The Ballad of Mr. Blue - part 3

Lessons learned

This is a change of pace from my usual writing here on “Building Docs.” What follows is the final part of a series involving one of my first, and most memorable, patients - Mr. Blue. I hope you enjoy the story and learn something in the process! If you haven’t read the previous posts- click the links below…

Part 1

Part 2

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This is the final entry regarding Mr. Blue and his interesting case. I want to go over his official diagnosis, and our team’s treatment plan, and then dive into some of the lessons I learned caring for him. Let’s dive in…

Diagnosis

Mr. Blue’s diagnosis was Conversion Disorder - a psychosomatic illness where present physical symptoms cannot be explained by neurological disease or another medical condition. The person is experiencing actual symptoms - in Mr. Blue’s case, he could not walk - but the symptom’s origin is emotional or psychological. Conversion disorder is also known as Functional Neurological Disorder, which encompasses many different types of psychosomatic movement disorders (eg Functional Gait Disorder).

After consulting with PM&R (Physical Medicine and Rehabilitation) and with Mr. Blue himself, he was ultimately transferred to an inpatient rehab facility where he underwent rigorous rehab. I never saw or heard about him after he was transferred.

Lessons Learned

Rule 173:  Illness behavior attracts attention. All illnesses have some secondary gain.

As Dr. Meador says with Rule 173, illness behavior itself has a secondary gain. Applied to Mr. Blue, a common observation was that he was dramatic and emotionally labile (quick mood changes; hot and cold behavior). This is NOT a judgment call, simply an observation of behavior outside of an expected norm.

Why would someone act in a dramatic fashion when ill?

Well, you would think that it would be to garner attention. However, it would be a mistake to end your questioning there. We must ask, why does someone who’s sick want to attract attention? One reason may be that they are suffering from a severe, life-threatening illness. In Mr. Blue’s case, this was not the reason. Conversion disorder, though serious, significant, and life-impairing, is not a life-threatening disease.

To find the answer, let’s look at Mr. Blue more closely. He lived alone, had a history of significant psychological distress (including hospitalization and substance use), did not have contact with his family, had no job, and seemingly few, if any, friends from what I could tell.

Why does this matter? Why mention it?

To ask this question - who did Mr. Blue have to care for him? And I don’t mean to cure him, treat him, etc. I mean care about him. If there is no mother, no sister, no friend, no preacher, and no anybody to go to when things go bad, the next logical step for a person is to act out. They may think to themselves, ‘If there is no one I can go to, then maybe I can make someone come to me…’

You might be saying that his attention-seeking behavior is made only to garner sympathy, which is something that’s generally viewed poorly in society. And that’s reasonable, and you may be right, but that does not make this behavior “bad.” Sympathy, and those other qualities like it, are rooted in caring. IF a person has no team of people around them (eg family, community), AND people have the capacity to care for other people, THEN those without community fail to be cared for. Going beyond medicine, it’s a fundamental necessity in a person’s life to experience love and to be cared for, and this truth only highlights the importance of a strong family unit bolstered by shared values. The reason I bring up the concept of family here is because of Mr. Blue’s personal history. He lacked his own family, his own group of people that he could care for and be cared for, so he did something that I think anyone would do - he outsourced that experience to the hospital system.

This is important because, if you understand this or that part this may play at hand, you can better address the underlying needs of your patient and your role in their treatment. Going further, the treatment itself (surgery, meds, whatever) isn’t just the treatment - you, as the doctor, are also a component of that treatment. Whether it’s with a passing smile or a friendly encounter, positive behavior and interaction will always positively impact others. Doctors, and the medical profession as a whole, are founded on this fact. So look past your patient’s behavior to what’s driving it, and always ALWAYS act in a caring manner.

Rule 192: A few patients seem to be saying, “I want you to help me, but I won’t let you.”

Dr. Meador seems to point to a paradox here - why would someone want help, but then not let someone help them? Though a paradox, this describes Mr. Blue.

This rule gets at the nature of helping. From this I want to discuss two questions:

Are some people and some patients unable to be helped?

Or put a different way, are there those who are beyond help? This is, admittedly, a dangerous question, but one that deserves untangling. And the answer is pretty simple.

As a future doc, the only appropriate way to answer this question is by saying “all people can be helped.” If you answer the other way – that there are people who cannot be helped – then you ultimately create a standard that will easily devolve into a slippery slope. If one person is deemed “unhelpable” then soon this person and that person will be deemed so too… This will eventually cease to be “who can be helped” and turn into “who deserves treatment.” This is the slippery slope and this is wrong.

Your role as a doc is to not judge who can be helped or not, your role is to help. Full stop.

How do you square that with Rule 192?

By looking at what it means “to help.” Helping, much like communication, is a two-way street. This is what Rule 192 states pretty explicitly. Help is given by the doctor, , and received by the patient. However, the fact that a patient refuses your help does not absolve you of your duty to offer it.

I would argue that offering help is, in a way, actually helping. Offering help is a way to express that you care about your patient. Sometimes, simply showing that you care enough about someone to offer help can be an impetus for that person to examine themselves and heal. Put differently, sometimes what is needed for someone to care enough about themselves to improve/heal is to be shown that someone else cares. This can also be tied back to the previous rule, on the importance of family and community.

Rule 240: Never take away hope.

Another reason why it’s so important to always offer help, no matter if your patient accepts it or not, is because failing to do so takes away hope. If a patient goes to a doctor and is dismissed, condescended to, not taken seriously, etc, then that patient will come away from the encounter with less hope than before. This is a cardinal sin as a doc because hope serves as the motor for positive treatment and outcomes. Said another way - hope for a better future is the reason why someone chooses to move forward with painful rehab, or a difficult lifestyle change, or an otherwise less desirable treatment.

This is why it’s much harder to improve if a person is hopeless, rather than hopeful. To improve (whether that’s through healing, learning, etc), you must believe that there is something to improve to - better health, a newly learned skill, a new opportunity, etc. Hope is the thing that elevates your mindset and is necessary for believing in improvement.

When this is applied to medicine - hope is necessary for healing. To take it away is to do harm to your patient.

1. Always supply hope to your patient by…

2. having the insight to see past dramatic or questionable behavior to what its pointing to and…

3. understand and believe that EVERYONE can be helped, and is deserving of it

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Thank you to Dr. Meador and his tremendous advice. I’m thankful for the great medical education I received while working on Mr. Blue’s team. I’m also thankful to those who read this! Writing this was a unique challenge and something that I think I’ll try again in the future. It was gratifying to reflect on past experiences and to take Dr. Meador’s rules out of the realm of the “theoretical” and apply them to my own budding career.