Lessons From My Left Foot

Thomas Bodenheimer

doi:10.1370/afm.1170

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Dr. Bodenheimer's Dilemma
Arthur W. Frank

Published on: 18 November 2010
The special vulnerability of physicians
Carol P Herbert

Published on: 10 November 2010
Thank you for Opening My Eyes
Stanley M. Kozakowski

Published on: 09 November 2010
Thank you Dr. Bodenheimer
Daniel I. Krell

Published on: 09 November 2010

Published on: (18 November 2010)
Page navigation anchor for Dr. Bodenheimer's Dilemma
Dr. Bodenheimer's Dilemma
Arthur W. Frank, Calgary, Alberta, Canada
Thomas Bodenheimer's wonderfully insightful exploration of his experiences of chronic pain pose at least two dilemmas: first, how he can live with his condition, and second, how to be the kind of physician that his left foot has taught him his patients need.
With respect to the first dilemma of living with chronic pain, I'd note two things. First, Dr. Bodenheimer creates a narrative about his troubles. He situa...
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Thomas Bodenheimer's wonderfully insightful exploration of his experiences of chronic pain pose at least two dilemmas: first, how he can live with his condition, and second, how to be the kind of physician that his left foot has taught him his patients need.
With respect to the first dilemma of living with chronic pain, I'd note two things. First, Dr. Bodenheimer creates a narrative about his troubles. He situates his foot pain in a history of how he has used his feet. The pain disrupts his life, but this disruption stops short of chaos --it makes sense. It's still depressing, but the story makes the depression seem reasonable, which makes it more livable. Second, Dr. Bodenheimer finds ways to take a lively interest in his troubles. He doesn't simply suffer them, he engages them. This too makes a difference, but not enough to prevent the depression he describes so poignantly. Which brings us to the second dilemma: what kind of a doctor is he called to be, to meet the needs of a patient like himself?
How can physicians address their patients' depression? What not to do is easier to describe. Once when I was about to have surgery for a suspected recurrence of cancer, a nurse asked a check-list question about how well my wife and I were dealing with this possible illness. I happened to tell the truth, which was that it was going badly. She had no response; she made a perfunctory comment and walked out, with no follow up. It was much worse than if nothing had been said. Far better if she had simply offered sympathy, as in "This must be difficult in ways I can't imagine; I'm sorry," and looked like she meant it. Beyond that, referrals are good, but only if the professional being referred to will actually hear what the condition is doing to the patient's life.
Dr. Bodenheimer challenges himself and his colleagues to recognize their patients' depression--to recognize everything glossed as "quality of life". The 15-minute visit problem is real. Equally real is that many people's healthcare options may not offer any good resources. Physicians have practical needs to limit what they can offer any patient. But they also have a responsibility not to coerce patients into pretending that problems like depression aren't real, just because the clinic lacks the resources to respond to those problems. Not to fix them, but to give them sincerest human recognition and respect.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (10 November 2010)
Page navigation anchor for The special vulnerability of physicians
The special vulnerability of physicians
Carol P Herbert, London, Canada
I identified with the experience decsribed by Bodenheimer in his excellent essay. A few years ago, I tripped and fell in a construction area on a city sidewalk and broke my elbow, necessitating replacement of the radial head. I too felt self-blame (if I was in better shape, I wouldn't have fallen, or wouldn't have had such a severe injury); hated being dependent (but I am the one on whom others depend); and experienced...
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I identified with the experience decsribed by Bodenheimer in his excellent essay. A few years ago, I tripped and fell in a construction area on a city sidewalk and broke my elbow, necessitating replacement of the radial head. I too felt self-blame (if I was in better shape, I wouldn't have fallen, or wouldn't have had such a severe injury); hated being dependent (but I am the one on whom others depend); and experienced mood changes related to feedback from my physiotherapist or surgeon (a five degree difference in measurment of range of motion could depress me for days, even though I know the unreliability of the measure - the implication I internalized was that I wasn't trying hard enough). But the worst was the generalized impact on my sense of self-efficacy.
I doubted my ability to function effectively in the future and decided not to pursue a career opportunity. I anticipated another fall and changed my pattern of activity, becoming unreasonably cautious in the way I walked.
It was more than a year before I could unpack my experience enough to understand its impact on me. I think disability hits physicians especially hard because of our unreasonable sense of invincibility, our feeling that we are stronger than the average person and somehow less vulnerable to injury, illness, or disability, our sense that we have the responsiblitiy of caregiver at all times. However, I am also reminded of how hard it for athletes to lose their ability to compete in their chosen sport - they have described to me their sadness at the loss of their sense of invincibility and special strength.
On the positive side, I too feel that I understand better the experience of people with chronic disability which has influenced how I communicate with patients and how I teach.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (9 November 2010)
Page navigation anchor for Thank you for Opening My Eyes
Thank you for Opening My Eyes
Stanley M. Kozakowski, Flemington, NJ US
I think that I am a "good doc" and practice "good medicine."
Your simple story of your left foot as a chronic condition has opened my eyes again to the challenge of being patient- and not physician-centric.
It is reminder to all of us who see patients to consider the need to ask the questions regarding the impact of the conditions presented by the patient, no matter how "simple" they seem to the phys...
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I think that I am a "good doc" and practice "good medicine."
Your simple story of your left foot as a chronic condition has opened my eyes again to the challenge of being patient- and not physician-centric.
It is reminder to all of us who see patients to consider the need to ask the questions regarding the impact of the conditions presented by the patient, no matter how "simple" they seem to the physician.
On a given day of patient care, I (sadly admit) that I am inclined to use the BATHE technique (1) in patients "that I think" might be having "difficulty" with a health care concern. Shame on me for being so presumptuous as to judge the importance of a patient's condition from my perspective and not to take the time to ask my patients the critical questions raised in your essay.
Your essay also challenges us all to consider the "hamster wheel" approach to medicine and why that model of care delivery may be selling our patients short by missing undiagnosed depression.
Thank you for opening my eyes again.
(1) Stuart, M., Lieberman, J. The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician. 2nd ed. Westport, CT: Praeger Press; 1993.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (9 November 2010)
Page navigation anchor for Thank you Dr. Bodenheimer
Thank you Dr. Bodenheimer
Daniel I. Krell, Portland, ME
By the time I entered med school, I had had two hip operations; a femoral neck fracture (as a 12-year-old, I was sure I knew more than my orthopaedist, and put full weight on my operated leg); 3 months in plaster from foot to chest; a year on crutches; and a painful, drawn-out recovery from pilonidal cyst surgery. Chronic (and yes, self-inflicted) knee problems resulted in surgery during my residency, two subsequent sur...
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By the time I entered med school, I had had two hip operations; a femoral neck fracture (as a 12-year-old, I was sure I knew more than my orthopaedist, and put full weight on my operated leg); 3 months in plaster from foot to chest; a year on crutches; and a painful, drawn-out recovery from pilonidal cyst surgery. Chronic (and yes, self-inflicted) knee problems resulted in surgery during my residency, two subsequent surgeries, and final (hopefully) surgery, 2 years ago, for a total knee arthroplasty. Though not fun to go through, I entered med school and residency in wonderment at all my peers who had never been on the other end of significant med/surg equations, and I felt richer for the experiences. They did nothing wrong, but there was a world of understanding that most of them did not have and could never get from a book, lecture, or series of interviews with a patient or patients. Having family, friends and neighbors empty your urinal and wipe your butt after a bowel movement, for 3 months, does give one a certain sense of humility and appreciation for being competent in ADL’s, much less being able to ambulate with any kind of competence.
Through training, I fantasized about and – half joking – advocated for all “inexperienced” med and nursing students to be infected with something benign that would make them extremely ill and debilitated, and dependent on others for weeks, in hospital and after they were discharged home. This would not be fun to go through, but it would enrich their personal and professional lives.
I applaud Dr. Bodenheimer’s response to his chronic foot injury, his insights, and his message to all of us; we all need to be educated and reminded, through our professional lives.
Daniel Krell, M.D.
Competing interests: None declared
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Competing Interests: None declared.