Don't become a doctor #16 - I've got a secret

Confidentiality is a legal requirement in medicine. There are only a few relationships where your conversations are protected by law: your spouse, your priest, your lawyer, and your doctor. We are entrusted with private information, and we have to protect it.

There are exceptions, instances where for the welfare of another person or the general public, we must disclose information, but otherwise, we are bound by professional duty and law to keep our information secret. Generally, this prohibition covers medical illnesses, medications, frailties, personal identifiers.

But that's just the tip of the iceberg. Patients have told me things, dark and secret things, long hidden, told to no one on the face of this earth but me. I have heard stories of rape and incest, physical and emotional abuse, spousal arguments, infidelity, greed, maliciousness and cruelty. I have had a husband and wife come in separately for STD screenings. I have had wives come in with injuries from their husbands. I have had patients tell me about being sexually abused as children.

When someone tells you a secret like these, you will not know how to feel. There will be anger and outrage, pity and sadness, compassion and anxiety. And as a doctor, you will want to fix the problem. But that is not what has been asked of you. You were asked to keep a secret, and that is all.

If you cannot live beneath the burden of all these secrets, then maybe medicine is not for you. But it is these secrets that make medicine into an art.


As as aside, if there is one thing that I hate, it is the abuse of children, and if it were possible to hate one particular form of child abuse more than others, it is child sexual abuse. Morality aside, the health consequences are staggering: insomnia, PTSD, eating disorders, sex disorders, anxiety, depression, substance abuse, anger and impulse control issues, headaches, chronic pain, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, asthma, obesity have all shown higher rates in victims of child sexual abuse.

Please don't infringe on copyrights

To all those who would republish or compile my blog, please be aware that all rights are reserved. That means no repackaging, no republishing, no copying except fair use.

Just a snapshot

One of the truly frustrating things about being a doctor is that it's hard to really understand someone's life. We only get to see little glimpses into a patient's life, like looking at a single frame of a movie and trying to tell its plot.

I had this experience recently with a patient. He is smart, pleasant, has a good job, and attractive (I'm not gay, but in my humble assessment). And he is single. I feel like if he is single, what are my chances? He has every advantage over me in the dating world, and he's striking out. Is he a jerk at home? Is there something else there?

I had another patient who is having marital issues because of his medical problems, and I don't get it. I found him to be really pleasant and engaging. I can't believe someone like him would have relationship issues over medical things.

It's tough to understand these situations, and I am picking relationship stuff because it's relevant to me, but I have no doubts that there are answers. It's just that I don't have them, and it's not my place to ask. But it's unsatisfying to go home and know that there is a whole side of a patient's life that I don't know and probably never will.

Cruel summer

This has been a hot summer, and as a result, we've seen sickle cell patients running into all kinds of trouble. Sickle cell is an annoying disease in that everything can set off a crisis. If it's too hot or too cold, too much exercise or not enough, dehydrated or drinking the wrong liquids... there are so many triggers and they're all common sorts of things.

Because sickle cell patients have been running into so much trouble, the nurses and physicians are complaining about them and their unbelievable consumption of opioids. I've seen some patients take in enough dilaudid to put down a horse. People accuse them all the time of drug seeking and inappropriate use.

The thing about having sickle cell disease though is that it is rife with chronic ischemic pain. That hurts. It also lowers life expectancy by decades with median age at time of death in the 40's. That sucks.

I hate giving out huge doses of opioids as much as the next guy, but pain is pain, and if I had sickle cell, then I'd want a little more dilaudid too.

Human lie detector

The show 'Lie to Me' is based on the idea of microexpressions, and if you can accurately see and interpret these findings, then you can be a human lie detector.

I seem to have a knack for this, as I am usually pretty good at spotting the liars, the folks who are outright dishonest about their history of medications usually. But they usually make it pretty easy when they tell me they need 6 xanax a day and oxycontin is the only medication that relieves their chronic back pain.

Knowing when someone lies to you is a remarkably depressing experience. It is one thing to be ignorant of what someone is doing, but to see the lies, that hurts. Still, one thing that people really have a hard time with is the manipulative patient who is actually in pain. I know that he's mean and demanding and wants dilaudid 4mg IV q2 hr, but he is s/p fasciotomy for necrotizing fasciitis. I think he deserves some pain medication, even if he is a jerk.