"I'm sorry I waited so long to come in to be seen," she told me after having symptoms for two weeks.  She had a truly apologetic expression on her face, looking to me for reassurance that I wasn't too mad at her.

"That's OK.  It's hard to know when you felt bad enough to come in," I reassured her.  "Obviously up to now you haven't felt bad enough to get seen, and now you do."

She relaxed after I said this and the office visit went on to deal with her problem.

I get this a lot.  People apologize to me for everything.  They apologize because they didn't come in soon enough, or because they should've waited longer to come in.  They apologize for their earwax, or because their socks aren't white enough.  They apologize because they didn't take their medications as directed, or because they took a pill from their husband's stash.  They apologize because they think they might not be sick enough, and (my favorite) they apologize because they are always sick when they come in to see me.

Geez.  As a doctor, I just hate seeing sick people.

"That's OK," I tell them.  "I spend a lot of time around sick people."  Somehow they are reassured by this.

Why are people so sorry when they come in to see me?  What makes my acceptance of their apology so meaningful to them?  What is it in being a doctor that makes it so people feel like they are accountable to me?

It wasn't until I became a patient myself that I started to understand the answer to these questions.  I had a broken shoulder (proximal humerus) and was going to the orthopedist for treatment.  There wasn't much he could do other than x-ray it and send me to physical therapy.  The healing had to happen on its own.  But each time I went in to be seen (often in a lot of pain), I felt a great need to be validated that my pain was really as bad as I thought.  I certainly didn't want my colleague to think I was a wimp.  It's not that he was at all skeptical about my pain, or that he ever suggested that I shouldn't be having as much pain as I did; I just needed validation.

It was at that point that I realized just how uncomfortable my patients feel in the exam room.  They want to be reassured in their pain.   It was hard enough for me with a clear reason to complain - a big broken bone - so I can only only guess how hard it must be for people with less obvious causes of pain.  What about the people with lupus, depression, migraines, or fibromyalgia?  How much does the doctor's acceptance (or lack of it) affect the patients' perception of their own pain?

I don't do anything to merit such importance.  I don't try to become the validator of their pain.  But simply by being their doctor, that is exactly what I am.  My role goes beyond diagnosis, treatment, assessment, and plan.  My role becomes that of a best friend who understands what they feel, or a "Dr. Rob scanner" that looks them over and says, "yes, you scientifically should feel this crappy."  If I can somehow make them feel validated, they go out happy.

This is harder than it sounds (and it probably doesn't sound easy) because there are times that people really make me wonder.  Do they really feel this bad, or are they just trying to use their disease as their identity?  There are people who need exactly the opposite of encouragement and validation, they need me to make them believe they are more than just a disease.  They seem to feel that if they didn't have the disease, they wouldn't know who they were.  This is especially common in diseases that people feel the need to convince others of the reality of their symptoms.  I had a woman with Lupus complain about having to fight the perception that she was exaggerating her symptoms for sympathy.  I also have people who don't let 2 sentences go by without mentioning their pain or their disease.

To the latter group, I do my best to focus on the positives.  I try to compliment their clothing, or imply that they are getting better each time they come in.  I talk about something other than their disease.  But I can't seem to be ignoring their pain, or even worse, to be skeptical of its validity.  It's a tightrope at times.  For the others - the ones who have no desire to hurt, but have to fight for others to believe - I need to be clearly in their camp.  They apologize because they are used to having to apologize, but I need them to feel that I am a person who actually does believe them and can help them.

I'm sorry about all the times I haven't done this.