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 800-Lb 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.