Sick Doctors: Texas Physicians Find Themselves on the Wrong End of the IV

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Cover Story -- March 2002

By  Larry BeSaw  
Editor

To use an old Texas expression, Jack Whitaker felt like he'd plowed up a snake. The day after undergoing a routine physical examination for a health insurance policy, his doctor was telling him that his PSA reading was 18.6.

"I said, 'That can't be right,' and I had it repeated three times just to be sure," he said, recalling the event eight years later as if it were yesterday. "The lowest I got it down to was 18."

He'd had no symptoms, but there was no doubt about it. Jack Whitaker had prostate cancer.

Prostate cancer in a man 61 years old is not that uncommon. But considering how he makes his living, he was amazed. You see, he's not just Jack Whitaker. He's Jack Whitaker, MD. And he's not just Jack Whitaker, MD. He's Jack Whitaker, MD, oncologist.

"I was stunned. I was like, 'Oncologists don't get cancer.'"

Yet there he was -- a cancer patient, about to embark on a journey into a health care system that he had shepherded so many patients through since becoming Austin's first oncologist in 1965.

After getting over his initial shock and undergoing some "uncomfortable" tests, he found that, like his patients, he had to make some major decisions about his treatment and how it would affect his life. And like his patients, the choices he had to make were not easy ones. A urologist told him he needed a radical prostatectomy. A radiation oncologist urged him to have radiation treatment.

"I consulted several sources and found out the prognosis at 10 years was exactly the same whether I took radiation or had surgery, and it was probably the same at 15 years. I was in financial distress at the time and I didn't feel like I could afford to have surgery and be off work for a prolonged period. I didn't want to be incontinent. I couldn't see making the rounds in the hospital wearing Depends." He also feared impotency.

So, Dr. Whitaker chose radiation and never missed a day of work. For all but one of the next 34 days during the summer of 1991 he received radiation treatment at 8 a.m., and then went about caring for his patients. The only day he did not get treatment at 8 was the opening day of dove season. He and his radiation oncologist were out in the field hunting at the crack of dawn, took a break for treatment at noon, and then went back to hunting in the afternoon.

After his treatment ended, his PSA reading began dropping, finally slipping below 1, where it has been for eight years.

The experience gave him a new perspective and an appreciation of his patients' burdens.

"Going through all this stuff, particularly going through all the tests, makes you realize what the patient's going through. CT scans are no fun. Having somebody look up into your bladder through your penis is no fun. Having stuff stuck up your rear end is no fun. I can appreciate my patients not wanting to go through it."

Dr. Whitaker, now 69, says cancer made him a better doctor for his patients -- particularly those with prostate cancer -- because he can speak from experience when he discusses treatment options with them, and he can help calm their fears.

"I've been able to let them know what to expect when they go through these various tests. I've been able to say, 'Well, ordinarily, I used to do this test routinely but I think the test is traumatic and I don't think we're going to learn much from it and let's avoid it unless we have to do it.' Some people just blindly order every test in the world. I think you can do way too many tests, too many x-rays, too many scans."

He also can personally vouch for the fact that "just because you've got cancer doesn't mean you're going to die from cancer."

A Soothing Touch

Physicians are like anyone else. They get sick. They get hurt. But what happens when a physician suddenly finds himself or herself on another doctor's exam table or in the hospital? That was the subject of a study by two Yale University School of Medicine faculty members, Howard W. Spiro, MD, and Harvey N. Mandell, MD, who collected stories from physicians about their experiences as patients and published them in a 1987 book, When Doctors Get Sick .

In that book, they say physicians are seldom admitted to a hospital unless their illness is so severe that they have no alternative, and that most doctors' medical care comes in telephone calls to a colleague, or in a hospital corridor, or in a "curbside consultation" in a parking lot. Most physicians, they believe, have little sympathy for the pain and fear their patients are experiencing until they themselves become ill. They theorize that many doctors may tend to believe that surviving the rigors of medical school, internships, residencies, and fellowships qualifies them for immortality.

"When a doctor is sick, especially in a hospital, he or she undergoes a role reversal," Drs. Spiro and Mandell wrote in a follow-up article in the Jan. 15, 1998, issue of the Annals of Internal Medicine . "Strangely, the doctor is the patient, and the familiar aspects of the hospital are unrecognizable from a stretcher. Loss of control is hardest of all for sick doctors, so used are they to the obedience of others: Sick radiologists try to read their own films and the bed-bound physician strains to scan the bedside monitor. Sick doctors are lonely patients, isolated but on watch, vigilant against error. Caught in the double bind of wanting to be a good patient yet worrying about what can go wrong, most sick doctors watch their colleagues as closely as they fear their colleagues are watching them. It is not easy to be a doctor and a patient all at once.

"Sick doctors learn new lessons when we lose control over our bodies and our lives. We learn how grateful patients are for physicians who are with them in their troubles. Immigrants to the nation of patients, sick doctors are grateful for minor details, for the kindness of strangers turned friends and caretakers. We become aware of the lack of privacy in hospitals, of the side effects of the drugs that help, and of how wonderful it is in that in their new fervor for quality improvement, medical personnel now strive to be kind as well as efficient."

That feeling of gratitude for the kindness of strangers is exactly how Victoria obstetrician-gynecologist Philip Suarez, MD, felt last September after becoming violently ill while in Denver for his niece's wedding. Recuperating from a microlaminectomy and hand surgery two weeks earlier, he awoke the morning he was to return home with a severe case of vomiting and diarrhea.

"Finally they dragged me to the ER, and I thought I was going to die," said Dr. Suarez, 45. "I was totally out of control. I was very, very sick. I had 101 or 102 fever and 23,000 white count. I was almost seizing I was shaking so hard by the time I got there."

As if that wasn't enough, he had a terrifying experience as he collapsed on a gurney and nurses rushed him into a treatment room. "I heard a nurse telling everybody, 'This guy is going out and we don't know what's wrong with him.'"

 Physicians are considered the captain of the ship, and others march to their orders. But like the physicians Drs. Spiro and Mandell interviewed, when Dr. Suarez became a patient, he was no longer in charge.

"I had no choice but to give up complete control," he said. "It was extremely painful. My back was hurting, my hand was hurting, and I was vomiting. They were throwing these garden hose-sized IVs in my arm, slapping the pulse oximeter on my hand, oxygen on my nose, and a giant hose in my arm, and putting a blood pressure cuff on me. There was no position I was comfortable in."

It turned out that he had a Clostridium difficile infection. "I don't know where I got it. It was the most horrible, god-awful thing. All I know is that you don't want it."

His illness gave him an inkling of how the women he treats feel. "I can now even better identify with them. I've seen 4,000 patients through this and now I've actually been in it. I now know what it's like to be in horrid pain and out of control in the emergency room and feel like you don't know what's going to happen to you," he said.

As bad as it was, the silver lining is that is has helped his patients.

"I learned from that experience to touch, touch shoulders, the head, the hands," he said. "I really felt like when someone was touching me, it really helped. I felt like I was connected to the person taking care of me. I wasn't a mathematical problem or a broken pipe. I was a person. I was far more comfortable if they were holding my hand or touching my shoulder and talking to me."

Dr. Suarez says he has incorporated more soothing touches into his practice and "now more enthusiastically express my concern for my patient."

Good Doctors, Bad Patients

Physicians who become ill will sometimes ignore or minimize their symptoms, or try to medicate themselves. When they finally do see a doctor, they may do the same thing that many of their patients do: not follow the doctor's instructions. It may be because they feel they know more than their doctor does, or because they don't want to admit they are sick. And more often than not, they go back to work too soon.

By his own admission, John Jennings, MD, was a "terrible patient." Dr. Jennings, 56, ignored the right lower quadrant pain and a decreased appetite he first noticed while skiing in Colorado and continued to work while self-diagnosing his condition. Not surprisingly, the pain didn't go away.      

A week later he was in bed with a fever, and his worried wife asked one of his friends, a general surgeon, to come to the house and take a look at him. Dr. Jennings, professor of obstetrics and gynecology at The University of Texas Medical Branch at Galveston, didn't think he looked that bad. That is, until the surgeon felt a mass and told him, "John, we've got to explore your belly."

A trip to the hospital ensued and a few hours later he awoke with his ruptured retrocecal appendix removed and a periappendiceal abscess drained. "After two days of IV antibiotics, my Jackson-Pratt drain was removed, and after being discharged I walked out of the hospital in my scrub suit. Two days later, I was back in the hospital in the much more comfortable role of an obstetrician delivering a baby."

In retrospect, he acknowledged, "I did everything physician-patients are accused of doing. I ignored my symptoms. I attempted to self-diagnose. I denied my illness and delayed treatment. I tried to control my circumstances as long as I possibly could and I resumed control as soon as I could. I refused to be a patient until I no longer had a choice. I wanted to be out of the hospital and back to work where I am 'in charge.'"

What did he learn from his experience? "That the most important aspect of illness is to get better. Getting better is leaving the hospital and resuming at least some normal activity. I encourage patients to ambulate early after surgery. I try to avoid excessive sedation so that patients can be alert and 'in control' as soon as possible. Because I have experienced the pain, I remove Jackson-Pratt drains very gently. Most importantly, I learned that even this stubborn physician-patient can be comforted by knowing that my life is in the hands of competent and skilled physicians."

For Houston neurosurgeon Bruce Ehni, MD, self-medication almost led to disaster.

Fifteen years ago, Dr. Ehni, 53, became acutely ill with an abrupt onset of ulcerative colitis. He went to gastroenterologist Craig Johnson, MD, who performed a colonoscopy and prescribed Azulfidine. That worked and he settled into a pattern of a bout with colitis every year or two. It never presented a major problem, and he considered it nothing more than a nuisance.

"In fact, I quit seeing Dr. Johnson," he said. "I just started phoning in Azulfidine for myself. It's a cheap medication with little or no side effects, so I started treating myself."

Then early in the summer of 2000 his mother was admitted to the hospital with colon cancer and underwent a bowel resection. Her illness probably saved his life.

"I thought to myself, 'Am I going to treat this again by myself or am I going to do what I've been told to do, which is go ahead and see the gastroenterologist.'" An endoscopic examination revealed a small adenocarcinoma in situ.

"It turns out that something I was vaguely aware of, but really hadn't taken seriously, was the fact that ulcerative colitis patients can develop adenocarcinomas really easily," Dr. Ehni said. "If you've got colitis, you've got a fertile ground for adenocarcinoma. They go hand in hand. It was sort of a lesson for me. I should never have treated myself for the last 10 years."

His colon was removed and he went back to work, wearing an ileostomy bag for three months. He then underwent a second operation in which surgeons fashioned a large bowel out of several loops of small bowel sewn together. The cancer has not returned, although he did have another operation to remove a bowel obstruction.

In hindsight, he recommends that physicians not try to treat themselves. "I got away with it, but I maybe wouldn't have gotten away with it."

But I'm a Doctor

There is a natural tendency to assume that physicians who do seek medical treatment receive gold-standard care by virtue of their position. They know how the system works. They know the nurses. They know the technicians. Their doctors are often their friends. But being a doctor can be a mixed blessing when it comes to health care.

"Sometimes doctors get worse care because they're doctors," Dr. Suarez said. "The staff may try to cut corners so as not to bother the doctor, so they'll not do everything according to the book. I think a lot of times doctors get curbside consults on themselves or their families. It's a double-edged sword. On the one hand, physicians are probably taken care of a little bit better because you're on staff and you work with these people and so they try extra hard, but on the other hand, and we all kind of joke about it, physicians sometimes get the worst care because we're getting care in doctors lounges and changing rooms."

Another complication is that a doctor may feel extra pressure in treating a colleague. That's what happened when Dr. Suarez experienced considerable discomfort when he had his back and hand surgery. The anesthesiologist had trouble getting the IV started.

"He's one of the top-notch guys and he couldn't get in. I'm a relatively young, pretty healthy guy with big veins that just kept rolling and popping. I felt more sorry for him than I actually did for me. He was nervous and just dying. I was one of his colleagues and friends. I had delivered his babies, and here he is and he can't get the IV going. I wanted to somehow just not be doctor for a second so he could get the IV in. When you try your best and the pressure's on, that's when little, stupid things happen. But he finally got it going and it was fine."

Being a doctor sure didn't make it easier for Dr. Whitaker when a urinary tract obstruction attributed to his radiation therapy left him unable to urinate and forced him to drive himself to the hospital "just praying I could pee in my pants." When he got there, even though the pain was so severe that he was bent over, barely able to walk, "I couldn't even get anybody to pay any attention to me in the emergency room of a hospital that I admitted more patients to than any other doctor in Austin. They just weren't paying any attention to me."

Finally, a nurse's aide recognized that he was in severe pain, and he began to receive treatment. "They tried to catheterize me six times: two by the nurse, two by the emergency room doctor, two by my urologist. They couldn't get a catheter in. Finally, he got a real thin metal cone up in there. I've never had so much pain. Even 10 milligrams of morphine barely touched the pain."

On the upside, however, both Dr. Suarez and Dr. Whitaker say there were some advantages of being physicians. After his hand surgery, Dr. Suarez managed to get himself admitted for recovery to the postpartum floor where he knew all the nurses. Dr. Whitaker's urinary tract obstruction occurred on a Saturday, and a friendly head nurse in surgery moved him up on the operating room schedule to Tuesday, when otherwise he would have had to wait until Thursday or Friday. "This time, they really took care of me because I was a doctor," he said. He went home the next day, "and I haven't had any trouble since."

Furthermore, adds Joel Dunnington, MD, associate professor of radiology at The University of Texas M.D. Anderson Cancer Center in Houston, being a doctor means you know whom to call when you need help. That's what he did before undergoing quintuple heart bypass surgery last June.

"You know what can go wrong so you have a little bit better idea of the risks you're going to face," said Dr. Dunnington, 47, who picked his heart surgeon based on recommendations from other physicians. "But you also have the benefit of asking around and figuring out who should be doing this and where you should be doing this. You know a little more about where you should go and where you shouldn't go. Doctors have that advantage over laypeople."

Dr. Whitaker agrees. Being an oncologist helped him know "who was good in certain areas" when he made his treatment decision.

Let's Talk

Physicians say they have learned many things from their own experiences -- the trauma of diagnostic tests, the claustrophobia of being in the MRI machine, the feelings of fear and uncertainty, and the immense value of a simple touch and a kind word -- that has helped them be better doctors to their patients. Dolores M. Carruth, MD, a Dallas neonatologist, adds another -- the need to communicate, especially to listen to the patient.

"We [doctors] continue to believe we are great communicators. We are great and fast talkers but we remain poor listeners," she said. "This habit is especially difficult for elderly patients who frequently do not understand their disease, their medications, or what is expected of them. They are very hesitant to engage the physician."

She is amazed at the difference in the reception she receives as Mrs. Carruth instead of Dr. Carruth when calling many physicians' offices. She is frustrated by rudely answered telephones, calls not returned, requests for information denied, inordinately long waits for lab test results, and lack of helpfulness for the patient.

She once called a doctor's office for a friend who is losing his vision and was greeted by a voice mail message telling her to leave her name and telephone number and that the call would be returned in 72 hours. The patient already had attempted to make an appointment on his own and no one had returned his call, even after 72 hours. Dr. Carruth left her name as a physician, and her call was returned promptly. When she asked the appointment scheduler why calls from ordinary patients weren't returned sooner, she was told, "We aren't acute care."

Such experiences remind Dr. Carruth of the customer service module in the classes she took to earn a master of medical management degree. Southwest Airlines' customer service philosophy was taught as a successful model. The airline says it does not train people to be nice, it only hires nice people.

"If physicians hired only nice, helpful people to answer the telephone, and dedicated, reliable people to be sure everything promised to the patient was done, such as faxing a copy of the lab report, our patients would be most grateful and probably would tell all their friends what a great doctor they had and about his nice office personnel. That would be a change for the good," she said.

Dr. Carruth says there are still "wonderfully run physician offices that are kind and efficient." She is thankful for the caring physicians who are good listeners and good communicators. "However, they seem to be in short supply."

Such experiences have changed the way she interacts with the parents of her patients. "Parents of sick children cannot be reassured enough. I encourage them to communicate with me by e-mail, in person, and on the telephone if they wish. They like the e-mail option and frequently ask the same questions over and over. I am a better listener and continue to work on improving my end of the communications, which includes answering those same questions again and again."

Empathy for their patients. A better understanding of what it means to be seriously ill. Better ways to care for themselves and the patients. The importance of communication. What else can physicians learn from being sick?

Drs. Spiro and Mandell conclude in their Annals of Internal Medicine article that "the powerlessness and loneliness of patienthood remind sick doctors of what in health we may have given up: close relationships with our family and friends, time for contemplation, many of the joys of living. In return, we have been blessed with the chance to help others and to earn the spiritual arrogance that comes from doing good."

Larry BeSaw can be reached at (800) 880-1300, ext. 1383, or (512) 370-1383; or by e-mail at Larry BeSaw .

March 2002 Texas Medicine Contents
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