What Are You Not Doing?

 K. Patrick Ober, MD
 

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I do not want most people to write [to me], but I do want you to do it. The others break my heart, but you will not. You have a something divine in you that is not in other men. You have the touch that heals, not lacerates. 

 Mark Twain

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 It was 1897.

Samuel Clemens was despondent.

His 24-year-old daughter had been diagnosed with meningitis a few months earlier.
He was out of the country.
She died.
He was not at her side to comfort her.
She died without him.
He was heartbroken.

When his friends wrote to offer their condolences, their words made it seem worse, somehow. Their well-intended words ripped open his fresh wound.

The exception was his friend, Joseph Twichell.
twichell’s words had a healing touch.
How did Twichell manage that? [It seems important for us to know that, if we hope to be healers ourselves.]

Several years ago, one of our students sent me an e-mail conversation on the subject of the healing power of words and the differences between the words that heal and the words that lacerate. She shared her own medical history to make her points. [She has given me permission to share her words.]

She had been diagnosed with diabetes thirteen years earlier. She remembered how her first diabetes doctor managed to make each clinic visit a healing event for her. Her endocrinologist began each clinic visit with a single question.

What are you not doing that you want to do? 

That question sparked a variety of conversations across a range of concerns, worries, and challenges she had been facing.

Our student eventually aged out of the pediatric clinic, and she sought care in the world of adult endocrinology. The transition was harder than she expected. Perhaps the empowerment she received from her pediatrician’s predictable query had something to do with it.

At the time, she did not recognize that the question had been a source of empowerment, but she knew – even as a young girl – that it had a special impact as nothing else did.
She understood that the question was more than a question.
It was a soothing mantra of caring and healing for her.
It became a tradition.
The question reminded her that she was being seen as a person first and foremost, a unique human being who had goals and hopes and dreams of her own.

Her first doctor, by asking a somewhat undoctor-like question, acknowledged her humanity and personhood.

Her first doctor was a healer.

Our student had trouble finding another healer to replace the first one.

Each new doctor she met seemed to see her as the embodiment of a disease, not as the person she was. [Perhaps diseases are easier to deal with than people?]
This dissonance created an uncomfortable tension between her and her doctors.
She wanted a doctor who cared about her individuality, recognized her distinctive attributes, and supported her goals in life. She wanted her new doctor to care about her, in the way her pediatrician always seemed to care. She continued her quest, and the pediatrician’s galvanizing question continued to weigh on her mind. It was her Holy Grail. She was on a search to find the quintessential question that defined a relationship. She knew the words by heart, but she wanted to hear those words coming out of a doctor’s mouth.

What are you not doing that you want to do? 

No other question came to matter as much to her as this one.
She searched, but she could not find anyone who was in the habit of asking it.
She didn’t understand why.

This has really stuck in my mind over the years, she wrote to me, as I have moved out of her pediatric office in search for someone who will treat ME for diabetes, not just treat my diabetes.

She eventually realized that what she was seeking was not going to be easily found.

It seemed like such a simple goal, but it was not.

This has been surprisingly difficult to do, she wrote. And it was disappointing.

She discovered that some doctors approach their patients as objects more than as people. With such doctors, she often had the feeling that she was being classified as a defective piece of work, an unfinished project that would forever remain incomplete, a false start in life’s journey with no real hope for a future. She was a person without sturdy pancreatic beta cells, the new doctors all seemed to say to her, and so to them she was hardly a person at all; she was only a package of damaged goods to be pitied.

It all seemed so dismal.

I am greeted as a survivor with a chronic condition that holds me back from life, and there is rarely a positive, encouraging comment in the visit.

She was probably right about all of that. The world of diabetes can easily become one of numerical goals and quantifiable targets and measurable expectations in our new age of “metrics” that turns patient care into a litany of tasks and prescribed goals. Nowadays, doctors get a “performance grade” based on their patients’ numbers; doctors interrogate their patients in order to improve their own grades.

How often are you monitoring your glucose?
What is your cholesterol measurement?
How high is your hemoglobin A1c?

In the aggregate, these targeted questions may help define a disease. They never define a person.

Our student’s search for a suitable doctor continued. Time passed, and then an odd thing happened.

She crossed over to the other side.

She joined the medical profession.

She started her clinical rotations, and she found that the view on the clinician’s side of the table felt different from the view she had come to know so well from the patient’s side.

And she [the same she who knew better than to do it…the very she who knew all of the reasons not to do it!] violated her own standards.
She did what was so easy to do.
She looked past the person in front of her, the human being who was her patient.
She focused on a diagnosis.
She looked at the numbers.
She passed judgment.

Then she made a discovery. She felt guilty.
She realized she had been betraying her own principles.
She made her discovery while she was rotating on – of all places – an endocrinology elective.

While looking at the pump settings and meter readouts for the past few weeks, it is easy to take a red pen and mark all the things that are wrong with the patients self-management. It is also easy to look at an A1c and judge the management based on that number.

She had learned [because we taught her] how enticing it could be to focus on the hemoglobin A1c of a patient she was treating, and never look at the patient.
In the rush of clinical medicine, it is easier to focus on a diagnosis.
We don't ever have to connect with our patient as a person.
It might be the most efficient way to go about our day, avoiding that connection.
It would let us be very workmanlike.
It can let us function like a machine, if that were our goal.

It was not her goal to become a machine.

Our student discovered a better way to turn herself into a healer. She remembered her experiences with her own favorite doctor, the doctor who taught her that the patient behind the numbers was more important than the numbers. She found that she could find that person by asking the same essential question she herself had been asked, so many times. Doors were opened. Communication happened. All it took was that simple declaration: “I care.” 

The times where I would hear the patients struggles about management, then have the ability to say, I understand ...those were the times the questions would flow.

By asking the essential question, she found for herself the touch that heals, not lacerates.

In some ways, our student’s essential question is an unusual question. It is not the question you and I would be naturally inclined to ask. It is not a question we are taught to ask. We tend to ask the ones that help us complete the chart, clarify the history and construct a note.

Our questions are asked to find out what is going wrong.

Why is your sugar so high?
How often do you skip a dose?
Why didn’t you start the cholesterol medicine?

Our questions tend to be the accusatory, blaming kind of questions.
We seem to be seeking confessions of negligence. “What are you not doing that you should be doing?”

Our student wants us to know that a far better question to ask is the one her pediatric endocrinologist always started with.

What are you not doing that you want to do? 

It has an attractive vagueness about it that makes it potentially noncommittal. There are an infinite number of possible answers, each important in its own way.

It's non-accusatory, for one thing.
It is conversational, perhaps.
It could be medical, possibly.
It might even be a greeting of compassion.
Perhaps it is the central question about Life. 

What a beautiful question to lead off a clinic visit!

What would happen if we always asked all our patients that same question?

We might get something valuable from our patients.

 We might learn something about them that we didn't know.

It is more likely we will give our patients something of greater value.

We might give our patients a declaration of empathy.

We might give them hope.

We might empower them.

We might convey the message that we care.

What are you not doing that you want to do?

Come to think of it, maybe we should all ask each other the same question. For the very same reasons.

November 5, 2014
Last Updated: 08-23-2016
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