One of the hardest things both at work and home is to see someone harming themselves and not be able to stop them. No matter how much your heart bleeds for their pain, you cannot fix them. Your beloved addicts are heedless of your loving concern, your words of warning or encouragement. Likewise, you cannot fix your patients by simply offering them education and information along with their treatment. The best medical care alone will not heal them. There is a quote from Hippocrates: “Before you heal someone, ask him if he’s willing to give up the things that make him sick.”
What I am writing about here is the exception to the rule, in that most patients want to get healthy and stay healthy. I want to make it very clear that I am not positing that illness is the patient’s “fault” or that everyone with a medical condition has caused it themselves. Nor am I saying that anyone with a chronic condition can keep it under control simply by following certain medical and lifestyle regimes. I have been in the field way too long for any such misconception. But we do see a small number of patients who have medical care access, information and support, and just do not seem to want to take care of themselves, for whatever reason. And to me this is analogous to other addictive behaviors and forms of self-harm.
The quote about not healing someone who won’t give up their harmful behaviors really fits in with a recent pre-surgery consultation. A patient came in to us for medical clearance to see if she was healthy enough to undergo a non-urgent surgery. Doctors here take on the responsibility to balance the patient’s need for surgery against their high risk of complications. Often, the patients are asked to follow up on some areas of their health and improve their situation before the doctors can clear them for surgery. In this case, the high risk of surgery was based on uncontrolled diabetes. So the doctor was telling the patient that she needs to stabilize her diet, take her medications as prescribed, and get better control of her diabetes, before she would be a good candidate for surgery.
The patient was open and honest, and I really honor her for that. She let us know she has good access to medical care and prescriptions through her insurance. But she is not regularly taking her insulin because she doesn’t like shots. And she regularly misses her blood pressure medication because she doesn’t like taking pills. She doesn’t check her blood sugar much because she doesn’t like poking her finger. And she is not following the diabetic diet because she wants to eat what she wants to eat. She believes that if her body craves something, that means what she craves is good for her, because that is what happens in pregnancy. “The body knows what it wants,” she told the doctor. When he suggested that with addictions the body craves what is harmful, like an alcoholic craving booze, she just shrugged her shoulders.
The doctor talked to her about going to a nutritionist but she said no thanks, been there, done that. “They take away my rice. They take away my bread, which I love! They take away my pastries, and there goes my daily breakfast: coffee and pastry. I can’t eat like that! And my blood sugar is only a hundred and something anyway.” It turns out she is only checking her overnight fasting sugar a couple times a week, and never checking after meals. The doctor tells her the long-term measure of diabetes, her A1C, shows that her average sugar is in the 300’s, dangerously high. She shrugs again, and asks, “Okay, but what about surgery?”
The doctor seems disconcerted by her answers and not sure how to impress upon her the actual risks of diabetes. He starts to talk about neuropathy, the loss of sensation to the feet caused by poor circulation that eventually leads to amputations. He talks about going blind from bleeding into the back of the eyeballs. And high blood pressure and heart attacks. He talks about kidney failure, and dialysis. He adds encouragement about how there are lots of good and tasty things to eat; it is a matter of balance and portion control. And how most diabetics can live normal, healthy lives, if they just take care of themselves. And how important it is. She finally interrupts and waves her hand in the air to dismiss it all. “I know. I know all about it. I’ve seen it! Everyone in my family is diabetic!”
The doctor has that painful question on his face, to which there is no good answer: If you know – then why?!?! Why are you harming yourself, even with the knowledge and experience of the outcome? Why wouldn’t you at least try to take care of yourself? Why don’t you want to be healthy? Why would you knowingly set yourself up for these painful and avoidable situations that you could put off or even prevent? I don’t understand! Don’t you want to live a healthy life? As much as possible? Don’t you want to take ownership of your life, and take responsibility for your body and your well-being? And if not, then why not?!?!
It turns out she has already seen a nutritionist. She has seen a social worker. She has seen her regular doctor. She has seen a kidney doctor. She has seen a diabetes specialist. She just doesn’t process any of that into lifestyle changes, medical compliance, or any measure of taking responsibility of taking care of her health and her life. She doesn’t seem slow-witted, just in the typical denial so common in addicts and people who refuse to take care of themselves. It is like magical thinking – if I don’t write a will, I won’t die yet. If I don’t take care of my illness, I don’t have it. I’m not really ill.
The doctor is so bewildered. He comes from the tradition that the truth will set you free. That the more you know the better off you are. That you gain knowledge and use it to be healthy, wealthy and wise. I am sure he takes exquisite care of his health. He is glowing and bright-eyed. He is competent and harmonious. He cannot grasp this patient. She cannot accept his attitude either. Because she has completely externalized her health and considers it a problem for the doctors to solve.
The patient crosses her arms and says, “So you’re not going to take care of me? I’ve been waiting forever for this surgery! And I’m in pain!”
The doctor answers her with a facial expression of deep concern. “No, I am not going to take care of you. No doctor can. It is time for you to take care of yourself. Your body has been waiting forever for this. Yes, your genetic makeup matters. But at this point, you are the one who is putting your body into pain and a future of more pain and disability when so much of it is avoidable. Can’t you take responsibility for yourself, your body and your health? Do you love your bad habits that are literally killing you – do you love them more than your life? More than your loved ones? You can’t help having diabetes, but that is no reason to give up and let it kill you! There is so much you can do. Why don’t you? Why don’t you care? Why can’t you try harder? Or try at all? Are you suicidal?”
Just kidding. The doctor didn’t say any of that aloud. Only his facial expression said it, and only to me. What he said to the patient was something soothing yet concerned. He repeated that if she gets her health under control, the surgery will be much lower risk. He repeated that as doctors, they have to weigh risks and benefits and make a medical decision as to whether surgery is in her best interest. And at this point, the risks outweigh the benefits. She has to get her diabetes under control, not only to get approval for this surgery, but for her own life. He sets up an appointment for her to meet our diabetes team, which she may or may not show up for. And they part in mutual frustration.