Sunday, July 1, 2012

Day 15

So, here's some really good news! I did not have any antibodies against last night's platelets and my platelets are 25 this morning. The first two bags they gave me I had lots of antibodies to and developed rigors and probably got no utility at all out of them. The second two bags I had no antibodies in the lab, but something was going on because my body chewed through them within an hour so I got only a transient bit of benefit from them (which I did for sure get, because my rash lightened and some nuisance bleeding that I haven't really talked about slowed down). But this bag was perfect and my body did not destroy those platelets so they will live their natural lifespan (which sadly is like 6 days:*) and circulate around happily stopping bleeding where ever they may find it. I wish I could write a thank you note to the donor, I am that grateful!

Also, my hair has hung in there, so Ellie and I will have a hair cutting event today--more good news.

Have a great Sunday, everyone, and thank you for your love and support!

What do you think? Does Ellie have a career in hair cutting?

 Terry and Ellie came and we had a fun visit. Ellie is a hoot rearranging the bed up and down and making it a chair, making it tip back, riding it up and down. We played pictionary and it was very fun. At Jill's suggestion, I bought a set of bananagrams and they will be delivered for next weekend. Here is the picture Ellie made for my white board:
Everyone loves my magnets and almost all my visitors do something to them at some point.

(trigger warning for violence, domestic violence, general acknowledgement of death)
So, shall we return to the doctor/patient relationship? Today, we're going to talk about reassurance. Sometimes I feel like my whole job with my primary care patients is just to hold their worries for them so that they can get on with their life. They're afraid sometimes of medical things that I can help them figure out, but often they're things I have no sway over: they're afraid for their kids in Iraq; they're afraid their husband is going to leave them or lock them in their house; they're afraid they have hep C or HIV because they were kind of wild in their 20's. My job in these cases and I can see that it is tremendously therapeutic for people at times is just to accept the worry. Sometimes I can help by offering hep C testing or my wishes for a safe return, sometimes there is really nothing I can do but explore it, agree that it is scarey and hold onto it for the person. It can be one of the most powerful things about being a primary care doctor and having a relationship with some one. Especially if in a few years, the worry I was holding has faded away and a new one has come up. It can be very moving to know some one well enough to say, well, remember that bad chest xray stuff and how you got through it? What did you learn from that that we can re-use? I think people find this sort of thing really helpful and I think it's an important piece of primary care (part doctor, part therapist, part cheerleader--that's me).

There are ways in which reassurance can be used to weaken the doctor patient relationship too. There is this idea of premature reassurance, which is not reassurance at all and which can be quite damaging. This was a new discovery for me--I mean I've read about it before. Premature reassurance is when the patient says, "I'm scared that I am going to feel traumatized by that procedure" and the doc says "Don't worry; I've done this lots of times; it's going to be fine." Or "I'm afraid that hospice was a bad choice for me." "Don't worry; it will be fine; we'll keep you very comfortable." The insidious thing about it is that it can be done by really nice, really well meaning people who are in a hurry or not quite feeling up to hearing about someone's trauma or who genuinely believe that that will be enough reassurance (which it might have been if the fear were explored first) or who are just not having the world's most sensitive day. I bet I have done it in the past. I am sorry.
(end trigger warning)

There are so many bad things about premature reassurance: that it can be done by people who are careless rather than jerks, that after the patient has made themselves vulnerable to say "I'm afraid" they get their fear minimized and themselves minimized; no reassurance is provided, but that patient is never going to ask for it again; an opportunity to build and strengthen a relationship is lost and instead the relationship is weakened.

In most settings that I practice in, there is enough time to explore the issues, but in the ED or the ICU, there might not be. I have made it a practice since residency when taking care of some one who I think is about to lose consciousness to say "you're doing a great job" and "we're going to take good care of you" while I strongly grip their shoulder and look into their eyes. People tell me from time to time that it has been very helpful to them and no one has complained about it. So, I guess it doesn't end up feeling like premature reassurance to people, but I worry a bit. I think it is also possible that people in the ED or ICU who don't have time to "explore" their issues don't come up with the sort of issues that need exploration. In those cases, maybe the "I've done this hundreds of times before and it's going to be ok" response is alright and not premature.

In fact, maybe that is the whole thing with premature reassurance is a mismatch between the amount of exploration the patient needs of their issues and the amount the doctor is willing to do. In the ED, it really might not be an issue because all a person who can't breathe wants to hear is that you will fix it. In the clinic, many people want a more nuanced message that starts with "I want to hear your concerns. In fact, I'm going to bother to actually find out what those concerns are."

Perhaps it's a different face of engagement.

This whole patient thing is really really eye opening and from the vantage of a few years out, I will be grateful? appreciative? no longer wishing I could just read some extra about the doctor patient relationship and skip the experiential time? I mean, I really think a gangrenous gall bladder would have been enough to get the points across.

Wishing you a restful Sunday and safe travels this holiday week.

*editted to correct. turns out platelets have a much longer half life than I thought so go, little platelets. It also turns out that I need more board prep in basic hematology than I might have thoughts (ahem).

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