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A Doctor’s Letter to Patients with a Chronic Disease

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Editor's comment: As fibromyalgia or ME/CFS patients, we often feel that doctors don't understand our illness and/or aren't really interested in helping us.  Do you ever wonder what your doctor is thinking and feeling about you?  Following is a very powerful and compassionate letter that gives us a rare and valuable insight into how our doctors might be feeling.  It was written to patients who have a chronic disease by Rob Lamberts, MD, in his blog “Musings of a Distractible Mind (Thoughts of an odd, but not harmful primary care physician).”  It was originally posted on July 14, 2010 and is reprinted here in its entirety by permission under a Creative Commons Copyright License agreement (bolding is mine).

A Letter to Patients With Chronic Disease

Dear Patients:

You have it very hard, much harder than most people understand.  Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I too can’t understand what your lives are like.  How do you answer the question, “how do you feel?” when you’ve forgotten what “normal” feels like?   How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue?   How do you decide when to believe them or when to trust your own body?  How do you cope with living a life that won’t let you forget about your frailty, your limits, your mortality?

I can’t imagine.

But I do bring something to the table that you may not know.  I do have information that you can’t really understand because of your unique perspective, your battered world.  There is something that you need to understand that, while it won’t undo your pain, make your fatigue go away, or lift your emotions, it will help you.  It’s information without which you bring yourself more pain than you need suffer; it’s a truth that is a key to getting the help you need much easier than you have in the past.  It may not seem important, but trust me, it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death.  I am not talking about doctors being afraid of the limits of their knowledge.  I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from: we are normal, fallible people who happen to doctor for a job.  We are not special.  In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help.  We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic unsolvable disease stands square in our way.  You don’t get better, and it makes many of us frustrated, and it makes some of us mad at you.   We don’t want to face things we can’t fix because it shows our limits.  We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different.  You see us getting frustrated.  You see us when we feel like giving up.  When we take care of you, we have to leave behind the illusion of control, of power over disease.  We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress.  You are the rock that proves how easily the ship can be sunk.   So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge.  You know more about your disease than many of us do – most of us do.  Your MS, rheumatoid arthritis, end-stage kidney disease, Cushing’s disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder – your defining pain –   is something most of us don’t regularly encounter.   It’s something most of us try to avoid.  So you possess deep understanding of something that many doctors don’t possess.  Even doctors who specialize in your disorder don’t share the kind of knowledge you can only get through living with a disease.  It’s like a parent’s knowledge of their child versus that of a pediatrician.  They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor – especially one you’ve never met before – you come with a knowledge of your disease that they don’t have, and a knowledge of the doctor’s limitations that few other patients have.  You see why you scare doctors?   It’s not your fault that you do, but ignoring this fact will limit the help you can only get from them.  I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand.   You encounter doctors intermittently (more than you wish, perhaps); I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors.  There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:

  1. Don’t come on too strong – yes, you have to advocate for yourself, but remember that doctors are used to being in control.  All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion.  That’s a good thing in the long-run, but few doctors want to be greeted with that reality from the start.  Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.

  2. Show respect – I say this one carefully, because there are certainly some doctors who don’t treat patients with respect – especially ones like you with chronic disease.  These doctors should be avoided.  But most of us are not like that; we really want to help people and try to treat them well.  But we have worked very hard to earn our position; it was not bestowed by fiat or family tree.  Just as you want to be listened to, so do we.

  3. Keep your eggs in only a few baskets – find a good primary care doctor and a couple of specialists you trust.  Don’t expect a new doctor to figure things out quickly.  It takes me years of repeated visits to really understand many of my chronic disease patients.  The best care happens when a doctor understands the patient and the patient understands the doctor.  This can only happen over time.  Heck, I struggle even seeing the chronically sick patients for other doctors in my practice.  There is something very powerful in having understanding built over time.

  4. Use the ER only when absolutely needed – Emergency room physicians will always struggle with you.  Just expect that.  Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home.   They might not fix your pain, and certainly won’t try to fully understand you.  That’s not their job.   They went into their specialty to fix problems quickly and move on, not manage chronic disease.  The same goes for any doctor you see for a short time: they will try to get done with you as quickly as possible.

  5. Don’t avoid doctors – one of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address.  I can’t work that way, and I don’t think many doctors can.  Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made.  It’s OK to keep a list of your own problems so things don’t get left out – I actually like getting those lists, as long as people don’t expect me to handle all of the problems.  It helps me to prioritize with them.

  6. Don’t put up with the jerks – unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you.  Some docs are not cut out for chronic disease, while some of us like the long-term relationship.  Don’t feel you have to put up with docs who don’t listen or minimize your problems.  At the minimum, you should be able to find a doctor who doesn’t totally suck.

  7. Forgive us – Sometimes I forget about important things in my patients’ lives.  Sometimes I don’t know you’ve had surgery or that your sister comes to see me as well.  Sometimes I avoid people because I don’t want to admit my limitations.  Be patient with me – I usually know when I’ve messed up, and if you know me well I don’t mind being reminded. Well, maybe I mind it a little.

You know better than anyone that we docs are just people – with all the stupidity, inconsistency, and fallibility that goes with that – who happen to doctor for a living.  I hope this helps, and I really hope you get the help you need.  It does suck that you have your problem; I just hope this perhaps decreases that suckishness a little bit.

Dr. Rob

Post Script: This post has generated a huge amount of conversation and interest (as witnessed by the large number of comments!).  I very much appreciate the dialogue it has spawned both here and across the web.  I’ve subsequently written follow-up posts explaining my thoughts in more detail – largely in response to the comments here.  One of them discusses in more detail my own experiences as a doctor and the second talks of the importance of knowing and being known.  Reading these will give you a better picture of my thought process and perspective on this. – Dr. Rob

You can learn more about Dr. Rob at Doctor-Rob.org.

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5 thoughts on “A Doctor’s Letter to Patients with a Chronic Disease”

  1. Mary_ says:

    Thank you THANK YOU thank you.

    Thank you for caring. Thank you for allowing yourself to be vulnerable and expressing your own perspective. This information is invaluable.


  2. eljulia says:

    Having a son-in-law in England who is a GP has gone a long way to help me understand the trials and joys of being a doctor. I’m glad I knew enough that when my primary care doctor dealt with my fibromyalgia diagnosis by continually asking what I thought we should do next (I was sorta counting on her and that whole “years in school” thing you guys do for some answers) that I moved on and have found a new doctor. She’s very supportive, will answer any and all questions and will get a specialist involved if needed. It’s been a great relationship.

    Thanks for giving your view of the job. 🙂

  3. big-ted says:

    We’ve actually had this discussion. I have multiple chronic illnesses and few of them seem to respond well to treatment. We’ve talked about my knowledge of my illnesses and how it exceeds his. We’ve talked about how doctors expect to be able to fix things and how I seem to be unfixable. We talked about his frustration at not being able to give me the relief he would like to see me get. You have brought up some very important points to help make this relationship work and work well. As patients it’s never good to outsmart a new Doc on the first visit. I’d suggest that with a few exceptions you need to have a few visits before you can let on that you know more than most. Respect goes a long way in all kinds of situations, this is no different. As far as the eggs go, I learned that the hard way, I have 2 specialists and a GP I trust. The others I respect but these three I really trust. Unless I think I need to be hospitalized I stay away from Docs who don’t know me. Too many quick fix diagnoses for what are actually longstanding chronic illnesses make me use ERs as an absolute last resort. I keep in regular contact with all my Docs just so we can be sure there is nothing hiding in the wings for a sneak attack. Don’t put up with Jerks is awesome advice. I did for many years thinking Docs could do no wrong and I had no choice. I have since learned that Docs are human, fallible and have bad days too but there is no need to put up with rudeness ever. I found a new specialist and he’s one of the 2 I trust. Yes I forgive you all including the Jerk! As I have become older and wiser I have learned as you put it “…we are normal, fallible people who happen to doctor for a job. We are not special.” Well I disagree with the last part. I do think you are special as even though “you” don’t have any answers none of the Docs who make up my team have ever suggested I am a lost cause even though there are no answers.

  4. SueLossing says:

    I want to thank you so much for admitting that while you treat us, you don’t understand the disease we have because you don’t have it. I know we scare doctors, I know I terrify doctors as I have 3 auto-immune diseases and know all of them well. I am lucky as my doctors are great, I love my PCP as he knows me and I know him and we “get” each other; my endo is another terrific doctor, my cardiologist is great also and then there is my rheumy. They all listen to me and I listen them and we have mutual respect and my team of doctors work well together which is always a bonus. Its just nice to hear a doctor say that someone with a chronic condition scares them and why. While most doctors are great, there is always one bad apple. The only time I go to the ER is after I have had a really bad insulin reaction (Type 1 Diabetes) and usually by the time I get to the ER my blood sugar is back up to where it should be, so the ER doctor gives me a quick once over and tests my blood sugar to make sure it isn’t low and then I’m on my way home. We really need more doctor’s like you who can tell a patient you know this disease better than me as you have lived with it and know when the disease is acting up.

  5. DTomei says:

    I wish you were my doctor. The idea of “have a relationship” with your doctor is lovely. When you only are allowed 10 minute appointments by the insurance companies, and he only has time for one symptom, there is no time for understanding what is really going on at all. We have basically stabilized at me telling him “order me these labs” “write me this prescription” he asks why, I tell him quickly the basic reason, he does what I ask, end of appointment. One day he said something (I don’t recall what) and I answered “You don’t HAVE 2 hours to listen to everything that is going on! You are dealing with incomplete data. I would love to tell you all of it, but we can’t.” He’s the best I have found in the area. They get worse.
    I wish you were my doctor.

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