the first place, because he supposes himself to be physically ill, and because certain neurotic symptoms can be at least alleviated by drugs… We can hardly expect the doctor to have anything to say about the ultimate questions of the soul. It is from the clergyman, not from the doctor, that the sufferer should expect such help.” – Carl Jung
I chanced upon that chunk of Jung’s writing (he was sympathetic towards spirituality, but not a Christian) on a contemporary article about psychotherapy being a modern-day, secular form of priesthood. It’s not just about the expectations from society. Medicine has high expectation of itself too. We seek to help, and that’s wonderful. Caring and listening well is therapeutic in itself, and healthcare does offer pharmacological and non-pharmacological resources for a variety of psychosocial problems. Yet, in our eagerness to do good, to alleviate suffering, to provide holistic biopsychosocial-spiritual care, we can utter false assurance and smear balms (quacky ones) that do not heal.
As doctors, perhaps in our puffed up notions about our abilities, we forget that more often, we are the layperson rather than the expert. Consider, are you actually the best person to help with that “question of the soul”? I thought of it often, especially during the not-so-medical consults. It helped me to pause when I wanted to quickly cover my own inadequacy with empty words. I found it immensely helpful to remember that I didn’t, simply by being a doctor, have the upper hand in understanding social dysfunction, meaning of suffering, life and death, forgiveness and healing, love and relationships, amongst a myriad of other matters.
Where is your salvation
“Those things that you couldn’t do, and those diseases you couldn’t reverse, were left unspoken [in Ethiopia]. It was understood… In America, my initial impression was that death or the possibility of it always seemed to come as a surprise, as if we took it for granted that we were immortal, and that death was just an option.” – Abraham Verghese, Cutting for Stone (novel)
Not only is there a limitation to what areas medicine has claims to expertise, there is a limit of what is possible even within our own field. From time to time, people ask about it, being Christian and a doctor, as if these were mutually exclusive. Don’t you believe in science? Why do you need God?
I didn’t know what to say to the slowly deteriorating palliative patient, or any of the others really. Partly it’s my insufficient “life experiences”. However, my profession does not not have adequate answers either, nor can it offer salvation from suffering and death. Well, maybe for a time, but never all the time. Dr Cutillo in his book acknowledges the remarkable contributions of medicine. At the same time he points out the folly of putting excessive hope in medicine, in the place of God himself:
“No area of medicine can escape this sense of failure. Most obvious is oncology, when it involves incurable cancer. But rheumatologists cannot cure lupus, cardiologists still lose patients after a heart attack, neurologists must help people live with disability after a stroke, and even dermatologists see some patients die from melanoma. In every case there is a sense of failure, for both the patient and the profession… But science and technology are bound to fail if we ask them to fulfil promises of biblical proportions.” – Bob Cutillo, Pursuing Health in an Anxious Age