Health Notes

Unreal Pain

As a primary care physician I’m in the helping profession: I spend my days helping solve people’s problems, both physical and mental. I love what I do and always take my patients’ complaints seriously. What may seem minor may be the tip-off to something major. No complaint is left unheard.

Much depends on the therapeutic relationship—the trust between a patient and her doctor. The confidential relationship is built on a bond of truth and honesty. If either party withholds information—not admitting to something they are or are not doing —then the appropriate next steps cannot be taken The therapeutic relationship fails.

Early in my professional career I had an unhappy therapeutic relationship, where the communication between me and a patient failed.

I had my first job practicing medicine as an independent physician after medical school and 3 years of resident training where one practices medicine, but under supervision. Not six months into my job I received a certified letter from the state. The Medical Quality Assurance Commission—we call it M-Quack for short—notified me that I was under investigation for malpractice.This commission regulates all health professionals, groups and programs to improve safety and protect patients.

I was devastated. I wracked my brain, went over in my mind the cases I had seen. I could not think of any disgruntled patient, any aggrieved party or medical mistake that I had made. Errors, of course, do occur and we all work hard to avoid them and correct them safely as soon as they are discovered. But I could think of none. My practice colleagues were as surprised as I, and several took me aside and said investigations are reviewed and are often dismissed before any court action takes place.

One of the many frustrations of the system is that you are informed only that you are being investigated. I had no idea who made the complaint, what the case was or even the type of complaint that was made. While this may protect the complainant against reprisals, the state of limbo it leaves the accused in is draining.

I carried on, the issue receding in the hectic pace of a primary care practice, but nagging quietly in the background, a sense of doubt creeping at the edges of each day.

Many months later I received another registered letter. In it was the summary of the investigation, and the notice that it had been dismissed. On reading the report, I was dismayed but finally not surprised at the case.

I remembered the patient, an overweight 50-something man who entered the exam room with an odd gait. Sort of limping, sort of sidling like he was looking for a chair. He complained of a back injury at work, after lifting some sheet metal weighing 100 pounds.

I recall remarking to myself that his limping was affected: it was not like the gait of a person who had a spinal injury, or any other recognizable injury. His examination was unimpressive—nothing was consistent with an injury or neurological disorder. But he was quite demonstrative about his “pain.” I put together an exercise plan for him, referred him to physical therapy, offered anti-inflammatory medicines and follow up in a month.

The next month he returned, strutting into the exam room, with a kazoo and going on about a football game he had attended. Yet when I proceeded to the exam, his hale and hearty demeanor suddenly diminished to a hunched and weakened shadow of his earlier self. He stated he was no longer able to lift the heavy loads of sheet metal at his job and should go on disability.

I suggested he continue physical therapy and work with his company to re-evaluate his work capacities as an older worker. He was not incapacitated and perhaps there were other more age-appropriate tasks he could perform. He left my practice, possibly seeking a more compliant provider.

When I had failed to put the patient on disability, the patient filed the complaint. His medical record, on the other hand, showed him to be healthy. While he may not return to the exact position in his company, nor was it advisable that he should be lifting 100-pound loads of anything, there was still plenty he could do. The commission recognized this and dismissed the case. I suddenly felt quite tall. For months I was tentative and nervous. This dismissal letter lifted a weight I hadn’t even known I was carrying.

Having an oversight board is important for all of us. Patients need a grievance system when services do not meet recognized standards of care. But the oversight system does not extend to people who might wish to gain unfair access to the social safety net. Any system can be misused.

I depend mightily on the honesty and trust of the therapeutic relationship. It helps us all find success in managing our health. Sometimes there is but a thin line between helping people and keeping people from harming themselves or the system. It’s a delicate tightrope to walk, one I walk nearly every day.

Dr Hoffman

Dr. Rebecca Hoffman is a Family Practitioner and works at Kaiser Permanente in Salmon Creek, which is in Vancouver, Washington. Interests include using diet and healthy living to stay healthy and attending to mental health and its physical manifestations. Personal interests include hiking, jogging, music (she plays the harp), dance, theater, storytelling and writing. She lives with her husband and two daughters.

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