"Denial is not a river in Egypt" I heard that somewhere and think it's brilliant! Sorry you had to go through the chemo experience...no fun...and glad you are able to return to your practice. You have a passion for caring for your patients and for life that is to be cherished!
As a dietitian I so agree. Moving patients out of denial and into a contemplative state is 90% of the work. The story about yourself resonates so strongly. Glad you are all well now!
Thank you, Elizabeth! Dieticians have so much denial and intertia to work against. We all have eaten for so long we think surely we don't need to be taught about that! (and, actually, yes, sometimes we do.)
Thank you, Regina. I'm so glad you enjoyed it and related to it. I am maybe not the best patient, even still, and there will be an essay or two dozen about that in the future.
I am also a physician and cancer survivor, breast cancer in 2011-2012. I can say "cured" now. What I realized that might be helpful was the bizarrenes of the patient role. We talk about the "doctor-patient dyad," but I think it's more complicated. Being a helping professional is full-time and intentionally chosen, and it makes sense to us. Being a patient is an unfortunate accident and a horrible intrusion on our true roles. My whole illness journey felt like something happening in a parallel universe. Being the patient doesn't make any sense, so it's hard to respond rationally. This might be just me, so take it for what it's worth.
Thank you for all of your thoughtful comments, Regina. I think part of my being too busy to have leukemia was that it just didn't make any sense for me to have leukemia. What made sense was for me to continue being a doctor. It was so crazy, too, because except for the cancer, I was the healthiest person on the hospital floor. I had run a 5K race the previous weekend, etc. etc.
I am officially "cured," but I never use the word. It feels like tempting fate. I'm in a nice, long remission.
A real nuisance of leukemia is that having leukemia feels pretty much the same as being tired because you are working too hard and maybe have a virus. Guess what jumps into my mind whenever I work too hard or maybe have a virus?
Best of luck on your recovery and thank you for sharing. Can tell you do what you do for your patient’s health and you are literally body deep in their very useful chronic and preventive care. It’s always difficult worrying about crossing that line - “being a patient” - how can we be such?! - we care for patients?! Wishing you the best in your recovery. Your patients seem fortunate to have you care for them.
I do think that it can be one of the most useful ways to improve one’s life, though. At that point, I was too busy to be sick and really too busy to do much of anything besides the next thing on my list.
Hah! Agree. But…..I had some tinnitus (probably too many rock bands as a kid). I ordered a brain MRI. Thinking I might have some simple acoustic neuroma. But….much to my surprise, I had a tumor in my Third Ventricle. A Colloid Cyst. Now, what to do about it. Sorry several neurosurgeons and weighed the pros and cons of surgery. Decided to watch and wait. One Saturday morning, after having been on call Friday night, I had neuro symptoms. Probably sleep deprivation. Had the tumor removed emergently Saturday afternoon. Not sure I needed that MRI. Not sure I really needed the colloid cyst removed. But, ordering the MRI led me down that pathway. I’ve done fine. Been 25 years since it was respected. Have a hole/channel in my corpus colosseum. Maybe have less frontal lobe control than I should. But, who knows, all for having ordered my own MRI
Wow! I’ve learned more about your tenacity which / thanks to denial / you can help others out of their own. I had an idea that denial wasn’t just a symptom of active addiction, but your story tells me more about the power of it. Thank you!
This was a terrific piece. What continues to amaze and dismay me are the large numbers of responses to this and so many other essays here that demonstrate the widespread mistrust and outright suspicion of the medical system, and especially physicians.
Did the flawed, but best-intentioned response to the pandemic, complete with development of a vaccine using new technology and with miraculous speed cause all this, or has it been simmering under the surface for much longer?
I fear that these mistrustful people will shun expert medical care and try to heal themselves from serious disease using quack treatments, with predictable results.
The medical system, including its basic research arm, must figure out how to regain that trust.
Thank you, JDM. I try very hard to be transparent about why I think what I think, how important I think it is and why. This is part of why I love story telling; it lets people make their own conclusions.
I have spent my whole life in the one on one enterprise of medicine with the patient. Writing and attempting to communicate with people I've never met before is a new experience for me.
The distrust predates the pandemic. But..... The medical industry invited scrutiny of itself by intruding itself on our daily lives for months on end. The financial conflicts and flimsiness of medical evidence then became apparent to millions of people who never would have cared previously.
Wow—I only thought I would see “excellent article” in the comments! People with no concept of the long term effects of “asymptomatic diabetes”??!! still have the right to free speech.
Excellent article, Dr. Bates! I appreciate the personal insight of denial and finding solid communication grounds. I hope you stay well, have lots of hair growth, and continue to practice with that wisdom.
My husband has had type 2 diabetes for the past 20 years. He takes Metformin and Lisinopril. He is fond of telling his friends, "my A1C is normal, always under 6.5, so I don't think I really have diabetes, but I take the medicine anyway". I then step in to remind him how fortunate he is to have a type of diabetes that is controlled with diet, exercise, and just one medication, and that the stability of his lab work is a tribute to his efforts and modern medicine.
As a psychiatric nurse, I know it's human nature to want to try to control a diagnosis without medication. The cascade of consequences from diabetes happens silently, at first, and over time. Due to their high impact on quality of life, the gentle persistence of Dr. Bates is warranted, especially when the end goal is preventing blindness, peripheral neuropathy/chronic pain, heart disease, and declining mobility and renal function.
First, I want to apologize for several of the comments here. As a functional medicine health coach, I embrace alternative medicine, and it saved my life, but some of the comments here are ill-informed. Having a blood sugar of 200 is never a normal thing, and it coming down after a walk to 175 doesn’t mean much. She still has diabetes. What I would like to address is that I think you’re very brave for posting this and very vulnerable and I’m sad that people completely missed the point of your article and instead decided to bash you for things that they are upset with the medical community about, some which are not even true.
Finally, and most importantly, I hope you are doing better. I’m a 20 year cancer survivor, and if I hadn’t become curious about why I developed cancer in the first place, I never would have found functional medicine and I never would have discovered through their help that I had toxic mercury levels.
I’m glad you’re blogging, and I also think that other physicians can learn a lot from your experience. Thank you for your article. My best wishes for continued recovery.
Interesting. (my comments include a dose of sarcasm based on real life)
1. A BG of 200! How could you, doctor? Why didn't you have her on more meds and insulin to more aggressively get her sugar down and more stable at recommended levels?
2. You spent an inordinate amount of time with your patient! Tsk tsk. She mentioned
side effects and you asked for further info. You could have just said, live with them if you don't want to lose a foot or get CKD.
3. You worked out a plan with your pt without backing off - explained the need for the medical intervention and found a way that would work for her. You probably thought or even told her that the plan could be twerked depending on the situation. Again, inefficient.
4. Your journey involved more than denial - this isn't sarcastic from here out. Medicine, some say healthcare, is known to be hard on us. We don't like to see a doctor - especially one who thinks medicine is 100pct of life. Who ignores the potential problems and many complications of any intervention for serious degredations in our health/performance/QOL.
You beautifully address our lives, not only our numbers and diagnoses.
We're all afraid to go to the doctor, not only to have a 'condition'. Why are we afraid? Money? Autonomy? Body image? Being alone with the beast and needing a person (a doctor ... a 'provider') to help us through our Life, not just the Dx and Tx. "See me in 3 months and we'll see how the Zoloft or allopurinol is working." Now that I'm on a potent intervention - it's supposed to make a significant change inside me - I'm on my own. For 3mos. "If this is a medical emergency call 911." We don't know if it's an emergency. I want to talk to the 'provider' who put me on this. "Sorry, you'll have see So and so." "But I don't know that person. I want to talk to MY doctor." Of course YOUR doc has been overworked and needs time to themselves , not to mention the SYSTEM won't allow it. Not to mention that a lot of pts are crazy dramatic.
My point: We're alone with our new body, out older body, breaking down slowly or quickly. Most people have no understanding of their bodies, psych, etc. There are not enough of us healthcare people to follow up more closely with our patients. To really educate them. There's no time to have a relationship (with proper boundaries) that is proportional to the orders we right or execute/administer.
We can't take the time/energy - often we are educated that it's unnecessary - to form a working relationship with our patients. A consistent reliable relationship that works for all of us.
There is little trust. In the patient. In the doc. In the nurse. In the insurance company. In the system administrators. In the billing.
Thank you, Barry. I can see that you truly understand the whole complex mess we've got going on. I appreciate that very much and I don't think I have anything useful to add.
I'm going to be chewing on that idea of the patient being alone with their new body for three months. I like that and feel it points to the seriousness of what we're doing for the person whose body it's being done to.
Thanks, Doc. I'm on both sides, like you. Nurse. In patient rehab. Strokes. Brains. Life changing. Much of the acute stuff has been done. Sometimes I tell patients that it's easier being in the hospital than going home - meaning that the new body, new interventions, new docs/staff, new life requires them to keep moving and do the work to have a life, gently.
You know, we keep people with more serious conditions alive for longer than we used to. It's more complicated. Stay strong and courageous.
I don't know, Rodney. I think old scars do sometimes itch and that's just the way they are. It's not anything that disturbs my life at all.
An unrelated aside, I asked for my explanted port and have kept it in a urine cup filled with saline in my bottom desk drawer--next to my spare clothes, snacks, and some random files. I pull it out when a patient is nervous about getting a port and it helps people feel less scared about it. My surgeon said I was the first person in, like 30 years who had asked for it!
Luc, I am a psychiatrist and I ask people to change their lives every day. I agree that the approach is everything. I am going to challenge you to look into a therapy approach called Motivational Interviewing. People have autonomy and rarely will change their behavior if they feel they are being badgered or nagged. The best advice often is perceived as nagging. I think this physician was gauging that her patient was not willing to have a longer discussion. Sometimes it's a win just to have that patient not cancel the appointment and be honest about not taking our advice. I know I struggle to admit to my dentist that I don't floss twice a day!
As the oncology ICU/PACU RN with stage 4 myself, I was captured by this article. Thank you. What pushed me over the edge? Severely neutropenic, femoral fracture requiring rod, my colleagues were switching assignments to protect me. That did it for me to go out on disability. Thanks again for writing this.
First of all. Good luck with what you are going through.
So let's back up here.... you said ""It was pretty high, like 300, but it came down by the time I got home. It was 175, and you said 200 was fine"
If that's true then why are you selling her pills to fix her diabetes?
Why didn't you leverage THAT to get her to prove to YOU that she didn't need it instead of insisting that she did?
IF you felt her life was in danger due to high blood sugar then put the POWER in her hands and say "Okay, let's do this. You are right that exercise will lower blood sugar. Let's do a test for one week. You take your blood sugar three times a day. Right it down. And I'll see you next week and we can talk about it."
Why were you so pushy? She's an individual. Don't treat her like cattle.
BTW did you Oncologist tell you that they made money off the chemo drugs they recommended you take?
I was diagnosed 13 years ago. I've had a good, long remission (and continuing as far as I can tell).
I didn't really think Mrs. W was the focus of the article so I glossed over a lot of details. I'm thinking that I need to write about diabetes. Thank you for the inspiration.
Mrs. W had had her diagnosis of diabetes for a long time. I wasn't making the diagnosis the day in the clinic.
Again, it wasn’t the issue of what she had it was the approach. Yes, you know more about diabetes than your patient (and again when the fictional person mentione numbers you didn’t refute that or say any different) but your patient wants feel that you are working together.
"Denial is not a river in Egypt" I heard that somewhere and think it's brilliant! Sorry you had to go through the chemo experience...no fun...and glad you are able to return to your practice. You have a passion for caring for your patients and for life that is to be cherished!
Thank you. I'v earned my passion!
We say sometimes that we'd like to encourage a particular patient to buy a scuba suit because they are already living in The Nile.
As a dietitian I so agree. Moving patients out of denial and into a contemplative state is 90% of the work. The story about yourself resonates so strongly. Glad you are all well now!
Thank you, Elizabeth! Dieticians have so much denial and intertia to work against. We all have eaten for so long we think surely we don't need to be taught about that! (and, actually, yes, sometimes we do.)
Author, thank you for sharing this powerful article. I hope you are being the best patient!
Thank you, Regina. I'm so glad you enjoyed it and related to it. I am maybe not the best patient, even still, and there will be an essay or two dozen about that in the future.
I am also a physician and cancer survivor, breast cancer in 2011-2012. I can say "cured" now. What I realized that might be helpful was the bizarrenes of the patient role. We talk about the "doctor-patient dyad," but I think it's more complicated. Being a helping professional is full-time and intentionally chosen, and it makes sense to us. Being a patient is an unfortunate accident and a horrible intrusion on our true roles. My whole illness journey felt like something happening in a parallel universe. Being the patient doesn't make any sense, so it's hard to respond rationally. This might be just me, so take it for what it's worth.
Thank you for all of your thoughtful comments, Regina. I think part of my being too busy to have leukemia was that it just didn't make any sense for me to have leukemia. What made sense was for me to continue being a doctor. It was so crazy, too, because except for the cancer, I was the healthiest person on the hospital floor. I had run a 5K race the previous weekend, etc. etc.
I am officially "cured," but I never use the word. It feels like tempting fate. I'm in a nice, long remission.
A real nuisance of leukemia is that having leukemia feels pretty much the same as being tired because you are working too hard and maybe have a virus. Guess what jumps into my mind whenever I work too hard or maybe have a virus?
Best of luck on your recovery and thank you for sharing. Can tell you do what you do for your patient’s health and you are literally body deep in their very useful chronic and preventive care. It’s always difficult worrying about crossing that line - “being a patient” - how can we be such?! - we care for patients?! Wishing you the best in your recovery. Your patients seem fortunate to have you care for them.
Thank you, cools! I can definitely understand some things from the inside that are not often understood in that fashion.
Contemplation of one’s own demise is hard.
It can be.
I do think that it can be one of the most useful ways to improve one’s life, though. At that point, I was too busy to be sick and really too busy to do much of anything besides the next thing on my list.
I enjoyed the story and am glad you are doing well.
Thank you. Me, too!
Thank you for the helpful information!
Hah! Agree. But…..I had some tinnitus (probably too many rock bands as a kid). I ordered a brain MRI. Thinking I might have some simple acoustic neuroma. But….much to my surprise, I had a tumor in my Third Ventricle. A Colloid Cyst. Now, what to do about it. Sorry several neurosurgeons and weighed the pros and cons of surgery. Decided to watch and wait. One Saturday morning, after having been on call Friday night, I had neuro symptoms. Probably sleep deprivation. Had the tumor removed emergently Saturday afternoon. Not sure I needed that MRI. Not sure I really needed the colloid cyst removed. But, ordering the MRI led me down that pathway. I’ve done fine. Been 25 years since it was respected. Have a hole/channel in my corpus colosseum. Maybe have less frontal lobe control than I should. But, who knows, all for having ordered my own MRI
What a great story, Rodney! So glad you're ok!
Wow! I’ve learned more about your tenacity which / thanks to denial / you can help others out of their own. I had an idea that denial wasn’t just a symptom of active addiction, but your story tells me more about the power of it. Thank you!
You're welcome, Jim. Again, I am looking forward to the new piece(s) that I feel certain willb e inspired by these thoughts.
This was a terrific piece. What continues to amaze and dismay me are the large numbers of responses to this and so many other essays here that demonstrate the widespread mistrust and outright suspicion of the medical system, and especially physicians.
Did the flawed, but best-intentioned response to the pandemic, complete with development of a vaccine using new technology and with miraculous speed cause all this, or has it been simmering under the surface for much longer?
I fear that these mistrustful people will shun expert medical care and try to heal themselves from serious disease using quack treatments, with predictable results.
The medical system, including its basic research arm, must figure out how to regain that trust.
Thank you, JDM. I try very hard to be transparent about why I think what I think, how important I think it is and why. This is part of why I love story telling; it lets people make their own conclusions.
I have spent my whole life in the one on one enterprise of medicine with the patient. Writing and attempting to communicate with people I've never met before is a new experience for me.
The distrust predates the pandemic. But..... The medical industry invited scrutiny of itself by intruding itself on our daily lives for months on end. The financial conflicts and flimsiness of medical evidence then became apparent to millions of people who never would have cared previously.
Wow—I only thought I would see “excellent article” in the comments! People with no concept of the long term effects of “asymptomatic diabetes”??!! still have the right to free speech.
Excellent article, Dr. Bates! I appreciate the personal insight of denial and finding solid communication grounds. I hope you stay well, have lots of hair growth, and continue to practice with that wisdom.
Thank you for your experience.
Thank you, Jenni, for reading and commenting and also for your good wishes. I'm 13 years out now so that's pretty good!
My husband has had type 2 diabetes for the past 20 years. He takes Metformin and Lisinopril. He is fond of telling his friends, "my A1C is normal, always under 6.5, so I don't think I really have diabetes, but I take the medicine anyway". I then step in to remind him how fortunate he is to have a type of diabetes that is controlled with diet, exercise, and just one medication, and that the stability of his lab work is a tribute to his efforts and modern medicine.
As a psychiatric nurse, I know it's human nature to want to try to control a diagnosis without medication. The cascade of consequences from diabetes happens silently, at first, and over time. Due to their high impact on quality of life, the gentle persistence of Dr. Bates is warranted, especially when the end goal is preventing blindness, peripheral neuropathy/chronic pain, heart disease, and declining mobility and renal function.
I can't add much to Tina's comment below except thank you.
Well stated! Amen
First, I want to apologize for several of the comments here. As a functional medicine health coach, I embrace alternative medicine, and it saved my life, but some of the comments here are ill-informed. Having a blood sugar of 200 is never a normal thing, and it coming down after a walk to 175 doesn’t mean much. She still has diabetes. What I would like to address is that I think you’re very brave for posting this and very vulnerable and I’m sad that people completely missed the point of your article and instead decided to bash you for things that they are upset with the medical community about, some which are not even true.
Finally, and most importantly, I hope you are doing better. I’m a 20 year cancer survivor, and if I hadn’t become curious about why I developed cancer in the first place, I never would have found functional medicine and I never would have discovered through their help that I had toxic mercury levels.
I’m glad you’re blogging, and I also think that other physicians can learn a lot from your experience. Thank you for your article. My best wishes for continued recovery.
Interesting. (my comments include a dose of sarcasm based on real life)
1. A BG of 200! How could you, doctor? Why didn't you have her on more meds and insulin to more aggressively get her sugar down and more stable at recommended levels?
2. You spent an inordinate amount of time with your patient! Tsk tsk. She mentioned
side effects and you asked for further info. You could have just said, live with them if you don't want to lose a foot or get CKD.
3. You worked out a plan with your pt without backing off - explained the need for the medical intervention and found a way that would work for her. You probably thought or even told her that the plan could be twerked depending on the situation. Again, inefficient.
4. Your journey involved more than denial - this isn't sarcastic from here out. Medicine, some say healthcare, is known to be hard on us. We don't like to see a doctor - especially one who thinks medicine is 100pct of life. Who ignores the potential problems and many complications of any intervention for serious degredations in our health/performance/QOL.
You beautifully address our lives, not only our numbers and diagnoses.
We're all afraid to go to the doctor, not only to have a 'condition'. Why are we afraid? Money? Autonomy? Body image? Being alone with the beast and needing a person (a doctor ... a 'provider') to help us through our Life, not just the Dx and Tx. "See me in 3 months and we'll see how the Zoloft or allopurinol is working." Now that I'm on a potent intervention - it's supposed to make a significant change inside me - I'm on my own. For 3mos. "If this is a medical emergency call 911." We don't know if it's an emergency. I want to talk to the 'provider' who put me on this. "Sorry, you'll have see So and so." "But I don't know that person. I want to talk to MY doctor." Of course YOUR doc has been overworked and needs time to themselves , not to mention the SYSTEM won't allow it. Not to mention that a lot of pts are crazy dramatic.
My point: We're alone with our new body, out older body, breaking down slowly or quickly. Most people have no understanding of their bodies, psych, etc. There are not enough of us healthcare people to follow up more closely with our patients. To really educate them. There's no time to have a relationship (with proper boundaries) that is proportional to the orders we right or execute/administer.
We can't take the time/energy - often we are educated that it's unnecessary - to form a working relationship with our patients. A consistent reliable relationship that works for all of us.
There is little trust. In the patient. In the doc. In the nurse. In the insurance company. In the system administrators. In the billing.
And so it goes.
Thank you, Barry. I can see that you truly understand the whole complex mess we've got going on. I appreciate that very much and I don't think I have anything useful to add.
I'm going to be chewing on that idea of the patient being alone with their new body for three months. I like that and feel it points to the seriousness of what we're doing for the person whose body it's being done to.
Thanks, Doc. I'm on both sides, like you. Nurse. In patient rehab. Strokes. Brains. Life changing. Much of the acute stuff has been done. Sometimes I tell patients that it's easier being in the hospital than going home - meaning that the new body, new interventions, new docs/staff, new life requires them to keep moving and do the work to have a life, gently.
You know, we keep people with more serious conditions alive for longer than we used to. It's more complicated. Stay strong and courageous.
Thank you, Eileen. Very much. I appreciate your entire comment.
I am 13 years out now. My port scar still itches, but I'm otherwise pretty much back to normal.
I'm glad you are enjoying my writing. Thanks for letting me know.
Hmmmm. I implant “Ports” for cancer patients. What should I do different so that they do not itch???
I don't know, Rodney. I think old scars do sometimes itch and that's just the way they are. It's not anything that disturbs my life at all.
An unrelated aside, I asked for my explanted port and have kept it in a urine cup filled with saline in my bottom desk drawer--next to my spare clothes, snacks, and some random files. I pull it out when a patient is nervous about getting a port and it helps people feel less scared about it. My surgeon said I was the first person in, like 30 years who had asked for it!
This doctor never denied she told the patient that 200 was fine, did she?
Reiterating fictional patient—this was about perception and communication, not diabetes.
And as I pointed out it was about APPROACH!
Luc, I am a psychiatrist and I ask people to change their lives every day. I agree that the approach is everything. I am going to challenge you to look into a therapy approach called Motivational Interviewing. People have autonomy and rarely will change their behavior if they feel they are being badgered or nagged. The best advice often is perceived as nagging. I think this physician was gauging that her patient was not willing to have a longer discussion. Sometimes it's a win just to have that patient not cancel the appointment and be honest about not taking our advice. I know I struggle to admit to my dentist that I don't floss twice a day!
As the oncology ICU/PACU RN with stage 4 myself, I was captured by this article. Thank you. What pushed me over the edge? Severely neutropenic, femoral fracture requiring rod, my colleagues were switching assignments to protect me. That did it for me to go out on disability. Thanks again for writing this.
Gosh, Caroline! I hope you're doing OK.
Thank you for your comment and I'm so happy you related to the article.
Your comment is a great reminder that denial affects family (in your case your work family), too. Thank u!
First of all. Good luck with what you are going through.
So let's back up here.... you said ""It was pretty high, like 300, but it came down by the time I got home. It was 175, and you said 200 was fine"
If that's true then why are you selling her pills to fix her diabetes?
Why didn't you leverage THAT to get her to prove to YOU that she didn't need it instead of insisting that she did?
IF you felt her life was in danger due to high blood sugar then put the POWER in her hands and say "Okay, let's do this. You are right that exercise will lower blood sugar. Let's do a test for one week. You take your blood sugar three times a day. Right it down. And I'll see you next week and we can talk about it."
Why were you so pushy? She's an individual. Don't treat her like cattle.
BTW did you Oncologist tell you that they made money off the chemo drugs they recommended you take?
Wow. You’re brutal. Not sure I agree. But appreciate your thoughts
Thanks for reading and commenting, Luc.
I was diagnosed 13 years ago. I've had a good, long remission (and continuing as far as I can tell).
I didn't really think Mrs. W was the focus of the article so I glossed over a lot of details. I'm thinking that I need to write about diabetes. Thank you for the inspiration.
Mrs. W had had her diagnosis of diabetes for a long time. I wasn't making the diagnosis the day in the clinic.
Again, it wasn’t the issue of what she had it was the approach. Yes, you know more about diabetes than your patient (and again when the fictional person mentione numbers you didn’t refute that or say any different) but your patient wants feel that you are working together.
Thanks, Luc. I'm in the middle of a long arc about heart failure, but I see that I need to tackle diabetes soon. Thank you.
Why is everyone not getting it really had NOTHING to do with diabetes it was the APPROACH!!
I think the doctor already had more than sufficient info to make her recommendation. It wasn't pushy it was in the interest of overcoming denial.
My recommendation to you is to read about proper blood sugar levels and the slow but serious progression of type II diabetes.
I never said anything about what her number should or shouldn't be. I was talking about the APPROACH to the problem.