Sunday, January 16, 2011

Family Medicine: People Who Are Too Tough

"I felt like I might die a few times recently in the middle of the night.  I had palpitations, dizzyness and shortness of breath and almost passed out when I got up to go to the bathroom.  I almost called the emergency squad but thought that they would think I'm crazy,"  one of my patients in the office with me for their quarterly visit about their diabetes, hypertension and chronic neck pain.

I'm immediately surprised at the implication that they would rather risk death than be embarrassed, or what ever the real message is at the various levels of communication between patient, physician and the world.  I usually seek to clarify how they make their decisions late at night when their life might be on the line before I seek further information about their situation.

Many of these people are what I refer to as "Too Tough".  I hear this type of story two or three times each month.  Occasionally, one of them dies because they wanted to wait until their next office visit to clarify what was happening, or the chest pain didn't hurt like they thought a heart attack would hurt.  Most sports fans are familiar with the stories of an athlete dying of an asthma attack or renal failure during a hot summer practice.  They were very tough people and wanted to keep going instead of "looking like a wimp" or losing the respect of coaches and their teammates.

Each person has their own threshold at which they feel ill.  And another threshold at which it may cause concern.  At yet another threshold, their illness may be called ("diagnosed") a disease.  I found some clarifying comments about this in The Foundations of Primary Care by Joachim P Sturmberg, MBBS DRACOG MFamMed FRACGP PhD (Monash University, Melbourne, Australia).  In an interesting chapter titled "Disease, Illness and Health", he reviews some cultural and historical aspects of personal/patient perceptions.
Joachim continues with a discussion of illness, "Though we may construct our own illness in unique ways based on familial, ethnic and cultural beliefs, it is our experience of feeling ill that remains the driver for seeking medical- and at times lay or paramedical- care.  Patients come to see us to share the story of their illness, to make sense of (or find meaning in) it, as well as getting relief from their symptoms."  He questions whether physicians are prepared to help patients to understand their illness because of preoccupation with the process of deciding on a medical diagnosis.

He then refers to a paper "An introduction to medical phenomenology:  I can't hear you while I'm listening", by R Baron in Annals of Internal Medicine. 1985; 103: 606-11.  Baron questions the mind-body dualism that prevents patients and physicians from understanding themselves and others.  Phenomenology also "questions  the erroneous beliefs inherent in Cartesian dualism."   He goes on to define illness as "a loss or disturbance of the unconscious taking for granted of one's body...the disruption of embodiment."  Instead of problems exclusively with individual parts, Baron emphasizes that we have whole person problems, including the parts and the mind.

The "Too Tough", then might not be good at feeling ill.  They might not notice the disruption of their embodiment and they might continue to take their body for granted when others would feel ill and take action consistent with the risk to their wellbeing.  The "Too Tough" might have a powerful mind that seems to be fully in charge and not concerned enough about the body.  This mind-body dualism may be protective at times for individuals and profitable for the business of healthcare, but overall not beneficial to most persons, too costly for the economy and possibly dangerous for the "Too Tough". 


  1. I liked this post a lot! It's not that I'm tough, but more me not wanting to bother people with my concerns. I was lectured by my hematologist one day because I went to my appt. and told him how well I felt (meanwhile dizzy w/ labored breath) and my labs came back showing severe anemia (he gets my labs before I see him). He said something like, "When I ask how you feel, I'm not making small talk." I then told him I'd passed out walking upstairs the previous day, but didn't tell anyone. He was dumbfounded. Funny how people are! What makes me so worried about other people that I would risk my well-being...especially when it's his job?! Crazy!

  2. Thanks for your comment, Stephanie. You bring up a great point about some people sometimes may undervalue themselves, at least relative to their current situation, including being in the presence of a physician. Dr Synonymous posts include several references to the human-human dyad of patient-physician. If we connect as humans first, the other roles will work better. Doctor is a person we all may need from time to time. We do want them to be special with unique powers that may allow us to feel less important in one way or another. It's a paradox, though that they have to be normal humans, too. See my next post about the illness, the disease and the doctor (Please Call Us Doctor). Dr S

  3. Unlike me, my mother is way too tough. This is an actual conversation I had with her this week. (FYI - she has recently been diagnosed with TIAs).

    Me: Hi Mom, how are you feeling?
    Mom: I had an awful night. I woke up with the worst pain in my chest, it was awful.
    Me: Maybe you should call your doctor?
    Mom: Oh no! I already spoke to their office this morning to get my INR results. I don't want to call them twice in one day.
    Me: (sigh....)