Should primary care providers screen their cancer patients for spirituality needs? A recent talk at Mercy Medical Center in Baltimore
A patient writes (and I share with her permission):
On the night of April 20 after dinner I felt a great pain in my left shoulder and up along my neck. Chills and the pain prevented my sleeping. This pattern continued, severely, along with utter exhaustion by 3-4 PM every day and no appetite, through the 28th, while the pain began to extend into my left rib area, under my left breast. The 3rd night I remembered I had the 800-mg ibuprofen pills that Dr. B had given me, which I began taking every night thereafter, and it helped me sleep somewhat better. While all these symptoms persisted, after 4-5 days the overall pain began to slowly decrease a bit. On April 25, with my brother's insistence, I went to the doctor. I was assigned to a Dr. A, who is working under Dr. D. She was worried that I might have had a heart attack, though we have no heart problems in my family. The nurse administered an electrocardiogram test, which turned out normal. Dr. D (whom I haven't seen in 15 years or so!) also examined me. They had me get a chest x-ray and a blood test (for kidneys?) Dr. A phoned me today saying that these uncovered no problems, though a couple of little irregularities which she said are too minor to bother about. It was these that prompted me to have her send you the results, and this note of mine will give you their context.
All that being fine, now I have to return, on my own, to my original theory of what caused all this pain, sleeplessness and weakness. From early on I suspected that in working assiduously on the computer all day of April 19 and 20, I was unconsciously leaning strongly on my lower left arm and elbow - not having the perfect ergonomic set up for working on the computer. Nothing like this has ever happened to me before, though periodically I have tried to deal with the seemingly incorrigible constraints limiting my desk and desk-chair arrangement for using the computer. Though when I saw the doctors on April 25 I told them this admittedly-lay diagnosis, it didn't interest them in the least, but now I"m pretty sure it explains what I experienced - though still not the complexity and severity of it.
Since you're interested in the patient-doctor relationship, I thought I'd share with you my reflections on this happy-ending experience. (Though your book does help us a lot to understand the physician's point of view). What I observed is that these highly trained physicians - both in "general internal medicine" - either weren't interested in the "muscles and nerves" dimensions I had first proposed as a diagnosis, or else they didn't have the basic knowledge or expertise to deal with what I related. I realize that they went for the potentially-fatal possibilities like heart, lung, kidney. Good. That's reassuring. But even when I asked, before they dismissed me, what they would suggest about the severe pain and other symptoms, in the event that the tests showed nothing serious -- even when I wanted to bring them back to the original problem, which still persisted - they offered no ideas about what might have caused all that I was going through, much less offered any details about how it might have happened, or guidance about what to do. And today when Dr. A phoned with the results, if I had not asked her specifically, she would not have addressed the problem itself. (She was not aware the pain had declined) When I did ask, she advised me to talk to a physical therapist, which I will.
Despite your excellent clarifications in your book, and re-orienting the patient's perspective, we laypeople aren't as compartmentalized in trying to think through our medical problems as you doctors are, though of course most of us are aware that the medical profession has various specializations. In my little episode, I thought that in the end the doctors I consulted would remember that I had come to them with a severe pain, and that they would eventually come back to addressing that. They seem very relieved that the worst hadn't happened; but... hello? what about "me"? okay, if my heart, lungs and kidneys are okay, but what do you have to say about my pain and what might have caused it? and what should I do about it? I guess my original expectations in going to them were unrealistic.
Today, really for the first time, I feel fine. No pains. I hope I haven't wasted your time with this little narrative, which I have not written out of frustration, but as part of our common interest in the "patient-doctor" interface.
Dr. G, a resident, tells me about his patient, a Ms. F.
Dr. G: Ms. F doesn't want to be on a statin [=cholesterol-modifying drug], since she says it is causing her muscle aches. So I'm going to order a CK [creatine kinase level, to diagnose muscle disease].
Me: But she's telling you she has muscle aches.
Dr. G: Yes, but without the CK I don't know if she has statin myopathy [muscle disease].
Me: She could have statin myalgias without statin myopathy. And CK isn't 100% sensitive for statin myopathy anyway.
Dr. G: So how do I know if she should stay on the statin or not?
Me: Ask her?
Dr. G: I think I'll order the CK, and if it's normal, talk about it with her.
The author of Talking To Your Doctor and Making Sense of Medicine blogs about the books, shared decision making, doctor-patient communication, and the redeemable imperfections of healthcare.