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.

Life is hard, Part 2

In my previous post, I discussed that by accepting that life is difficult, we have taken the first step to preparing ourselves for those difficult times. 

This is not a new concept. In fact, the first of the “Four Noble Truths” that Buddha taught is that “Life is Suffering.”

The Myth of Sisyphus is an essay by French philosopher Albert Camus. It analyzes the Greek myth of Sisyphus who was condemned to the underworld to roll a giant boulder up hill, only to have it roll back down and for him to start again. At the outset, all of us would think of this as the ultimate punishment. It would seem as if you could never reach a state of contentment. However, Camus argues that one could imagine Sisyphus happy. How could that be? He suggests that Sisyphus was able to find happiness only after he acknowledged the futility of his task. After that, he was freed to reach a state of contented acceptance.

Really? Happiness?

His task is not much different than the series of tasks that we all face in life.  We all have difficult tasks, whether it is in our jobs, our family, or simply our home life. We work hard to get these tasks done, and before long, there is a new task at hand. Just because our lives are taken up by a series of difficult tasks, is that a reason for despair? Are we to think of ourselves as condemned to the underworld? I think not.

Happiness is achieved by taking pride in the accomplishments of our individual achievements. Conversely, happiness is hard to find if all we do is focus on the fact that we have a lot of work ahead of us. In fact, it can be overwhelming to think of all the projects that need to be accomplished. There seems to be an infinite number of boulders to roll up the hill. In fact, there probably are. But, acceptance of that fact helps us to move on to something more important, which is doing a good job, and finding happiness at our current task. 

I like to think that Sisyphus focused on pushing the boulder up the hill each time like it was a new task. He could take pride in looking at the boulder sitting at the top of the hill. And by thinking this way, he was able to find happiness in a situation that seems awful.

Noted sculptor Donald Gialanella* was commissioned to sculpt an interpretation of the myth of Sisyphus, seen here. 

In it, Sisyphus is depicted holding a chain, in a never ending effort to hold up four solid granite slabs. Sisyphus must be proud to demonstrate that he is so strong that they never move. In the metaphorical sense, he is not really holding up the slabs. No, they are holding him up.


*http://www.donsculpture.com/

Life is hard

Surgery is hard. Of course there are always technical aspects which are difficult but I am speaking of something completely different. I think most surgeons will tell you that one of the hardest parts of their job is telling the patient and his or her family bad news. Certainly other specialties have this same issue. But somehow, taking a patient to surgery is usually viewed as a major, invasive step toward improving their lives. It is an aggressive intervention which at its heart, is designed to result in immediate gratification.

For instance, most patients with colon cancer go into the operating room with a tumor and leave the operating room an hour or two later without a tumor.  With or without the use of additional chemotherapy, they may be cured. However, if this scenario doesn't happen, it can be anxiety producing at best.

Not long ago I had a patient present with what appeared to be a “routine” colon tumor. At the time of exploration the patient was found to have tumor widely spread throughout the abdomen and was unfortunately completely incurable.* From a technical aspect, this operation was not hard. I removed the tumor in order to prevent intestinal blockage and sampled the tumor throughout her abdomen for microscopic diagnosis. Nothing there was technically difficult.

The difficult part of the operation came next. That was telling her friends and family the news. As it turned out, the patient had only recently gotten out of a 35-year abusive relationship, and the hope prior to this surgery was that she could live the rest of her life in peace. All that had changed now. The rest of her life would be spent with increased abdominal bloating as this tumor progressed, possibly toxic chemotherapy, and getting her affairs in order for her untimely death. The prognosis was months, not years, and months of pain, not happiness.

It's a terrible, sad situation. To somehow see hope or goodness in this is difficult. But, life is difficult and inherently, we all know that. It just sometimes takes situations such as this to make us remember that.

I find that as I get older, and hopefully wiser, I deal with these situations a little easier because I approach them with the underlying understanding that yes, life is hard. There are times in everyone's lives when we will experience pain, sorrow and sadness. Without that we would not be human. Without that, we would not know happiness. And, without that, we would not be real.

Life is hard. Approaching life with this attitude doesn't make sad times any less sad. But it does normalize it. And in some way, it helps me to put everything in perspective.

*some patient details are changed so as not to identify a specific patient