The physician as patient

Learning the science is easy. Learning what is actually important is so much more difficult.


As a physician, like many of you, I was an achiever. Not necessarily an overachiever, but an achiever nonetheless. People with the dedication and ability to persevere seem to self-select into the endeavor of medicine. I was no different.

I was raised in a family of hard workers. Responsible taxpaying citizens, if you will. My family gets up early every day, goes to work and grinds it out—for the greater good. We enjoy life, but not at the expense of others, and certainly not at the expense of responsibilities in the community.

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Throughout my adolescence, I was an active athlete; long distance running was my strength. The longer the distance, the better I did—I was simply determined not to lose. I was raised to persevere. In running as well as in life.

Throughout undergraduate, graduate and medical school, my running had fallen off somewhat, along with some other aspects of my life. I had struggled from some anxiety issues as a medical student, more than the all-too-common medical student-itis.

And then on to residency—a chance to start over. New town. New job. New friends. New outlook on life. With my newfound career, I sought to get back to my original passion—long- distance running.

At first, my progress was slow. So was my speed. But as time passed, and I became more and more determined each day to continue to run, I began to feel better. I began to eat better. I began to lose weight, to improve my physique. I got engaged. I went off my serotonin–norepinephrine reuptake inhibitor, which I had been taking for four years.

As I began to get more and more in shape, I felt the need to increase the distance of my runs—three miles, five miles, seven miles.

Things were looking up, and with my wedding less than four months away, I was living the dream. Then, while on a run in the heat of a beautiful Saturday afternoon, I began to feel incredibly poorly. I felt as if I was extremely dehydrated, nauseous, even dizzy, and I simply walked the last half mile or so back to my home. I continued to feel terrible into the evening. I was drinking large amounts of water—about seven liters in a few hours. While I continued to urinate very frequently, my mouth was dry and my lips were cracked.

Perhaps I should not have taken that allergy medication last night—perhaps that could explain my feeling of excessive dehydration, I thought.

However, the following morning, and the following few days, my feelings of dehydration never quite subsided. My thirst could not be quenched. I was having trouble with fatigue, as well. I began to have difficulty getting out of the bed in the morning, difficulty completing a day's work without experiencing excessive exhaustion.

Excessive exhaustion? Well, I am a resident in a large program. Maybe I am sleep-deprived, I thought.

I had lost some weight over the course of the last few months, but now I began to melt away in a not-so-pleasant way. In fact, I had lost more than 30 pounds—and five of those pounds fell off in a week when I was not running and had briefly reverted back to a less-than-ideal diet.

Still, as the overthinker, I had an explanation for each of my symptoms—weight loss, fatigue, excessive thirst, and excessive urination. One particular Friday morning in my continuity clinic, however, I began to feel even worse than I had felt over the course of the last week. I was urinating every 30 to 45 minutes—and I had only had one cup of coffee.

Now I began to get worried. I had a strong feeling that something was going wrong, and going wrong very quickly, at that. I had one of the staff nurses for the clinic check my blood sugar level “just to see,” I told her.

408 mg/dL.

What?!?

“Why don't we check that again?” I politely asked. My last meal had been dinner the night before. I had not eaten breakfast on account of fatigue that morning.

Repeat: 408 mg/dL.

“Well, that isn't good,” I said. The nurse asked if I was a diabetic.

“I guess I am,” was all that I could think to say, as I mentally attempted to create a long differential diagnosis for myself that would not include insulin.

And then the fear struck. I again remembered what it was like to have a panic attack, just like in medical school. Heart racing. Sweating. Nausea. I was paralyzed by fear. Thoughts were entering and leaving my head in an entirely counterproductive way.

Think, Anthony, think! You're a doctor for crying out loud!

I decided to call an attending friend of mine. A man I trusted and respected.

As we went over the possibilities on the phone, he informed me that I needed to go directly to a physician. Luckily he knew a very well-respected endocrinologist who agreed to see me within an hour. By the time I made it to the examination room, I had begun to process the situation better than before.

I urinated in a cup. Ketones. Dammit.

Over the course of the next 24 hours, I went from being a healthy, active 28-year-old physician to a new-onset type 1 diabetic, with the antibody tests to prove it.

On “D-day”, as I call it, I experienced myriad emotions. Fear. Anxiety. Anger. Sadness. Thankfulness. As physicians, we are taught to be compassionate and empathetic, to treat people as we would want to be treated were we in the same situation.

Over the course of the next two weeks, I had multiple physician visits, both with my endocrinologist and my primary care physician, whom I had never seen until after I was diagnosed.

It had been so long since I had been to a physician, I forgot what it was like to wait to be seen. The time to wait wasn't even very bad. Worse was the new information potentially coming through the door with the physician. I had forgotten what it was like to worry about something so basic as my life.

Would I be OK? What does this mean? Why did this happen?

Do I need to start an aspirin? What about a statin? What about an ACE inhibitor?

What if I change jobs? What about my insurance? How much will this cost? Will this limit what I can achieve in the future?

Back in 2006, National Public Radio ran a fascinating story titled “When physicians get cancer.” The point of the article, written primarily by two physicians recently diagnosed with cancer, is that diagnosis and disease may affect physicians differently. As truly fascinating as this was, I was skeptical regarding the findings of the article. Why should a new diagnosis be any more painful, upsetting, and fearful for a physician compared to any other patient?

According to the authors, it is different. Doctors know what's coming. As a physician, you are trained in seeing the worst, treating the worst and expecting the worst. At the very heart of our education is a realization that many times our efforts are unrewarded, and either we fail our patients, or the disease defeats our best efforts. The mere mention of some diseases elicits thoughts of potential complications, life expectancy, statistics on morbidity and mortality. In short, a physician diagnosed with a disease is more aware of what the future holds.

There is also the dichotomy. In the same day, you can go from treating others, to being treated by others—colleagues, perhaps. From counseling others about their fears to worrying about your own. You counsel others to stay strong and persevere, though you are not sure that you can.

This got me thinking. The health care machine differs depending on which side of the curtain you are on.

In theory, physicians went into medicine to help others who may be less fortunate in the game of life. Anyone who doubts this statement need look no further than the entering class of any medical school each fall—full of idealism, enthusiasm, confidence.

But in the grand scheme of things, physicians are not infallible, not perfect, not always idealistic, and certainly not always enthusiastic. Long hours, overnight calls, sleep deprivation, and high levels of daily stress take their toll on the body and spirit.

Perhaps this is where the true fear lies. The fear that you are now on the other side of the curtain. As physicians, we have seen the strings at the proverbial puppet show.

In all honesty, before my “D-day” I did not truly grasp the importance of the physician-patient relationship. Although I took numerous courses in medical school on compassion, caring, empathy; studied the stages of grief; listened to real patients discuss their fears and concerns…the full effect was lost on me. And I surmise that it is truly lost on many others as well.

There is no formal coursework that can help you see something through someone else's eyes. You can never truly experience what someone is going through physically or mentally. In my brief experience as both a patient and a physician, there are a few emotions that have been most prominent. Foremost in my mind? Shame. Second? Thankfulness.

My shame is for those patients whom I have not spent adequate time with. Whom I have not spoken to as a comrade, but rather a doctor. For those many times when I have not engaged with families, instead putting myself and my own needs first. To those patients and families, I am truly sorry. The depth of the relationship between a patient and a physician, and its paramount importance, was not clear to me in my haze of residency.

I am thankful that I am truly able to be a patient. While I am not thankful for a chronic disease, or its complications—which I know all too well—I am truly thankful that my diagnosis has allowed me to appreciate the emotional connection between patient and physician.

In short, learning the science is easy. Learning what is actually important is so much more difficult. I am remembering what made me want to dedicate my entire life to a field as fascinating as medicine: people.