Balls and Walnuts
more than you ever wanted to know
The barbarous craft
One of the reasons I like my particular branch of medicine is that I occasionally get to do things which are 100% the right thing to do. If someone’s ear is full of wax, it’s never a mistake to remove it. Same goes for a kid with a bead up her nose. There are times, happily many times, when I know exactly what to do and then I do it and then I have a happy patient (or parent).
But like any doc, there are times when I don’t know what’s going on, when my best guess is probably no more accurate than a Magic Eight Ball, when my only asset is that semi-mystical laying-on-of-hands thing. When success depends upon my shine as a huckster, a salesman hawking something he really doesn’t believe in but knows that if his pitch is good, he’ll still have a happy client.
There are, for example, patients who have so many varied aches and pains and dysfunctions that I have to wonder if I’m either (A) missing something that only Dr. House could figure out (I know — it’s palladium poisoning!) or (B) dealing with a patient with a conversion disorder. That’s when the patient’s mental/emotional ailments “convert” into physical problems. Not terribly common, I’m afraid. I mean, I can remember one patient who developed a ball in the throat sensation the same week her husband died, and pointing out that “coincidence” was enough to cure her problem. But I have to think that conversion disorders are extremely uncommon.
Which leaves me in the dark, of course. If I’m not bright enough to apply Occam’s Razor and come up with the one brilliant diagnosis that knits it all together, and if I’m not willing to consider every stumper a psychological issue clad in physical symptoms, then I’m forced to admit ignorance. I do this most of the time, but I realize I’m not making anyone happy, least of all my patient. Some people want honesty. Most don’t.
Fortunately, no one else has been able to figure out my patient, either, and most of my predecessors haven’t even tried. So the first thing I discovered long ago is that trying matters. The mere fact that a doctor cares enough to want to figure things out is, pathetically, therapeutic. (Pathetically because it’s sad how often people are blown off by their other doctors.) And that’s step one of Good Hucksterism Good Doctoring. Step two is Doing Something. Doesn’t always have to be a prescription, and in fact I had one angry patient today who said his doctor “admitted he prescribed antibiotics for his patients because it made them feel better to get a prescription.” (Step three: the wizard never peeks out from behind the curtain. Never.)
Doing Something could mean framing the problem to make the patient realize that it truly is multifactorial. Your weight problem contributes to your sleep apnea, which exacerbates your nocturnal reflux (as does your smoking, by the way), which is giving you that cough (and the smoking doesn’t help your cough much either), and if you got a little more exercise you’d lose some weight and your apnea might improve and your fatigue would lessen etc. etc. Now, suddenly, all these disparate symptoms start making sense. It’s not so much that your body is falling apart and it’s not age. It’s your damned lifestyle.
Interestingly, my theory — the way I’ve framed the problem — need not be correct. It helps if I’m right, but it’s not essential. Because sometimes what people want is not so much relief of their symptoms as relief from worry. If I can exclude life-threatening illness (and yes, I can do that most of the time with imperfect certitude . . . but nothing is perfect . . .) and I can help them understand what’s going on, more often than not they’ll say they can live with their symptoms.
But getting back to the stumpers: it’s true, sometimes I play the Magic Eight Ball*. And if I make my pitch with verve and style, and if I make them think someone cares, and if I can sell them on the wisdom of this or that treatment strategy, well, the patient might get better. Often does.
And I’ll never know if I was right, or merely skilled at slinging the bull.
D.
*Mind you, I’m not so proud that I won’t send such patients to other specialists, or to other ENTs for a second opinion within the specialty. But what do I do about the patients who have seen all the other specialists and who are coming to ME for a second, third, fourth opinion? Do I tell them, “I’m as dense as everyone else you have seen,” or do I try to help, even if helping carries with it a dollop of dishonesty?
I prefer a doc who is honest enough to tell me he doesn’t know, because that way I’m not pissed when I find out his answer was bs. That;s why I go all the wayy across town to see my endocrinologist. 🙂
Just like my students prefer teachers who don’t make up answers when they don’t know them, I prefer a doctor who is going to be honest with me. As patients, I think many of us know when something is wrong, but I also function on the the old saying, think the worst and you’ll be pleasantly surprised. Of course when it really IS the worst, that old saying is of no help at all. Many times it feels good just to hear the doctor tell you it’s not as bad as you thought it was.
It isn’t all black and white. With the head-scratchers, I’m able to admit enough uncertainty that the “honesty” factor is satisfied. Assuming I can make an educated guess and that I’m reasonably certain that a mistake on my part will do no more than delay appropriate care (and not actually jeopardize someone’s health), then I have no problem playing out that guess. The art here lies in juggling that honest admission of uncertainty with the pitch for why this therapy will help.
aaargh . . . once again foiled by privacy rules. This would be so much easier to explain if I could discuss cases.
Hmmm, your Doing Something example is a pretty good description of my better half’s health.
I am always suspicious of good news and wonder what I’m not being told. When I was looking into fertility specialists, I was very put off by a doc who gave me a very rosy story and when I expressed concern about mutiples, she told me that I wouldn’t have any problems carrying twins or more or if I wanted I could have a “selective reduction”. Not what I wanted to hear! The clinic we went with was very frank about the chances of failure. Of course fertility treatments are elective and the clinics are designed to make money, so there’s perhaps a bit more “marketing” than elsewhere.
It seems we read more and more about body-mind interactions, so I think that your taking the time to seriously consider these mystery problems and took reassure patients, when appropriate, is probably therapeutic.
I’d like a selective reduction around the midsection. Think they’d accommodate that request?
I still remember Karen being told by THREE fertility specialists that her chance of conceiving was something like “3 in 10,000”. Lifetime chance. And yet here we are with a kid produced the old-fashioned way (by earning him!) Gonifs.
I don’t like to tout the mind-body connection to loudly, Kira. The downside is that it can too easily be turned around: it’s YOUR fault you’re sick.
I can completely agree with you on that last message. My mother has that mind-body connection down to a T. She has some hard times of the year depression-wise, and ALWAYS her other problems flair up. With more worry = more problems, which makes you worry about them, which makes them seem horrible, which makes you worry… well, you can see where this is going. But, I have found that Doctors that at least try to do something, make her feel so much better. Even a doctor that flat out tells her that her dizziness has been looked at so much that they really don’t know what causes it, and it’s probably something that may never go away. Hey, that’s progress. It’s those doctors that look at you with a smile and say something stupid like “It’ll be okay, I’m sure that you’re just having a bad day.” or *smile* “That just goes along with being old” and leaving it at that. THAT pisses me off.