Monthly Archives: November 2024

Is It Luck? Is It Privilege? Or Is It Something Else?

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She was in my thoughts more than I expected for how little time we’d spent together. She and I crossed paths while I was volunteering for a local organization. We were born the same year. Yet, she was born in Afghanistan and I in the US. She can’t read any language, as she reminded me, women are not allowed to attend school in her country. As a US physician, I’m among the most educated in the world. She has multiple children. I have none. We do not speak any common languages. Despite the differences, I noticed a few commonalities between us beyond our birth year. We are both married. We are both women. We both drink tea.

Soon after meeting her, I read updates in The Economist about the Taliban. Summarized, the Taliban issued more limitations on women in Afghanistan. It is so difficult to be a woman in Afghanistan that the EU has made being a woman from Afghanistan a criterion for asylum – no other qualifications necessary. 

Yet the horrors that I’ve heard about Afghanistan and the complex interconnected history of the US and Afghanistan are not how I want to know this Afghan woman. Life has taught me that the stories the media tell are not the stories of individuals. The negative thoughts and the sadness I have about how different my life is from this Afghan woman I know originate in my biases and my ignorance of her.

I do not know enough to guess what she thinks or feels about her history and her future. I do not know her story while living in Afghanistan. I do not know her story of coming to the US. I do not know what she thinks of her life in the US.

We were born the same year. Was it luck, privilege, or something else that I was born in the US and she in Afghanistan? How can one compare two lives so different? What does she think about when she has a quiet moment? What does she dream of? What does she enjoy? What makes her happy?

I interact with many people who have different backgrounds and cultures. But this woman and I seem even more different than most people I encounter. The Peace Corps taught me that difference is not better or worse just different. It also taught me that what I believed to be laws of humanity were theories – theories with counter theories, and most importantly, not proven to be true or correct. I know this Afghan woman and I have more in common than I can see now while also acknowledging that our views of the world are likely as different as views can be.

As I write this post, I wonder if I will ever have the chance to learn more about her. I hope so. I have grown most profoundly when given the opportunity to learn about new cultures and about new people. It is the diversity of humans that makes us so remarkable. And while I imagine her story is one marred with sadness, I know she has things she is proud of, moments of joy worth remembering, and stories of success. I hope that someday she can choose which stories and things I know about her, rather than my limited knowledge of her culture fabricating a story of her. Reality, I’ve found, is always sadder and more beautiful than imagined worlds.

I’m grateful that being born in the US allowed me to become a doctor and choose my own path. I hope that the US is as generous to her, whatever her hopes and dreams upon coming here are. The future is one we are each molding in our own way. Be it luck, privilege, or something else clearing the path.

Meeting in a Common Place

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Over dinner with a non-medical friend they said, “Even though I will inevitably have a heart attack [in relation to their love of ice cream], I’d rather enjoy a short life than live a long miserable life.” They brought this up even though I hadn’t made any comments about health during our meal. I’ve noticed that since becoming a physician family and friends make comments like this about their lifestyle with a frequency that surprises me. It seems that they feel guilty or defensive because they think I might be judging or evaluating the healthfulness of the life they lead. 

Perhaps more important than highlighting that I don’t judge my friends’ lifestyles just because I’m a physician is pointing out that in my role as a physician, I also do not judge my patients’ lifestyles. Society likes to use guilt to control people and create hierarchies of worse and better. Many health and physical attributes have been used to define people as better and worse. The list of such attributes is long; several common examples are weight, cholesterol level, blood sugar level, and brain functioning. Despite this societal tendency, guilt and creating arbitrary lists of good and bad don’t help achieve health, so they are not part of my practice as a physician.  

My job, especially as a primary care physician, is not to make my patients feel guilty or inferior. My job is to help my patients increase their chance of living a long, healthy life. Health is defined, in my mind, as a physical and mental state where a person can do the things they want to do with as little suffering as possible. My goal is to help my patients avoid suffering, illness, and pain from medical conditions and physical injury. Especially in the primary care setting, I provide my patients with recommendations to optimize their health. But my recommendations are recommendations – they are not law, and they are nonbinding.

Science continues to investigate what the optimal lifestyle is to ensure that one avoids illness and lives a long time. Yet, while we know many things, we don’t know what the perfect lifestyle is. Further, research can not account for the complexity of human experience. It is absurd to think that all people can live the same lifestyle. Individuals have different access to resources, different preferences, different priorities, and different realities. There is simply no universal fit for lifestyle.

When I discuss lifestyle with my patients my goal is not to make them start a different life. My goal is to identify reasonable adjustments that have a high chance of improving their health. For example, I might ask a patient about their typical diet. As I learn about their diet, I might offer education tailored to specific goals – such as reducing salt to help control blood pressure, strategies to ensure a stable weight or weight loss, or adjustments to prevent diabetes. I try to identify realistic adjustments because unrealistic suggestions are not likely to happen (by definition). For example, some of my patients only eat out. In those cases, rather than telling them they need to start cooking, I ask about the menus at the restaurants where they frequently eat and offer suggestions to optimize their health based on the menu choices they have. I might ask patients about exercise, tobacco, alcohol, drugs, sleep, stress, and any number of other things. The process remains the same for each: 1) Where is the patient now? 2) Is there some optimization that can be done? 3) What are the small steps and adjustments that can help my patient reach that optimization?

As a physician I meet my patients where they are in terms of their health goals and health situation. I see our relationship as a partnership where I’m an expert and they are advice seekers. Just as people hire financial advisors as experts and planners for their personal finance, physicians are experts and planners for lifelong health. As a physician I relay what research has shown is important for health; help my patients make decisions about specific medications, procedures, and tests; and form a plan for how my patients might optimize their health.

To my friend who thinks everyone who eats ice cream will have a heart attack – that simply isn’t the case. To my friend who thinks a heart attack is trivial – I’ve met hundreds of people who have had heart attacks and even those who survived were changed forever. So, in a general sense my response is, why not consider a middle ground where one can have ice cream and not have a heart attack? Curious how to do that? Consult your primary care doctor; she’s an expert in health and you hired her to help you reach your health goals.

Reading the Crystal Ball I Don’t Have

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“Will I make it until then?” the patient asked. They were referring to the cancer treatment which was their only chance at long-term survival. Their cancer was everywhere yet, likely, treatable and maybe curable…but only if they got treatment. Their social situation created roadblocks. To be approved for chemotherapy in our medical system they had many hoops yet to jump through and hills to climb.

“I don’t know. I hope so,” I said. My answer was genuine.

The patient signed. They closed their eyes for a long blink. They looked down. They slumped in their chair. Their stuffiness (from lymph nodes so large it was hard for them to breathe) made their breathing loud. The room felt small.

“You’re strong. You’re a fighter. You told me recently you wanted to do everything you could to beat this. We are trying to get you there,” I said. These were truths but they didn’t mean much.

This post could easily be about the inequities of our healthcare system. This patient was a victim of those inequities. But whether everything is going right or going wrong, the truth remains that neither I nor any physician know the future. We have probabilities and expert opinions to guide us. We have previous similar patient cases and the risks/benefits of medications and other treatments to consider.  But as much information as we have, we do not have a crystal ball that tells us exactly what is to come. We make educated guesses which are often right but also have a higher-than-desired chance of being wrong.

What is to come, the outcome, is exactly what my patients want to know. And, if I were in my patients’ shoes, that is what I’d like to know too. When thinking about my patients’ futures, I try to balance hope with reality which (for me) manifests as honesty. If I’m worried, I say so. If I’m confident in their chance, I say so. And, if I’m unsure then I will explain the contrary things I’m considering and why I’m undecided.

I didn’t know if the above patient would make it to chemotherapy. The oncologists (cancer doctors) were not offering this patient treatment when the patient and I had the above conversation. The oncologists felt that the patient had too many other things going on to start chemotherapy. Chemotherapy is hard to endure. One must be physically strong to survive it. One also requires lots of social support.

“We are trying to get you treatment. Remember the next steps we talked about?” I reviewed the follow up appointments and things lined up for the patient before they saw the oncologists.

The patient nodded. They looked out the window. “I’ve been here [the hospital] so long,” they said. They’d been in the hospital for about 6 weeks.

“I know,” I said. “You still have a long road ahead.”

I wish there was a crystal ball like in fantasy books that would reveal my patient’s futures. But part of life is not knowing exactly where it’s going. Part of being a physician is becoming comfortable with uncertainty. Perhaps that’s one reason why physicians study for so many years. Day by day my predictions about my patients’ futures are more informed and more often correct. But, on the opposite end of the spectrum, even the most seasoned physician is sometimes wrong about a patient’s future.

When the patient and I had the above conversation, their survival was unlikely but possible. The sliver of hope that remained is why I reminded the patient that they had told me they wanted to fight their cancer. That is also why, when the prediction is tragic and my patients say they believe in miracles, I say “I hope you’re right.” No physician wants their sad-outcome predictions to come true. Yet, we are obligated to provide our best guess even if it is bad news. As physicians we also plan for all the likely outcomes.

While I reminded the patient of their desire to fight, I also reminded them that if things changed there was an alternative option called “comfort care*.” I reminded them that they could change their mind about their goals at any time. I reminded them that we (their care team) were here to help them on their journey regardless of where it led them.

The only certainty about my patients’ futures is that their care team will be there no matter what. And while patients’ care teams change with work shifts and specialty, the purpose remains the same: to help as the unknown unfolds. Being a physician hasn’t given me a crystal ball to see the future. But being a physician has given me hope. While there are illnesses no human body can overcome, the body is incredibly resilient. Further, the human soul is a force of bravery and grace even when faced with insurmountable challenge. And when I witness these human strengths, my faith in life is renewed.  

*Comfort care is end of life care where the focus is treating symptoms rather than prolonging life. For example, if a patient has anxiety, then we will treat it; or if they have pain, we will treat it. Comfort care is offered to patients who have conditions that will kill them and either there is no treatment or the patient declines treatment. In comfort care we don’t treat chronic conditions such as high blood pressure or diabetes because the focus is to make the patient’s remaining time as comfortable as possible rather than trying to make them live as long as possible. Comfort care is the type of care that people receive in hospice. Hospice is end-of-life care for people whose life expectancy is 6 months or less. Comfort care is not about hastening death, but it is possible that people will die sooner on comfort care than with traditional care because the goal is no longer to cure illness.