Brian was in a lot of pain, I could see it. But his lumbar MRI showed only modest changes. Two back surgeons said they couldn’t help him. Physical therapy, chiropractic and osteopathy didn’t help or made him worse. Duloxetine helped only a little. After one day of a higher dose, he felt “loopy” and stopped it completely.
Then he found that marijuana helps a great deal. The only problem was that he started smoking a lot and began to act under the influence. His family didn’t support him becoming a “pothead”. His wife asked if there was anything other than duloxetine he could take.
A website that promised minimally invasive laser surgery several states away had caught Brian’s attention. He asked me what I thought.
The same day I saw a woman who cries a lot.
Holly carries a diagnosis of bipolar disease. She is on one of the newer “atypical” antipsychotics. She functions pretty well, but told me she cries very easily: Movies, songs and good news can affect her. She doesn’t feel sad, just the opposite, she cries more tears of happiness or empathy than of sadness or hopelessness.
She asked me if I knew of a medication for that.
In both cases I thought for a moment. Then I entered that mental space that gives me a sense of quiet authority and wisdom, as if I were speaking as a clergyman or a therapist.
“Brian”, I said, “I don’t think any medication will help you right now. You have your mind set on a surgical cure, and as long as you hold that vision, pills won’t work for you.”
He nodded in agreement.
“You gave up on the 60 mg dose after one single day of nonspecific side effects. You need to research the laser procedure.”
He nodded again.
“But let me point this out to you: you’ve told me that marijuana makes you less stiff and makes your legs move better. That means you’re not all rusted up. Marijuana does nothing to the bones, disks, muscles and ligaments in your body. The only thing it does is change how you experience things. If marijuana makes you limber, do you really need to have surgery, or can you change the pain experience through it and any other chemical or yoga, meditation, Reiki, prayer or whatever?”
His wife turned to him as if to ask him to answer me.
“The problem in your back can be overcome by changing how the nerves from your back and legs communicate with your brain. They are sending exaggerated signals that your back is completely broken when it really isn’t. It has some glitches, but even smoking weed makes you able to use it with less pain, and the duloxetine starting dose did the same thing.”
He looked straight at me and made a slight frown.
“But you’re not ready to work on it that way. You will only be able to do that if you know for sure surgery can’t make you “perfect”. Go see the laser folks and talk to me again afterward.”
I rose from my swivel stool and ended our visit. Brian and his wife seemed to exchange telepathic comments as they left the room.
“Holly”, I said, “I could give you some Paxil and make you cry less, but you would very likely then also feel less joy and empathy. Is it worth risking losing a really good quality that you have?”
“No. I think of myself as a very empathic person. I would give my sweater to a cold homeless person, I’m like that.”
“Right, you have bipolar disease, your mood may change quickly, but you are a very feeling person and maybe this world needs more people who can really feel things, be present in the moment.”
“I like to be called a feeling person. I wouldn’t want to not feel…I was just wondering if it is normal.”
I held my hands out, palms up.
“It is normal. It can be beautiful.”
She smiled and said “Thank you”. Her eyes moistened as she got up from her chair.
I didn’t offer any cures to these two, but I’m trying to help them see themselves as not some potentially flawless machines, but imperfect human beings, as we all are, who can still make the most of who they are and what they have.
Seeing your patients as having agency and telling them you see it and honor it is one of the many things that make you a wise caring physician. Thank you for sharing the struggles of these two patients and how you cared for them.
As I sit and watch the really misleading drug ads on TV, I keep wondering why viewers can't see that they don't have to be made perfect with a pill. Would really like to see medication ads banned from TV. I'd much rather see a Marlboro man on a horse. As you note, finding out the real cause of a problem takes time and thought. How many patients are handed a pill today instead of a careful look at what is really going on in their body.