Doctor and patient: Insecurity meets insecurity

She looked at me, eyes pleading, telling me without needing to say a word: I am not lying to you. I am not crazy. I am not making this up.

I sighed. “We’ve done the work-up and know this is not your heart. I don’t think there are a lot more tests that can be run.” I studied her expression, trying to discern what she wanted to hear from me.

I’ve come to understand that there are two questions my patients are looking for me to answer:

  • Is there anything serious?
  • Can you make me feel better?

Doctors don’t seem to know this list, instead either focusing on a third question, What is wrong with me?, or failing to answer one of these two questions. I’ve heard countless tales of frustration over hours spent at the doctor’s office only to hear the final judgment of “nothing is wrong.” These doctors have answered question #1 without addressing #2, leaving the patient to feel like they aren’t believed by the doctor. In the best case, this is a well-minded doctor who simply doesn’t consider the patents’ perspective; in the worst case, the doctor questions the validity of the patient’s story.

Not knowing which question was weighing on my patient, I asked directly: “So, are you still concerned that this is a dangerous condition? I know it’s hard to have chest pain whenever you exercise and not be a little worried, but I think the risk of this being serious is pretty low.”

“It just hurts,” she told me flatly. “I exercise through the pain, but it gets pretty bad at times.”

There. She clearly wanted question #2 answered. Yet I had already been trying different things to get rid of this pain, none of which were working. Part of me wanted to shrug and explain that I’d done all that I could do, sending her home only with the reassurance that she wasn’t going to die from it, it was just going to hurt and there was nothing I could do.

Attempting to remain disciplined in my approach, I thought through the list of possible causes: What lives in that zip code?

  • The heart does, but we’d pretty much ruled that out as the cause.
  • The lungs are there, but when does a person simply experience pain in the upper chest because of the lungs, especially without shortness of breath? I don’t think it’s that.
  • The esophagus takes a trip through that area, but again, what’s the chance of exertional esophageal pain? Not impossible, but quite unlikely. Besides, she’s already on Prilosec.
  • People with anxiety sometimes complain of chest pain, but it’s usually during emotional stress, not physical exercise.
  • That leaves only the chest wall as the best explanation, but I’d already gone after that with both systemic and topical medications with little improvement.

A small voice spoke out in the back of my consciousness: It makes no sense! She must not be telling the truth! Clearly I’ve done all I can do, and so there must not be an answer. There is nothing wrong with her really!

I hear that small voice whenever I am at a loss. The voice comes out of frustration at not being able to help patients, but mainly out of my own insecurity. I don’t want to fail. I want to be a superhero, swooping in with my cape to solve my patients’ problems and to make them all happy. I don’t want people to be disappointed in me. You don’t go into medicine without at least a small need for people to admire you. For me, that need is a 800lb gorilla. I want people to be proud, not disappointed. I want to look smart, not dumb.

Another part of this voice comes from the small group of people who want to use the doctor as a vending machine. They know if they say certain things and push the right buttons, the doc will give them what they want, whether it’s an antibiotic, a pain medication, or an order for a test. They hit me at a second insecurity: the fear of not being in control. It should come as no shock that most doctors have this insecurity. We hate being used or manipulated (do you hear that, payors?). I’ve concluded that, in my population at least, few of my patients are this way (and those who are, eventually leave disappointed).

Fortunately, I’ve learned to ignore that voice of my own insecurities.

Unfortunately, many docs out there haven’t been so successful, and some will actually openly question whether the patient is actually experiencing the symptoms they report. The skepticism with which patients are met as they tell their stories is most acute in the “quick fix” settings, like the ER or urgent care center, but it happens everywhere. Patients are on the defensive as they tell about their symptoms, trying to justify their visit to the doctor, and to “get the doctor to believe” what they are saying. It’s as if the patient is considered duplicitous until proven honest.

Here’s the problem I faced as I met with this patient: If I accepted her story as true, I had to accept my inability to help; but if I didn’t accept her story, I label her as a liar, someone who wastes my time, a cheat, or an incredibly mentally disturbed person. For what reason would she make this stuff up? I couldn’t come up with any. She was telling me her experience: that for her the pain goes like this, the medications I did helped like that. To her, the grass looks green. If I doubt her reality, I am essentially telling her that pain isn’t what she said, the medication didn’t have that action, and that the grass actually is blue, not green. I am telling her that her reality is not real.

Who am I to invalidate another person’s reality? I can question conclusions she draws, but not the reality itself. Our realities are all we’ve got, and we have to trust our own senses.

“I’m kind of stumped here,” I confessed to her, going through my list of possible causes. Together we discussed the possible options of diagnostic testing and treatment. While we talked, she continued showing a glimmer of fear in her eyes. It wasn’t that she thought she’d die from this, and I don’t even believe it was a fear that I couldn’t help her; it was a fear I would tell her the grass was not green. Maybe her reality isn’t real. Maybe she is crazy.

Doctor and patient. Insecurity meets insecurity. Weak helping weak.

Humans.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.

Comments are moderated before they are published. Please read the comment policy.

  • Shirie Leng, MD

    Wow. Beautifully said.

  • Suzi Q 38

    “……..Who am I to invalidate another person’s reality? I can question conclusions she draws, but not the reality itself. Our realities are all we’ve got, and we have to trust our own senses…….”

    I used to think that doctors had x-ray vision, or was a computer of sorts that could process my symptoms and come up with a diagnosis and treatment.

    I remember after describing my symptoms numerous times after my surgery, my doctor just said that he did not know.
    After I overexerted myself during a vacation, I could barely walk.
    My treatment and complaints were a year and a half of wasted time.
    No one was listening.

    Here I was, at one of the best cancer hospitals in my state.
    I had PPO insurance.

    It took a couple of doctors at that hospital to finally listen to me when I told them that I had had these symptoms since my surgery and that I was leaving to go elsewhere.

    The gastro finally made the correct diagnosis.
    It was severe spinal stenosis of the c-spine. Not the surgeon or the neurologist. The gastro. I was on my way to becoming a quadraplegic with the next fall.

    I realized that physicians are very, very smart when they want to be.
    I envisioned my doctor to be all knowing and to have a large staff at h/her disposal if he did not have the answers. I was so wrong.

    There was no caring physician thinking about what my condition could be. He forgot about me as soon as he closed the door to my exam room.
    To ask him to write a referral was too much for this physician.

    My suggestion to any patient is this:
    Every doctor is smart in their own way. How else could they have passed medical school, residency, and fellowships? On the other hand, if they do not believe you, for all their education and positive attributes, they are worthless to you. If they do not wish to explore other possibilities for determining what you have and have nothing less to offer you, do not give up. Do your research with family and friends and get a doctor who will listen to you or find the answer.

    You can not make the nice doctor into the one you want h/she to be for you. Quit wasting time with your condition getting worse and get some help and some answers if you can afford it.

    Leave graciously, but do not stay with a physician who does not believe you.

    • rbthe4th2

      Whooo hooo you said it!

  • http://doctor-rob.org/ Dr. Rob

    Admission of weakness is certainly a form of strength. I agree that it takes more strength to admit weakness than to deny it. Still, one must always know their real limits. Relatively, this is a show of strength, but it is still weakness in the absolute sense.

  • Karen Ronk

    As a patient, I think it is about finding the right doctor and establishing a relationship. After suffering nerve damage after a routine surgery, I had a list of symptoms that were initially misdiagnosed and then under-diagnosed. I found a physician willing to stick with me who knows that if I say something is happening, then it is happening. In my case, there is physical evidence to back it up, which I know makes a difference.

    Unless you think your patient is suffering from mental or emotional instability, then you need to do all you can to address their concerns – even if it means sending them on to another physician or perhaps a psychologist if you think that is warranted. Having become a “professional patient”, I know I would do anything to get off this merry-go-round and any “normal” person would feel the same way.

    • rbthe4th2

      Yes! I agree. I go to doctors to get my physical problems fixed. That’s why I keep coming.

  • rbthe4th2

    Wow. I am impressed. I would have no problem with a doctor that did the above, in going thru all the steps and see what we can do to fix a problem. God bless those doctors, because I’ve had a few who can’t face their insecurities.

    Or their patients that they blame because they can’t feel that way.

  • Suzi Q 38

    “…You see, I am just like your patient. Different symptoms, but entering into every conversation with the fear of hearing it is all in my head, and waiting for the depression card to come out….”

    Yes, these two doctors with no empathy probably thought it was all in my “head,” and I was a hypochondriac. My neurologist told me nothing was wrong, just my lumbar spine was slightly swollen. He neglected to order an MRI of my c-spine and t-spine. He did not think it was necessary. He thought I was making it all up.

    In desperation, I went to see an endocrinologist, hoping to find some answers metabolically since I had gone through a hysterectomy and abrupt surgical menopause. She was such a nice physician. She told me, “I don’t know what is wrong with you, but it has nothing to do with endocrine or your menopause. You are experiencing nerve symptoms, and they are escalating. Get to a neurologist who will order you an MRI on your entire spine. Don’t let a couple of doctors waste any more of your time.”

    I finally told my neurologist who thought that I was a hypochondriac that the other doctors didn’t think so. I told him about the gastro and the endo telling me to get a full MRI.
    When he looked annoyed and hesitated to write the order, I told him that Dr. D the gastro “said so.” With that, he finally did his job.

  • querywoman

    Oh yes, I used to get them freaking out over BP too instead of caring about whatever I chose to pay money to discuss.

    Strep seems like such an easy diagnosis! Some doctors are just thick to the obvious!