The Back Story

In the movie Love and Other Drugs, Jake Gyllenhaal plays a drug rep for Viagra. At one point, he is forced to go to the emergency room after having taken Viagra, because of a rare side effect called priapism, or persistent painful erection. No doubt, this was one of the funnier parts of the movie.

As a physician, the way I would approach this patient would be much different than the way I acted as I watched this movie from my couch. Sure, its tempting to act the same way, laughing about the awkward situation. But, the reality of being a physician is that patients rely on you to be above that. If I was in that position as a patient, I would want a doctor who could see that I was in trouble and treat me like any other patient with an urgent problem.

What helps me to get into that mindset is to figure out what the patient’s story is. I call it the back story. Sure, it may be as simple as the movie’s recreational Viagra use. But maybe not. 

An 80-year-old man presented to the emergency room with priapism. The back story of this man is that he underwent radical prostatectomy for prostate cancer 15 years ago, leaving him with erectile dysfunction. Years went by with only frustrating sexual experiences. Finally, after much discussion with his urologist, he decided to try Levitra. The result, an embarrassing emergency room visit. This is hardly a laughing matter. He is not Jake Gyllenhaal’s character. He is a real human, with a frustrating disease, now suffering an embarrassing complication of his treatment.

Much of being a physician is understanding not just the disease process of the patient but also the setting in which this disease occurs. For example, two patients recently presented with similar abdominal pains. One of the patients had a sister that had recently died of colon cancer. My approach to the work-up of these two patients was similar, but the way that I talked to them was much different. I had to be cognizant of the emotional distress in the patient whose sister had just died. In that patient’s mind, this abdominal pain was surely cancer. And there was nothing that I could say or do to convince her otherwise until I proved that it wasn’t.

Everyone's back story is different. 

As a physician, learning and understanding that back story is part of your job. It helps you to empathize and it helps you to treat the person, not just the disease. As a human, having an appreciation for the back story is imperative for acceptance.

Many times, I have discussed with my children the importance of acceptance because we simply don't know someone's history. For example, my daughter once told me that a girl in her class was weird because when she got frustrated she would hit people or nearby objects. I cautioned her not to label people as weird for the same reason that I cannot laugh at a patient with priapism. You have no idea what someone has been through or what has gotten them to this point. In the case of my daughter’s classmate, I knew that this girl lived in a household where her parents’ frustration would often lead to hitting and physical abuse. The child's behavior made sense. It is what she learned as the “normal” response to frustration. Seeing her back story suddenly made what seemed like weird outbursts understandable. 

This type of open-mindedness is critical to understanding people. Acceptance of people will not occur without it. The same is true with patients. If you approach the patient with the underlying knowledge that there is a back story which explains much of who they are, empathy and good judgment will follow.

Understanding the back story makes people real. Understanding the back story makes you a good physician, not just a person laughing at a movie character. And, with that knowledge, empathy and professionalism will go hand in hand.