- Joined
- Feb 17, 2004
- Messages
- 20,639
- Reaction score
- 3
Each of you will ask yourself this question many times practicing in the ED. "Why?"
After a failed pediatric resusitation, while you prepare to talk with the parents of the expired teenager killed by a drunk driver, when you search for the words to explain to the widow that her husband of 50 years will not be going home tonight, when you have to tell the married couple that the lab reports confirm acute leukemia....
I have been a practicing medical oncologist and hematologist
for 20 years. Although I initially trained in academic
bone marrow transplantation and cellular immunology,
I decided against an academic life in favor of a purely
clinical career because I was more of a clinician than an
immunologist. On a personal level, I developed relapsing?
remitting multiple sclerosis shortly after I moved into my
community practice in oncology and hematology. Over
these 20 years of practice, I have had 2 episodes of transverse
myelitis, 1 episode of internuclear ophthalmoplegia,
and 1 episode of left-sided apraxia. None of these events
have incapacitated me or forced me to take time off from
work until recently, when I experienced another relapse of
my multiple sclerosis. I lost my vision when I awoke on the
morning of the anniversary of my wife?s death from disseminated
breast cancer. As a patient, I am trying to grapple
with this new turn of my illness from the perspective of
someone who also happens to be a physician who cares for
patients with life-threatening illnesses.
As a physician, I have rarely given much credence to
?stress? as a factor in illness. In my line of work, it is
difficult for me to believe that stress has anything to do
with colon cancer or leukemia. I can neither measure nor
image ?stress,? yet how can I explain the coincidence of my
multiple sclerosis reactivating on the anniversary of my
wife?s death? That morning, I had no nausea, no abdominal
cramping, no pain of any kind, no palpitations or skin
rashes. Aside from thinking of her and our life together, I
had no evidence of any ?stress.? And yet, I woke up with
impaired vision.
I am more of a believer now. Whatever stress is, it was
present that morning and profoundly altered my immune
system to behave in a dysfunctional fashion. I have no
doubt that the immune activation that happened to me
could adversely affect the outcome of a serious pneumonia
or a case of active lupus. ?Stress,? which I can neither feel
nor see, has affected my own health. I am confident now
that it affects my patients? illnesses and undoubtedly leads
to poor outcomes in ways I did not understand in years
past. Stress contributes to illnesses through initiation,
maintenance, and magnification of the processes responsible
for the disorders. Now, as a physician, I understand
better the need to respond emotionally to the reality of
stress in patients? lives and to show empathy. A meaningful,
empathetic response to patients makes the physician?
patient encounter more therapeutic and useful.
To be precise, my new lesion, which caused my multiple
sclerosis relapse, was a left homonymous hemianopsia,
something I had not thought about since medical school.
Moreover, for someone who reads charts, examines laboratory
data, and reads tables and graphs in journals, its effects
have made medical practice more difficult for me. I have a
diminished area of focus on the left side of my vision. I
now understand that my vision is as important to my occupation
as is my ability to use a pen, to write orders, to
palpate an enlarged and tender liver, or to auscultate a soft
aortic insufficiency murmur. My vision was one of the
many things in my life I simply took for granted. Until my
vision recovers, however, it is harder to practice as a medical
oncologist or hematologist; I might still be a father, a
widower, a weekend cook, and a lover of groundcovers, but
it is much more difficult to function at the same level as I
did previously. Losing my sight and profession at the same
time has been profoundly unsettling. It challenges my fundamental
identity. Like hemianopsia, my professional
identity was something I had been too busy to reflect upon
seriously, but I now understand that illness takes our identities
away and makes us different people. I know that
anyone who has ever cared for sick patients has seen this,
but I comprehend this at a visceral level in a way I never
did before. Illness robs us of our sense of self and who we
think we are.
I would be disingenuous to dwell entirely on the disability
my hemianopsia has visited upon me. There are
actually some gifts that flow to me as a patient from the
illness. Beyond the biological and physiologic aspects, illness
has the potential to provide a metaphor for life, which,
when well turned, can be useful and instructive to us as
humans. Suffering reminds us that life is both short and
fragile and not to be taken for granted. This kind of insight
is trite and hackneyed until it is made relevant, and personal
suffering makes these kinds of insights powerfully
relevant. As a physician, I tend to lose that perspective. I
try to focus relentlessly on the physiologic and anatomic
because that is our training. Our scientific training does
not instruct us in suffering or anguish. We are taught to
focus on objective, measurable, and quantifiable biological
syndromes. Recognizing and treating medical entities like
gram-negative septicemia or bowel obstructions demand
clear-headed thinking about pharmacology, anatomy, and
physiology, rather than the emotional complexity of suffering.
And yet, as I reflect on the possibility of my own
potentially devastating visual disability, I find myself thinking
not about autoimmunity and multiple sclerosis but
rather my family and my real identity: Who am I if I can
no longer work or see? I think how odd it is, considering
my personal background in cellular immunology, that I do
not obsess on the arcane details of autoreactive T cells in
multiple sclerosis, but rather on soft, nonquantitative issues
such as my children and my deceased wife, our life together,
and ruminations about the future. Must we lose
our sight to discern who we really are?
As I think about my life and my family and struggle
with my identity, I find it oddly comforting to be able to
trust my physician to make prudent treatment recommendations.
Trusting my neurologist is liberating because it
frees me to reflect on the things that really matter to me,
and that trust will speed my recovery emotionally and
physically. This point of view places the treating physician
in a paternalistic role objectionable to many health care
consumers. However, from my own personal perspective as
a patient, trusting my doctors alleviates a substantial
amount of stress by avoiding the process of second-guessing
my physician. In this manner, the doctor?patient relationship
avoids becoming adversarial and actually can become
therapeutic, both emotionally and physically. The
benefit to me as a patient derived from trusting my physician
was another insight I had never understood about
illness until I lost my vision.
As a physician, I understand that there is much randomness
to sickness and health. We all see this. We see
smokers and drinkers who somehow defy all odds, and
then other patients who are cut down or disabled unfairly.
I do not believe that ?Why?? is a useful question for these
injustices. ?Why?? implies a reason, and attributing causality
has limited benefit for patients except to avoid future
mishaps. Rather, the utility of suffering is that it helps us
sharpen our internal focus to more clearly see the true
contours of our lives. This sharpened focus can be potentially
transforming for patients, and it would be wise for us
as physicians to acknowledge this. If illness changes our
identities and the way we look at life, let us try to profit
from the change emotionally and learn from the different
perspective it gives us. Let us learn to empower our patients
to see what is important in their lives and help them embrace
those entities. There are always lessons to be learned.
Peter A. Beatty, MD
University of Wisconsin Medical Foundation
Madison, WI 53715
Current Author Address: Peter A. Beatty, MD, University of Wisconsin
Medical Foundation, 1 South Park Street, Madison, WI 53715; e-mail,
[email protected].
Ann Intern Med. 2004;141:404-405.
On Being a Patient Physician as Patient
www.annals.org 7 September 2004 Annals of Internal Medicine Volume 141 ? Number 5 405
After a failed pediatric resusitation, while you prepare to talk with the parents of the expired teenager killed by a drunk driver, when you search for the words to explain to the widow that her husband of 50 years will not be going home tonight, when you have to tell the married couple that the lab reports confirm acute leukemia....
I have been a practicing medical oncologist and hematologist
for 20 years. Although I initially trained in academic
bone marrow transplantation and cellular immunology,
I decided against an academic life in favor of a purely
clinical career because I was more of a clinician than an
immunologist. On a personal level, I developed relapsing?
remitting multiple sclerosis shortly after I moved into my
community practice in oncology and hematology. Over
these 20 years of practice, I have had 2 episodes of transverse
myelitis, 1 episode of internuclear ophthalmoplegia,
and 1 episode of left-sided apraxia. None of these events
have incapacitated me or forced me to take time off from
work until recently, when I experienced another relapse of
my multiple sclerosis. I lost my vision when I awoke on the
morning of the anniversary of my wife?s death from disseminated
breast cancer. As a patient, I am trying to grapple
with this new turn of my illness from the perspective of
someone who also happens to be a physician who cares for
patients with life-threatening illnesses.
As a physician, I have rarely given much credence to
?stress? as a factor in illness. In my line of work, it is
difficult for me to believe that stress has anything to do
with colon cancer or leukemia. I can neither measure nor
image ?stress,? yet how can I explain the coincidence of my
multiple sclerosis reactivating on the anniversary of my
wife?s death? That morning, I had no nausea, no abdominal
cramping, no pain of any kind, no palpitations or skin
rashes. Aside from thinking of her and our life together, I
had no evidence of any ?stress.? And yet, I woke up with
impaired vision.
I am more of a believer now. Whatever stress is, it was
present that morning and profoundly altered my immune
system to behave in a dysfunctional fashion. I have no
doubt that the immune activation that happened to me
could adversely affect the outcome of a serious pneumonia
or a case of active lupus. ?Stress,? which I can neither feel
nor see, has affected my own health. I am confident now
that it affects my patients? illnesses and undoubtedly leads
to poor outcomes in ways I did not understand in years
past. Stress contributes to illnesses through initiation,
maintenance, and magnification of the processes responsible
for the disorders. Now, as a physician, I understand
better the need to respond emotionally to the reality of
stress in patients? lives and to show empathy. A meaningful,
empathetic response to patients makes the physician?
patient encounter more therapeutic and useful.
To be precise, my new lesion, which caused my multiple
sclerosis relapse, was a left homonymous hemianopsia,
something I had not thought about since medical school.
Moreover, for someone who reads charts, examines laboratory
data, and reads tables and graphs in journals, its effects
have made medical practice more difficult for me. I have a
diminished area of focus on the left side of my vision. I
now understand that my vision is as important to my occupation
as is my ability to use a pen, to write orders, to
palpate an enlarged and tender liver, or to auscultate a soft
aortic insufficiency murmur. My vision was one of the
many things in my life I simply took for granted. Until my
vision recovers, however, it is harder to practice as a medical
oncologist or hematologist; I might still be a father, a
widower, a weekend cook, and a lover of groundcovers, but
it is much more difficult to function at the same level as I
did previously. Losing my sight and profession at the same
time has been profoundly unsettling. It challenges my fundamental
identity. Like hemianopsia, my professional
identity was something I had been too busy to reflect upon
seriously, but I now understand that illness takes our identities
away and makes us different people. I know that
anyone who has ever cared for sick patients has seen this,
but I comprehend this at a visceral level in a way I never
did before. Illness robs us of our sense of self and who we
think we are.
I would be disingenuous to dwell entirely on the disability
my hemianopsia has visited upon me. There are
actually some gifts that flow to me as a patient from the
illness. Beyond the biological and physiologic aspects, illness
has the potential to provide a metaphor for life, which,
when well turned, can be useful and instructive to us as
humans. Suffering reminds us that life is both short and
fragile and not to be taken for granted. This kind of insight
is trite and hackneyed until it is made relevant, and personal
suffering makes these kinds of insights powerfully
relevant. As a physician, I tend to lose that perspective. I
try to focus relentlessly on the physiologic and anatomic
because that is our training. Our scientific training does
not instruct us in suffering or anguish. We are taught to
focus on objective, measurable, and quantifiable biological
syndromes. Recognizing and treating medical entities like
gram-negative septicemia or bowel obstructions demand
clear-headed thinking about pharmacology, anatomy, and
physiology, rather than the emotional complexity of suffering.
And yet, as I reflect on the possibility of my own
potentially devastating visual disability, I find myself thinking
not about autoimmunity and multiple sclerosis but
rather my family and my real identity: Who am I if I can
no longer work or see? I think how odd it is, considering
my personal background in cellular immunology, that I do
not obsess on the arcane details of autoreactive T cells in
multiple sclerosis, but rather on soft, nonquantitative issues
such as my children and my deceased wife, our life together,
and ruminations about the future. Must we lose
our sight to discern who we really are?
As I think about my life and my family and struggle
with my identity, I find it oddly comforting to be able to
trust my physician to make prudent treatment recommendations.
Trusting my neurologist is liberating because it
frees me to reflect on the things that really matter to me,
and that trust will speed my recovery emotionally and
physically. This point of view places the treating physician
in a paternalistic role objectionable to many health care
consumers. However, from my own personal perspective as
a patient, trusting my doctors alleviates a substantial
amount of stress by avoiding the process of second-guessing
my physician. In this manner, the doctor?patient relationship
avoids becoming adversarial and actually can become
therapeutic, both emotionally and physically. The
benefit to me as a patient derived from trusting my physician
was another insight I had never understood about
illness until I lost my vision.
As a physician, I understand that there is much randomness
to sickness and health. We all see this. We see
smokers and drinkers who somehow defy all odds, and
then other patients who are cut down or disabled unfairly.
I do not believe that ?Why?? is a useful question for these
injustices. ?Why?? implies a reason, and attributing causality
has limited benefit for patients except to avoid future
mishaps. Rather, the utility of suffering is that it helps us
sharpen our internal focus to more clearly see the true
contours of our lives. This sharpened focus can be potentially
transforming for patients, and it would be wise for us
as physicians to acknowledge this. If illness changes our
identities and the way we look at life, let us try to profit
from the change emotionally and learn from the different
perspective it gives us. Let us learn to empower our patients
to see what is important in their lives and help them embrace
those entities. There are always lessons to be learned.
Peter A. Beatty, MD
University of Wisconsin Medical Foundation
Madison, WI 53715
Current Author Address: Peter A. Beatty, MD, University of Wisconsin
Medical Foundation, 1 South Park Street, Madison, WI 53715; e-mail,
[email protected].
Ann Intern Med. 2004;141:404-405.
On Being a Patient Physician as Patient
www.annals.org 7 September 2004 Annals of Internal Medicine Volume 141 ? Number 5 405
