I just read an article about expectations in medicine.  Expectations can make or break a relationship.  They can be the source of great excitement and joy or of great disappointment and sadness.  Expectations, in medicine need to be clearly defined and, when possible, successfully met.

Several years ago, I did a full physical on a new patient.  Patient “X” had been referred to me by a mutual friend and I did my usual, thorough job.  I was dismayed when my friend called me to report how disappointed patient “X” had been!

I called patient “X” to discuss the results of his exam and why he felt I did a “crappy” job.  Mr. “X” started with, “Doc, I like you, but you did not do/order a stress test, Carotid Doppler, lung function test, PSA or colonoscopy.  I went to Dr. “Y” and he ordered them for me!”  To Mr. “X’s” surprise, I asked him why he thought he needed those tests.  Mr. “X” responded, “My partners’ docs ordered those tests.”

In retrospect, the problem was obvious.  Mr. “X” had expectations I did not meet.  I had expectations, as well.  My expectation was that Mr. “X” wanted a thorough, customized physical.  “Mr. “X”, I’m sorry you were unhappy.  Let me venture a guess:  your partners are all in their mid-sixties.”  His answer was “yes”.  “Mr. “X”, had you been in your sixties, I would have ordered those tests and perhaps more.  You are 41 years old and, with your personal and family history, as well as excellent physical condition, I did not feel you warranted any of those tests.”

Mr. “X” cancelled all of his tests and sees me yearly for his exam.  I learned a valuable lesson.  My patients’ expectations may not match mine.  Setting realistic expectations are an important part of any doctor-patient relationship.  Patients must recognize that doctors have expectations and doctors must realize that patients have their own, distinct expectations.

Expectations can range from fantasy to reality.  In the medical arena, it is crucial that expectations be founded in reality.  As your doc, I expect you to follow my instructions.  I expect that, if you are going to vary from my instructions, you will let me know.  These are realistic expectations.  

An example of false or unrealistic expectations would be if you were 75 pounds overweight, drank a bottle of wine and six cocktails, and smoked two packs a day; and I expected you to lose your excess weight while giving up smoking and alcohol simultaneously within 6 months.  (I would give the above patient at least 6 1/2 months). 

Sometimes I set unrealistic expectations for myself and my patients.  When the stakes are high enough, you do what you have to do in order to survive.  Unrealistic expectations can be met when truly necessary!

Patients often set unrealistic expectations.  The most common example of an unrealistic expectation is when the patient, mentioned above, expects his doc to cure his cough, repair his damaged liver, and save him from the heart attack he is about to have.  Doctors don’t heal patients; they help patients heal themselves.  Expecting your doc to save you from a sinking ship while you are punching holes in the hull is another example of false expectations.

So, what can you do?  Discuss your expectations with your doc.  Let him/her know exactly what you want; what you are thinking.  Be sure of what your doc expects of you.  Expect that your doc will work your expectations.  If he/she falls short, discuss it with him.  Work at meeting your doc’s expectation.  Expect that your doc will confront your shortcomings, as well.  Most of all, be honest with yourself and your doctor.

P.S. – I believe in miracles.  I have been blessed to see many miracles in the last 40 years of practice.  It is ok to have false or “fantasy” expectations, as long as you know that the only way they will come true is to receive a miracle.  It is not OK to sell yourself on false hope as the vast majority of time it will end in disaster.  

Ever noticed that being happy can be hard work?  I have.  For the most part, my patients are hardworking individuals and lead blessed lives.  Most of them have jobs, homes, family, and food on their tables.  Their Blessing Lists are full!

So why do they have to work so hard to be happy?  There are lots of reasons to be unhappy.  Sometimes, my patients are unhappy because they or their spouse are married to their jobs and not their families. I addressed this issue in “Another Kind of Affair”.

Sometimes, they are unhappy because they don’t have “enough.”  Did I tell you the story about the identical twins that lived identical lives and had identical fortunes?  One of the twins had “everything” and was a happy man; the other had “enough” and was not happy!  It’s often a matter of attitude.  Even though the twin with “enough” had the same things his brother with “everything” had, he wanted more.  What he was missing was an attitude of gratitude for what he had!

Sometimes, life is going fine and illness strikes you or a loved one.  When illness strikes, you really have to work hard to maintain any degree of happiness!  When I lay out my “Wellthy” lifestyle plan for a patient, I ask him to establish five retirement funds:   a financial fund, a physical fund, a nutritional fund, an emotional fund, and a spiritual fund.  I tell him that, to be truly “Wellthy,” he needs to make deposits in each of these funds on a regular basis.  I warn him that putting off deposits in any of these funds could spell catastrophe.

When illness suddenly strikes you or a loved one, the deposits you’ve made in your emotional and spiritual funds will provide the assets you need to draw on to maintain “happy.”  Remembering the good times spent rather than regretting time wasted is essential.  In “Don’t Delay the Happy,” I wrote, “sometimes there are no more ‘one day.”  Enjoying every day and saving memories will help you get through those days where no amount of work will maintain your “happy.”

I often tell my patients that “spirituality” is the glue that holds a “wellthy” account together.  According to Wikipedia, spirituality can be defined as “an inner path enabling a person to discover the essence of his/her being; or the “deepest values and meanings by which people live.”[2] Spiritual practices, including meditation, prayer, and contemplation, are intended to develop an individual’s inner life.”  It’s that inner life and the understanding of the essence of his/her being, that will help sustain your “Wellthy” plan through sickness and loss. 

Yes, being happy often takes work.  As in any endeavor, having a game plan helps.  Make your Blessings List and read it night and day.  Make sure those you love know you love them.  Invest in your “Wellthy” accounts on a regular basis.  And, most of all, don’t delay the happy!   

Is your loved one having an affair?  No, not a sexual affair with another human.  I’m referring to an affair with his job!  Yes, some people are bigamists, married to their jobs and their spouses.  Is your spouse married to his work?

A work affair can be worse than a physical entanglement with another human.  It can be harder to break up with work than with a human lover.  An affair with your job can be just as destructive to your marriage and can cost you your life.

Not long ago, I saw a leader of American industry whose job took precedence over all else.  Being responsible for a Fortune 500 company’s success is an awesome responsibility.  The company demands constant attention, nurturing and stroking the company’s growth. Responding to changing needs.  Being a successful corporate leader requires long hours, travel, business meals, and more, leaving no time for self and family.

As in any affair, denial plays a major role.  The unfaithful spouse will deny any impropriety, claiming that his/her long hours at work are spent on behalf of his family!  He/she claims that he/she works long hours in order to provide financial security for his/her family.   He/she claims that, one day, he/she will retire and enjoy his/her family and life.

As a patient, the office bigamist often neglects his health, skipping appointments, running out of medicine, and complaining that there is never time for exercise.  Certainly, business lunches and dinner are not amenable to proper eating habits.

Diets and Other Unnatural Acts was partially inspired by just such a corporate giant.  Being married to your business may provide for financial success and security, but money without health and family is worthless.  Carl was living proof.

Are you married to your work?  Is your work an abusive spouse?  Does it demand so much of you that there is no time to take care of yourself or others?  Or are you a stress junky?  A success junky? 

Sometimes business demands are not the problem.  Sometimes the personal need for success creates stresses that are self-imposed.  I’ve written about the two brothers, one whose has “everything” and the other who has “enough.”  Both brothers have identical assets, the difference is perspective.

Whether you are a work bigamist or a stress/success junky, it’s time to change your perspective!  Money without health is worthless.  Over the last 30 years, I have seen many patients sacrifice their health and family relationships in the name of making a living.  I have seen many spouses cheat on their loved ones by marrying their businesses.  In every case, the only thing the family ever wanted was time with their father/mother/spouse.

Success in your job is important.  Success as a spouse and family man/woman is more important.  They need not be exclusive of one another.  Make your health and your family your primary responsibility.  They will be with you long after your business is gone.  Don’t wait until your health fails or your family is irreversibly estranged.  Remember, the life you save may be your own and that life is important to others.

Yesterday, I published Jugglers and Midlife Crisis.  I often use the analogy of juggling when dealing with the assorted problems my patients have.  I was explaining my concept to a patient, explaining that I envision us as professional jugglers, constantly tossing balls into the air and catching them.  Each ball represents a part of our lives and those of others.  Yes, others toss us balls to juggle, as well.  Some of us don’t know how to say no and end up juggling both their own problems, as well of those of many others (a topic for a future article).

Some of us are better than others at juggling the day to day tasks we all face and how well we juggle those tasks directly relates to the level of stress we experience.  Using my model, I ask my patients to name each ball they are juggling (and who owns them) and then take them out of the air, one by one, placing them on the table.  By doing this exercise, patients can then organize their problems into groups and then slowly reduce the tasks they are juggling by removing those they can’t deal with, working with smaller groups, and finally finish their tasks in a more reasonable manner.

The patient referenced above was a teacher and life coach.  She was familiar with my approach and took the time to share her version of juggling with me.  I want to share it with you, as it is excellent.  She told me that there are two basic forms of balls we all deal with:  one set are made of glass, the other is made from brass.

Glass balls are fragile, and, if you drop them, they shatter into a million pieces.  They cannot be repaired. Glass balls relate to health, family, and friends.  Brass balls are all the others.  If you drop a brass ball, you can always pick it up.  It may be marred or dented but can be repaired or replaced.

So, when you are hard at work juggling all the problems and tasks you have to deal with every day, remember which are made of glass and handle them with care.  In a pinch, let the brass balls fall to the ground.  Catch and cradle the glass ones until they are safely put away, then go back and clean up the mess.

We are all jugglers. At every age and stage of life, we juggle from the time we get up to the time we go to sleep. Some of us are really proficient at juggling, others struggle. Often, the young juggler finds the act of juggling entertaining, even exhilarating. As time passes and life becomes more complex, juggling becomes stressful. By now, you are probably confused, wondering where I’m going and if you should close out of this blog. Stay for a minute more. 

We juggle personal, family, work and social issues. Think of each task you have to do today as a baton in the air. When you catch it, you need to finish it so you can catch the next one. In your early life, you have just a few batons in the air. In time, you add new ones. So, your wife asks you to buy play tickets. You finally have a chance to do so. You have that baton in hand when your boss comes in and tells you he needs those figures he asked for yesterday, right now. So, you toss the play tickets in the air and catch your boss’s baton. You start churning out the needed figures when your mother calls; her computer is broken. You catch that baton and toss it in the air with the one labeled play tickets. The baton the IRS tossed you last month won’t leave you alone. You’ll tackle it later; so, for the time being, you keep catching and tossing it back into the air. In time you have so many batons in the air, that as soon as you catch one, you have to toss it back for fear of dropping the next one.

Boom, you dropped one and it shatters. Boom, boom, boom, you drop more. Welcome to a midlife crisis. When you are juggling so many items that you can’t possibly keep them in the air, you crash and so do those around you. I treated midlife crisis all too often. Sometimes my fed up, overwhelmed patient simply quits juggling, turns and walks away (or gets admitted to the hospital). ALL, THE BATONS COME CRASHING DOWN AT ONCE! IT’S A DISASTER! Family, friends and work suffer simultaneously. Other times my patient manages to safely deposit enough items on the floor to maintain some semblance of life and tries to rebuild.

So, what can we jugglers do? One recipe for success looks like this:

1. On a regular basis, everyone should take a break from juggling. 

• Put each baton carefully down on the table and step back. 

• Analyze what is on the table. 

• Get three boxes and label them past, present and future. 

• Sort the batons in to three piles: those that you can do nothing with; those that need immediate attention; and those that you can’t do anything with but will need to be handled in the future. 

• Fill the boxes. 

• Only juggle the items in the current box. 

Too often, my patients have old items (guilt, regrets, hurts) in the air, catching and tossing them to no avail. Getting them out of the air and into the past box is a big relief. Putting them away frees up time to work on the current box.

Often, my patients are tossing and catching items that are coming up at some time in the future (jury duty, a visit from the dreaded in-laws, colonoscopy). They cannot do anything with those items now, but they can’t quite let them go either. Putting them in the future box frees up time to work on current items. 

With added time and less batons in the air, you can get proficient at finishing and throwing away those items that need present time attention. As you deal more efficiently with the present box, you’ll find time to go into the future box, remove and finish those items and avoid that dreaded midlife crisis. When you are really doing well, empty the items in the past box into the waste basket.

What if the above recipe doesn’t work? That’s when you turn to counseling, family and community. A skilled counselor will help you safely get the batons out of the air. The counselor will help you sort each item and move it to a place of safety for future action. Perhaps you need to toss a few items to your family and your community. Perhaps you need to say NO to those who are tossing their batons to you. There are many ways to avoid the crisis. Whatever you do, just don’t quit and walk away!

When is it ok to say, “I told you so”? Most of us suppress the urge to say, “I told you so” while trying not to make a friend or relative feel worse than they already do. After all, saying “I told you so” really doesn’t accomplish anything. Or does it? 

Does being right feel good? Most of the time, it feels great to be right. An “I told you so” loudly declares, “I was right!” I guess the polite thing to do is to feel good inside but, outwardly, be sympathetic. 

In my profession, I would rather be wrong about a great deal of things than be right and have to suppress my “I told you so.” Confusing, isn’t it? Let me explain. 

Mrs. “S” has smoked 2 packs per day for the 28 years I’ve known her. For many of those years, I’ve warned her that the price she would pay for smoking would be a life of misery. She ignored me. She felt fine. Her usual refrain was “I have a friend who is 95 and smokes three packs of Camels a day and he is fine. You, docs, just hate cigarettes.” 

Mrs. “S’s” was in the office the other day. She is recovering from pneumonia and can’t understand why she can’t breathe. She is using maximum doses of her albuterol, Spireva, and Advair and just can’t catch her breath. She wants me to do something. Her docs aren’t helping her and she wants me to speak to them. She feels horrible. Brushing her teeth is a chore. 

While Mrs. “S” lungs were marginal before she got pneumonia, she still had enough lung capacity to function. The pneumonia finished the destruction of her lungs she began 50 years ago. Mrs. “S” is out of lung and is going to be oxygen dependent for the rest of her life. Her lifestyle is changing rapidly. She is angry and demands “fix me!” Unfortunately, no one can. 

Sure, I will send Mrs. “S” to another pulmonologist. He will do a full battery of pulmonary function tests and diagnose her with end stage lung disease. He will start oxygen, maybe add pulmonary physical therapy, and switch her meds around. That’s what specialists do. Unfortunately, he has little to offer. Verifying the diagnosis will only serve to reinforce how bad her situation is. 

Mrs. “S” will become sedentary. She still insists she is cutting down on cigarettes and is only smoking 3 a day. I explained that “only three a day” is like saying “I only plunge the knife in my chest three times a day”. Why hassle her now, after all, her lungs are shot! The answer is easy. Oxygen is flammable. 

Mrs. “S’s” heart is strong. Her brain is sharp. She will probably have a long time to regret smoking. She may well end up in a hospital bed and then a nursing home before her life ends. Her treatments will be expensive. Medicare will pick up much of the bill. Eventually, her treatments will exhaust the nest egg she and her husband accumulated. Mr. “S” will become her caregiver. They will apply for Medicaid. 

Even a self-righteous “I told you so” couldn’t make me feel better. I would rather that I had been wrong about her smoking. I would have rather her be able to say, “See, doc, I’m 100 years old, still smoking and still breathing on my own.” That would have been great. Instead, I get to watch a 70-year-old struggle to find her next breath. 

Are you still smoking?

“Life sucks!”  I can’t tell you how many times a week I hear that expression.  I hear it from both young and old.  I hear it from the rich and the poor, the employed and the unemployed.  I hear it coming out of my mouth way too often. “Life sucks!”  

How can life suck?  Life, itself, is a gift.  Life carries with it limitless potential.  Every day you are alive is a day in which you may find success, happiness, love and wealth.  Happiness is a choice!  You can choose to concentrate on the good things in your life or ignore all that you have and concentrate on what you don’t have.

There are multiple articles on this blog aimed at helping you find health and happiness.  “Blessings List” is still my favorite.  Do you have a Blessings List?  You should.  You should accept every day as a gift from G-d and be thankful for what you have even if the only thing you have is life itself.  If all you have is your life, you are rich with potential!

What sucks is going to the wake of a young adult.  What sucks is mourning for the recently departed.  Life doesn’t suck but some days do.

Would you hire a painter and ask him to paint your house blindfolded?  Would you call your auto mechanic and ask him to repair your car over the phone?  Would you ask your attorney to draw up your will without sitting down with him and discuss your needs?  Of course not!

So, why would you call your doc and ask him/her to treat your body over the phone?  There are reasons:

• “I’m too busy.”

• “I’m too sick.”

• “I don’t have the money.”

• “The wait’s too long.”

These are among my favorites!

“But, doc, it’s just a cold!  I don’t have time to come in.  The last time you gave me the Zpack.  I promise I’ll come in if I don’t get better.”

Mr. C’s cold turned out to be heart failure.  Yes, Mr. C has a cough and congestion.  He also had swollen legs, a cough that worsened when he laid down and an EKG that suggested that Mr. C had suffered a recent heart attack.  Caring for Mr. C over the phone may well have been a fatal mistake. 

Mr. C was too busy to come in.  He had lots to do around the house and was having trouble finding time to do it all.  He also was not very productive as he was short of breath and weak. His heart was having trouble supporting any physical activity.

Mr. C was too sick to come in.  He didn’t know how right he was!  When you are too sick to be seen, you really need to be seen.  If you are too sick to come in, it may be time to call the paramedics.  

Mr. C didn’t have the money to pay his co-pay.  Mr. C drinks a lot.  His congestive heart failure is the result of too much alcohol.  At the price of a fifth a day, it’s no wonder he can’t afford to see the doc.

And yes, the wait is too long.  Mr. C called the office to get his Zpack.  The front desk had to answer that call and take a message.  The message had to be routed to a nurse who then called Mr. C to tell him to come in.  The front desk had already told him to come in and he had ignored them, asking to talk to the doc.  Mr. C ignored the nurse’s advice, telling her he was sure that “Stu” would take care of him. (For some reason, patients think calling me “Stu” infers that they are my personal friend.   My friends don’t call me “Stu.”)

Ultimately, I had to call Mr. C.  By the time I called Mr. C, it was too late for him to be seen.  I told him to go to the emergency room.  He ignored me and showed up the next day.  Shortly after being seen, the paramedics picked up Mr. C.  His wait time was short.  Everyone else’s wait time was excessive.

Not only is phone medicine potentially harmful, it is very time consuming.  With the new year comes new deductibles. Patients will try to avoid coming.  Patients will be putting off rechecks and instead, asking for refills over the phone.  Some of those patients desperately need to be seen.  

So, what’s a doc to do?  From my viewpoint, your doc should avoid phone medicine and see you.  I often end articles with a reminder: “The life you save may be your own.”

Do you worry? Does worrying ever keep you awake at night? Does your worry make you less effective at work and home? Does your worrying about this and that accomplish anything positive?

Most people worry. I worry about a lot of things! Worrying about lots of things is usually unproductive and downright unhealthy. Tonight, I saw a patient who was exhausted due to being sleep deprived. He wanted a sleeping pill or something to take the edge off. He stated that when he went to bed (11 p.m.), he couldn’t turn his mind off. He would toss and turn until he finally fell asleep at 2 a.m. Three hours of misery and wasted time.

Mr. W has a lot to worry about. The economy stinks. He has bills to pay. His health is failing. His friends are in trouble. He worries about what goes on in Washington and the Middle East. The list goes on and on. When I asked him what he has been able to accomplish by worrying, he realized that he always worries about the same things. Nothing ever changes.

Years ago, one of my mentors taught me an excellent technique for helping worriers. I told Mr. W that a sleeping pill or tranquilizer was like patching a leaky pipe with chewing gum. Instead, I asked Mr. W to schedule an hour of “Worry Time” every night.

“Worry Time” is the solution to sleepless nights. The first half hour of worry time is spent making a list of everything you are worried about. Once you have the list, divide it into those things you can control and those you can’t. The second half hour of “Worry Time” is spent designing solutions to the problems you are worrying about. The solutions to those problems that are totally out of your control are to take them off your list or give them to someone else to worry about. Once your list is complete, you can go to bed knowing that your concerns have been addressed.

“Worry Time” is only part of the solution. Mr. W’s second task was to schedule a half hour of “Resolution Time” during his morning breakfast. During “Resolution Time,” Mr. W is to start acting on the solutions he designed the night before.

Mr. W’s first impulse was to insist he did not have one-and-a-half hours to work on a worry list, solution list, and resolution action plan. I pointed out that he had been wasting three precious hours every night in unresolved worries. My plan would not only free up one-and-a-half hours but, for the first time, effectively relieve some of his worries. I think Mr. W is going to do great.

So, if you worry a lot, can’t sleep, and never resolve the issues that plague you, schedule yourself a little “Worry Time.” Let me know how it goes. On my list of worries today was writing tomorrow’s article. I can go to sleep now. 

For some reason I cannot fathom, the following article showed up on my phone today.  It appears to have been published on KevinMD in 2016 which would have been around the time I had one of the hardest conversations I’ve ever had with the family of one of my patients.

My patient had a massive MI followed by an equally devastating stroke.  He was in the ICU of a local hospital, intubated as he was not able to breathe on his own.  He had multiple large gauge IV lines, an arterial line and a bladder catheter.

The MI and stroke were not unexpected.  My patient was overweight, suffered from hypertension, high cholesterol and diabetes.  He drank too much and despite all of my warnings, failed to take care of his body and health.

The nurse informed me that the family was waiting in the ICU waiting area and wanted to meet with me.  Family conferences are one thing I was particularly good at, but I was not looking forward to this one.  Telling his children that he was unlikely to recover from his MI and stroke and that, if he did, the chances of any meaningful life was slim to none was going to be very difficult.  Stripping a family of hope is a lousy thing to do.

Nonetheless, it was my job to give them as true of a picture of their loved one’s condition as possible and help them as best I could.   As death was emanate, I also needed to discuss a DNR order so my patient could die in peace.  My patient and I had many prior conversations about quality of life and illness; and, while he told me he was going to sign a living will and DNR papers, he never got around to it.

His family took the bad news well.  They knew it was coming.  They, too, had tried to get him to care for himself.  They knew he was not taking his medications as directed.  They knew he was drinking too much and ignoring their pleas.

Despite everything discussed, they ended the conversation with, “DOC, do everything humanly possible to bring him back.  NO, we want a full code status and will not sign DNR documents!”  I was dumbfounded, got no where after further discussion of his condition and subsequently notified the nurses he would be a full code.

Over the next few days he coded multiple times.  We used every tool at our disposal, added more tubes, broke a few ribs compressing his chest, started tube feedings, etc.  I met with the family again.

As it was apparent that we were not getting anywhere with the family and, in my mind, torturing my patient, I asked his family, “What did he do to you all to make you want to torture him?”  I know that my question was harsh and, for a moment, thought that his eldest son was going to hit me.

He was outraged, proclaiming his love for his father.  He actually eulogized him without realizing it.  “How dare you ask such a question.”  I explained my actions.  I told them that I prayed that he did not feel the pain from the fractured ribs, tubes and intensive care he was receiving.  I told them I knew they loved him but that very love was prolonging his life at great physical and emotional cost.

The answer to the dilemma we were dealing with hit me like a bolt of lightning.  “I have been taking care of your family for many years.  Like you, I want to do everything humanly possible for your loved one.  And we have, save one thing. The one thing we are not doing that we should be doing is letting him go.  I can’t let him go until you give me permission, but I know in my heart that he is ready and willing to meet his maker.”

In the end, the family found some peace in knowing that they did the hardest thing to do, they let him go.  So perhaps the next family who finds themselves in a similar situation will read this and realize that sometimes, the loving thing to do is nothing.  I’ve given you a link to two excellent commentaries on this topic.

Warning, I cry whenever I watch “Ain’t the way to die”

AIN’T THE WAY TO DIE

The family said, “Do everything.”

DEBBIE MOORE-BLACK, RN | CONDITIONS | JULY 27, 2016