September 24, 2012

On a regular basis, someone asks me, “Can I be perfectly honest with you?” I wanted to reply, “No, just be dishonest, I like it better that way!” “Can I be . . .” implies that, in past conversations, my patient has been dishonest. Dishonesty is a relationship breaker. Dishonesty leads to distrust and if I cannot trust what a patient is telling me, I cannot be effective; the doctor-patient relationship is terminated.

Am I being too harsh? Are there degrees of dishonesty that are acceptable? While there may be a place in the real world for partial truths and degrees of honesty, there is no room for dishonesty in the exam room. In June of 2011, I published “Three Things,” an article about the importance of being honest with your doctor and being honest with yourself. When surveyed about the three most important things a doctor can tell his/her patients, the most common theme was to be honest. Don’t lie.

Today was one of those days! A second patient admitted that, when he saw me on Friday, he was not honest with me. His condition had worsened dramatically, the pain making him regret not haven’t been “perfectly honest”. Both patients had their own reasons for hiding the truth. There are many reasons patients exercise various degrees of honesty. Some patients feel their actions make them look foolish; some fear the doctor’s scorn, some fear the answer to their problem will be too much for them, others are simply embarrassed. Sometimes, patients are in denial.  No matter what the reason, the doctor-patient relationship should be a partnership based on mutual trust and respect. In a relationship of trust and respect, there is no place for dishonesty.

Unfortunately, it’s a two way street. There are times when I want to be less than totally honest. There are times when I want to “soft sell” the truth, knowing that the truth is going to hurt. After all, my job is to heal, not to hurt. Nonetheless, if I shelter my patient from the truth or mislead him, I break the relationship of trust and respect.

There are other times when family members ask me to spare their loved one the horrors of a bad truth. They want to lessen their loved one’s (my patient’s) pain and suffering. Telling the truth, the whole truth, can be a real problem.

So, what to do? Risk the relationship of mutual trust and respect to spare someone pain? Then what happens when your patient needs honesty and discovers your deceit? It’s not an easy choice.

We are all humans, striving for the impossible goal of being perfect. The doctor-patient relationship is as imperfect as the two people who make up that relationship. Each has to recognize the other’s imperfection. Each has to strive to be “perfectly honest”. Each person has to realize how difficult it is to be “perfectly honest”, and that honesty can save a life, can take a life,  and can hurt!

I have chosen the path of seemingly brutal honesty, pulling no punches, for the vast majority of my career. I think people deserve the truth and that my job is to preserve the trust in the doctor patient relationship. There have been times when I have regretted that choice.

I hope my patients will choose the honest approach, no matter how difficult that choice. I hope they will understand how important knowing what is truly happening to them is and how the truth will ultimately impact their diagnosis and the success of treatments. I hope they recognize that the life they save may be their own!

I also hope that they will forgive me when I tell them what they didn’t want to hear, what hurts.

Sunday Special

September 23, 2012

  1.  The following article addresses the difference in perspective between the patient and his/her doc:


When going to see your doc, planning your visit in advance helps.  What do you want from the visit?  What questions need answering?  Organizing your thoughts in advance of the visit will help you and your doc communicate better.

  1.  Confused about Medicare?  Don’t know who is telling the truth?  Read:


It appears that neither political party is capable of telling the truth!  I think there must be a LCS Virus (Lying/Cheating/Stealing) going around D.C. that has a predilection for politicians.  How else do you account for what happens to the well meaning people we elect?  Maybe if we limited terms, we could limit the spread of the LCS Virus.

  1. Once again Dr. Grumet waxes eloquent regarding the aging process and death:



  1. My duh moment of the day regards the recent report that drinking sugar causes obesity:


An AHAH Moment

September 22, 2012

I just had one of those AHAH moments.  I was counseling a patient about his weight and the diet he was on when I had a moment of mental clarity that explained a phenomena I have witnessed throughout my entire career!

My patient was on his third go at one of the better commercial diets.  He had been successful in the past only to find his weight return.  Succeeding, only to fail, is miserable.  The diet he is following assigns points to food.  It’s the patient’s job to weigh, measure, and record what he eats, assigning points to each meal.  If he stays within his allotted points, he will lose weight.  Easy, isn’t it?

It should be, but isn’t.  For some unknown reason, the longer he is on the diet, the more likely he is to fail.  I’ve always thought my patient’s ultimate failure was related to a certain cockiness that success and familiarity breeds.  Yes, a cup of item “X” is valued at 4 points; and, as long as you measure your portions, weight loss ensues.  In time, most of my patients stop measuring and “eyeball” item “X,” scooping what they think is a cup onto their plate, assigning their 4 points but really consuming 1 ½ cup and 6 points.  “Eyeballing” their intake leads to failure.   Failure leads to weight gain and great harm.

Now, here’s the AHAH I had.  I am now thoroughly convinced that inside each of our brains lives a politician who will lie, cheat, and steal to get what he/she wants.  It seems obvious to me now that the old image of an angel on one shoulder and the devil on the other needs to be modernized.  There is a politician sitting on our shoulders, whispering lies in our ears.

If my premise that the secret to good health is to first define what your strengths and weaknesses are and then refine yourself, then I have finally found what I have been missing for years.  It’s time to get that lying, cheating politician out of our brains and live “Wellthy!”

“No, I can’t eat those Reeses Pieces!  No, that’s not a cup, that’s 2 cups!  No, it’s not ok to cheat! Now, shut up and leave me alone!”

Reality Trumps Theory!

September 21, 2012

I just had an interesting conversation with a pharmacist about a patient of mine.  The pharmacist did not want to fill my patient’s order for Celebrex.  The pharmacist insisted that Celebrex should not be given to a patient with known heart disease as it might worsen the patient’s underlying heart disease or even kill him.

I am well aware of the risk of giving Celebrex or any non-steroidal anti-inflammatory (NSAIDs) to a patient with heart disease.  I am also acutely aware of what living with chronic back and joint pain is like.  In my world, reality trumps theory every time. 

The realities of living 80 plus years is that, often, your joints hurt, you have trouble moving from one position to another due to joint stiffness, and the quality of your life diminishes as you become more and more immobile.   NSAIDs relieve joint pain, diminish stiffness, and improve quality of life.

The realities of living 80 plus years are also that often, you have heart disease, your kidneys start to fail, you have leg swelling, and an assortment of other problems.  NSAIDs are contra-indicated in heart disease, kidney disease, and an assortment of other conditions.

So, what’s a doc to do?  I can withhold NSAIDs and maybe keep my patient alive a little longer, but at what cost?  Confined to his bed or chair, plagued with constant joint pain, taking acetaminophen or codeine to no avail?  This is not the quality of life I would choose.  Would you?

What a doc should do is discuss the risk versus benefit ratio of NSAIDs with his patient and let his patient decide how he wants to live out the remainder of his life.  My patient is well aware of the risks of taking Celebrex, fully understands the implications and chooses to be able to move about and walk with minimal pain.  Others may choose differently.

I do not fault the pharmacist for doing his job.  I know what my patient knows and wants, the pharmacist does not.  The system works:  the pharmacist watches the patient’s back, alerting me to possible medication interactions and risks.  My job is to make sure the patient knows about the possible problems that medications can cause and carefully weighs them against the realities of his life.

Unfortunately, this particular pharmacist seemed intent on watching his own back.  Yes, the pharmacist and I carry risk when prescribing an NSAID for an octogenarian with heart disease.  While my patient understands the risk he takes and wants to take that risk in order to live with less pain, his family may not.  They may see a law firm advertisement on TV claiming that their father’s heart disease and death were caused by his NSAID and inviting them to sue.  Law firm- sponsored advertisements suggesting medications cause harm and inviting suits are a part of life in the medical world.

Another fact of life in the medical world is that reality trumps theory and in the end, patients and physicians alike do whatever is necessary to preserve the best quality of life even when it may be at the expense of quantity of life.  In the end, it is the patient’s decision.  I can only hope my patient has shared his decision making process with his family.