Thursday, January 26, 2006

A most uncomfortable question

[NOTE: This story is loosely based on a real patient encounter, but some details have been changed, and there's no way for the reader to know when the event upon which the story is based actually happened.]


"Doctor?"

I paused. I had been on my way out the door of the examining room, having completed the visit. I turned around again. "Yes." I said. Maybe I had turned around too soon after having asked if she had any more questions.

"Do you believe in God?"

*****

The patient list had simply listed her as having an abnormal mammogram. That's probably the most common complaint of breast patients that come in to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal. The next thing they know, they're sitting in one of my examining rooms. However, the patient list is quite brief. It's just meant to be a quick capsule of what patient has what basic complaint. Nothing on the list prepared me for the woman I greeted when I walked in the examination room.

This patient was enormous, and I do mean enormous. Morbidly obese, she told me she wasn't sure how much she weighed, but that it was at least 450 lbs. Sitting in a wheelchair massive enough to support her, rolls of fat hung over the armrests, and her breath wheezed like a mortally wounded Darth Vader near the end of Return of the Jedi, right before he took his helmet off and revealed Anakin Skywalker beneath the mask. Indeed, on the same theme, I could not help but be reminded of Jabba the Hutt. Yes, I know that physicians aren't supposed to think that way about their patients, and, honestly, I tried not to. However, we're human, just like everyone else, and even our years of professional training can't entirely suppress our baser thoughts. At least I managed to keep enough self-control to restrain myself from voicing such thoughts to my nurse or any of the clinic staff. Not all clinicians exercise such self-restraint, and, I'm embarrassed to say, there have been times in the past when I didn't either.

Normally, dealing with a patient with suspicious microcalcifications on her mammogram is fairly simple. A biopsy is indicated, and there are basically two techniques to choose from. You can do a mammotome or stereotactic biopsy, which is in essence a mammogram-guided core needle biopsy, or you can do an old-fashioned wire localization (or needle localization) breast biopsy. Given that even the surgical option is usually a same day surgery using local anaesthesia and sedation, even that isn't so hard. The surgery can sometimes be a little trickier than one might think, but even then it's not all that hard. Oh, sometimes you get patients with multiple abnormalities, and you have to decide if you want to go after them all or if you want to perform a triage and decide that some of them need to be biopsied and some of them don't, all the while realizing that if you miss a cancer it can be a major disaster for the patient.

Of course, a 450+ lb. patient adds a new level of challenge. For one thing, she was way too heavy for the table; so stereotactic biopsy wasn't even an option. Not surprisingly, her health was horrible. She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians' Desk Reference. I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it. So I made do and did my best to examine her while she was sitting in her wheelchair. It was a suboptimal examination, but, given the size of the room, it was all I could manage. Morbidly obese patients, because of their size, frequently make it very difficult to provide optimal care to them.

By the time I was done, I felt profoundly sorry for this woman. How on earth does such a person live, given her physical and medical problems? Despite my sympathy, I maintained the professional bedside manner that we're all trained to keep up and explained what was abnormal about her mammogram, that she would need a biopsy, and how the biopsy would be done. I also explained the risks (which, for her, were much higher than the minuscule risks most patients undergoing this procedure face), and arranged for her to be seen by her pulmonologist and cardiologist in case something more than local anaesthesia were needed.

When finished, I asked if there were any more questions, gave her my card, and made my way past the family members to the door. Although it was near the end of the day, there were still a couple of more patients to see.

*****

"Do you believe in God?"

I was still standing there, hesitating. To be honest, my first thought was: Why on earth should it matter whether I believe in God or not? Belief in God has nothing whatsoever to do with whether I'm a competent surgeon or not. Personally, if I needed surgery I'd prefer a surgeon who is a flame-throwing militant atheist like PZ or Richard Dawkins, as long as he or she is highly competent and has a bedside manner that doesn't bother me (and, of course, doesn't push his or her beliefs on me), over a believer who is not as competent. In the same vein, it wouldn't matter to me if the surgeon is a Bible thumper, again as long as he or she is highly competent, easy for me to get along with, and doesn't push fundamentalist beliefs on me. To me, the question of belief in God is utterly irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way. Thinking back on this incident, I can't help but remember an interview I had heard with Eddie Tabash, an atheist attorney who mentioned during the interview that he sometimes defended prostitutes. During the interview, he went on to mention that it was not infrequent for prostitutes to become very uneasy about having him as their attorney when they found out about his militant atheism. I had never encountered this phenomenon among my patients, however.

My second thought was: Why on earth would this woman still believe that there was a benevolent God looking down on her? She was a mess. She couldn't walk more than a few feet without assistance; she could hardly breathe; and she was on enough medications to stock a Walgreens. Her health was so bad that even a minor surgical procedure such as a breast biopsy could put her life at risk.

Worse, the question brought into sharp focus a question that I myself have been wrestling with myself for the last three years or so, a question whose answer seems to be yes one day and no on others. There's nothing like being trapped in a small examination room with a 450 lb. woman and three members of her family, with nowhere to run and no way to dodge the question. I was trapped. A believer might have said that the woman's question was God's way of making me face my fluctuation between belief and disbelief; an atheist might say that such an assertion is wishful thinking. Whichever was the truth, that didn't prevent the formation of a little bead of sweat that was rapidly enlarging on my brow. I suspect the question would have still been uncomfortable for me to answer even if I were as religious as I was when I was younger, as even then I tend to view religion as a private matter, one I didn't usually talk about much.

What if I were to tell her that was an atheist, that I didn't believe in God? Would she have sought out another surgeon? For a fleeting moment, I was sorely tempted to say just that. It might have been an out, a way of not having to do the case. On the other hand, this woman had no insurance and had to rely on charity care/Medicaid, which meant that she probably didn't have the option of going to a different surgeon. (Working for a state institution, I take care of quite a few Medicaid patients.) If that were the case and I said I was an atheist, she would then be going into surgery with no confidence in her surgeon, clearly an undesirable situation. Besides, saying that I was an atheist wouldn't really be the truth; so I couldn't say that anyway.

So what did I finally say?

I punted. "I'm Catholic," I said. A pause. "But, to be honest, I don't go to Mass much anymore."

This answer was perfectly true. It also seemed to answer her question, but in reality didn't. Not really. The truth is much more complicated, but she didn't need to know that. Fortunately, because the patient was Catholic herself, my answer seemed to satisfy her. "God will guide your hand," she said.

"I hope so," I replied. Bullet dodged successfully.

I walked out of the examination room not looking forward to the day when this patient and I would meet again in the operating room--or to contemplating her question seriously when the day was done.

20 example(s) of insolence returned:


At 1/26/2006 8:08 AM, Blogger rgmb said...

I think your masterful ability to do no harm was more important here than your personal ethical necessity for complete honesty. By considering the whole patient, your treatment was commendable.

Well done.

 

At 1/26/2006 12:07 PM, Blogger GJ said...

Punting is what you do if you are not an "evangelical" atheist. I was once a Catholic myself, and did the classic "other religions--then agnostic--now atheist" transformation. However, most of my relatives, coworkers, and neighbors are still believers in one religion or another. Few of us have interest in becoming a pariah, as once that occurs you lose any influence you had to help people see the world from a skeptical viewpoint.

So far, no one has pressed further. I'm confident somebody will in the future...but I'm in no rush to hurry it.

Like rgmb said--you did fine. There would be nothing to gain from detailing your true viewpoint...and much to lose.

 

At 1/26/2006 12:42 PM, Anonymous Anonymous said...

If you don't want your tables, chairs etc damaged, it is time to invest in some sturdier office equipment. I don't see Americans getting any smaller.

 

At 1/26/2006 12:43 PM, Anonymous Anonymous said...

I'm also a general surgeon. I've been asked the same question several times. Usually, more specifically, "Are you a Christian?" My reaction has been the same as yours; not wanting to adversely affect my relationship, not wanting to lie, and feeling mildly to moderately angry that it should matter. I'm Jewish the way you, apparently, are Catholic. I figure even evangelicals think Jews are fine doctors and accountants, so I tell them. I don't mention that I'm an atheist. When they say such things as "I believe God brought you to me" I usually try to get to saying that I believe that faith is a strong element of recovery and move on... The subject of a patient's faith or lack thereof has always interested me. I think that having faith seems to help most people when they face critical illness (in terms of coping, not in terms of increasing cure); although one of my most overtly religious patients quite decompensated when she developed breast cancer with 28 positive nodes, wondering how God could have done this to her. Interestingly, she underwent monster chemo/radiation and bone-marrow transplant and is alive 15 years later.

 

At 1/26/2006 2:42 PM, Anonymous Anonymous said...

It's hard to be a believer patient when your beliefs are part of the way you manage your health and the doctor treats you like you are an idiot for having your beliefs. The doctor has the power, especially if you are on medicaid and don't have the choice of going to a different doctor. Fortunately, most doctors have not treated me like I'm an idiot (maybe 5% have) for my beliefs, or maybe because they just didn't like me. Most doctors understand that people have a fundamental right to believe and that abusing patients doesn't make for good healing.

Still, even when the doctor is polite, it's odd to have that chasm of different approaches to life standing between you and your doctor. I always hope that doctors realize that I don't want my beliefs to cause them problems and that I respect their expertise.

Anyway, thanks for this essay, it brings up some rarely examined issues.

 

At 1/26/2006 3:00 PM, Blogger PZ Myers said...

The last time I performed surgery on a mammal was almost 20 years ago, and it involved planting an electrode array in its brain for a series of tests that would later involve slicing up that brain into thin sheets.

If you want to get better, I don't recommend coming to me for your surgery.

 

At 1/26/2006 4:00 PM, Anonymous Anonymous said...

I'm a PK (pastor's kid) who is a christian in the same way you are, and I take the same approach as you do.

But I wonder if it is sufficient in this god-drenched world. It's not that I'm hiding my atheism, it's just that being an atheist isn't a big part of my identity. Being a rationalist or a humanist, yes.

I think that atheists get a bad rap partly because we don't stand up and declare our beliefs, but who am I to say that if I'm not willing to stand up.

I guess I should close by saying that such discussions have no place in professional relationships, and that you did the absolute right thing.

 

At 1/26/2006 4:08 PM, Anonymous Dianne said...

I'm more or less an atheist in "real life" (though I do acknowledge that my belief system, ultimately, is based on faith as well: the faith that observation is reliable). However, with patients I tend to favor Karl Marx's view of religion as an opiate. However, unlike Marx and Nancy Reagan, I see opiates as useful in certain settings. Such as when one is faced with intolerable pain. All of which is to say that I think your answer was a good one for the situation. If your patient's belief helps her get through what is almost certainly going to be a difficult time, who's to say that she is wrong?

 

At 1/26/2006 6:07 PM, Blogger LadyGrey said...

My neurologist, who is otherwise a reasonable-seeming person, and someone I trust with my care, once asked if I believed in God and suggested I should pray about getting into medical school. (My chances weren't that bad, as here I am, doing quite alright in my first year). As a stated atheist/agnostic (which label depends on mood and what the distinction means to the person I'm talking with), it made me extremely uncomfortable.

I've also used the "raised Catholic, but not really practicing" as a vaguely true but non controversial answer. What would you do if a patient asked you to say a prayer for her after you left her? I had that experience as an EMT; having said that I would, I felt obligated to run through the words in my head, even though I didn't believe them.

 

At 1/26/2006 7:39 PM, Anonymous Anonymous said...

"Why on earth would this woman still believe that there was a benevolent God looking down on her?"

Perhaps because she might be finding out about an afterlife rather soon!

I've had reflective listening training at a crisis centre, and one thing they emphasize is that people often ask questions which do not require an answer. It is enough to acknowledge their feelings and offer emotional support.

I think you handled it well; I don't think she wanted to have a theological debate.
VKW

 

At 1/26/2006 8:27 PM, Blogger TheJollyNihilist said...

This is a really terrific site. Keep it up! I will be reading regularly from now on, for sure.

Some sites you might enjoy browsing, when you have the opportunity...

http://libertariandefender.blogspot.com - The Libertarian Defender (atheist, skeptic, science-enthusiast)
http://www.atheistresource.co.uk/index.html - The Atheist Resource (self-explanatory, methinks)

Keep up the great work. Cheers mate!

 

At 1/26/2006 9:02 PM, Blogger Greg P said...

I think it's important not to take these questions too "seriously."
Now, what I mean by that is that the patient is not expecting a discussion worthy of a philosophy of religion couse or even Sunday school.

I usually get the "Are you a Christian?" also, and I've heard this same question asked to my partners who are Jewish. I say, "Yes, I'm a Christian," they say, "No, I'm not, I'm Jewish."

If one pays attention to what happens afterward, and I think your story is a good example, you find that the doctor's response doesn't matter, since what the patient was really looking for was an opportunity to express their own faith, and make sure you knew this.

The somewhat curt summary might be phrased, "this isn't about you, it's about them."

 

At 1/26/2006 10:34 PM, Blogger CFeagans said...

Eddie Tabash also commented, perhaps in that same interview, that the militant atheist might have legitimate reason to worry should he/she be in the hands of a believing surgeon. I must say, that gave me pause to think. I'm a closet atheist in person (with co-workers, etc.) until I've actually gotten to know someone, but I'm more outspoken on the internet.

Should I ever become a more public personality like Tabash, Dawkins, Sagan, etc, I think I'd be a somewhat worried if my life depended upon the actions of a surgeon with fundamentalist Christian beliefs. Do such people even exist? Does the amount of science and critical thinking applied to their educations filter out such magical thinking?

If not, then perhaps Tabash was correct. His logic was that the fundamentalist surgeon would know that on his operating table sat a person who spent decades of convincing others to turn away from religion or not seek it to begin with by speaking at universities and the like. If he were to let Tabash die on the table, the surgeon might save hundreds, even thousands of souls. If he allowed him to live, Tabash might be able to go on converting theists to agnosticism/atheism.

Personally, I think such surgeons would be rare. But I'd still rather my atheism be anonymous if going under the knife.

 

At 1/26/2006 11:37 PM, Anonymous Anonymous said...

I've used the same "Catholic" dodge with patients too. Boy howdie it's fun to answer the same question when some fundie comes to the front door to "spread the word" though.

 

At 1/27/2006 3:25 AM, Blogger graefix said...

What an awkward situation.

This is such an interesting topic for me lately. I am an atheist, but like cfeagans, I am "closeted" with casual acquaintances. I don't exactly know why this is. I'm trying to put together a little post for my blog about religion, as the subject of faith has been percolating in my brain for years.

I was lucky enough to hear Peter Atkins speak when I was in college (talk about your flame-throwing atheists!), and he and - to a lesser extent - Richard Dawkins kind of solidified my atheistic viewpoint.

Orac, I think you handled the patient's question very gracefully. So far, I have only been able to answer the belief-in-god question with "I'm not really religious." This is miles from the truth, but I worry about the reaction honesty would get me.

The truth? I don't believe in God, I don't believe in an afterlife and I don't believe in "souls." cfeagans is right: it is certainly easier to be honest online!

I can think of a good example of a fundamentalist Christian surgeon (but I don't know how sincere he is): Bill Frist. I don't think I would want him to operate on me - for all sorts of reasons.

Everyone interested in this topic should take a look at the December issue of the Atlantic Monthly. There is an article by Paul Bloom entitled "Is God an Accident?" I'm too tired to give a summary of the article, but I thought it was quite good.

 

At 1/28/2006 3:32 AM, Blogger JM O'Donnell said...

I couldn't care less about what a doctor who treated me believed or thought. Only that they were competent.

 

At 1/29/2006 8:58 AM, Anonymous msprint said...

Anyone asking this question will likely be deceived. I suspect many atheists secretly believe, as much as many believers actually doubt.

 

At 1/31/2006 2:43 PM, Blogger Kim said...

I was baptized Catholic and consider myself, now, an evangelical Christian.

I don't care if my my surgeon believes in bowing to tiny Simpson figurines, if he is good, he is good and if he is ethical he is ethical (in medical standards).

I know of neurosurgeons who are the biggest jerks on the planet, but when my brain is on the line, I'd see them in a minute.

Maybe being a nurse I can separate the professional from the personal a little easier.

More on topic: I get the impression that your patient was deathly afraid she was going to get a cancer dx (and why not, she had every other dx around?)and was afraid.

 

At 1/31/2006 5:30 PM, Blogger Mrs. Coulter said...

I recently had an acquaintance ask me to pray for an ill friend of hers. I responded that I would keep her friend in my thoughts, which isn't praying, but doesn't wave my atheism in her face. I'm not sure why I feel such a need to keep it private, as so many Christians are quite open about their beliefs. Yet, perhaps if atheists were more open and "out", the believing population would have a less negative view of us (i.e., that we are a bunch of baby-killing satan worshippers).

 

At 1/31/2006 7:39 PM, Blogger DrEtak said...

I think that when people ask this, your own answer is not important. They want to talk to you about something, their fears, whatever, but the way they're getting to that is by asking you the question.
It's an old psychiatrist trick, but the best answer is asking, "why do you ask?" They'll tell you.
I know it takes more time than you normally take during an office visit, but your patients will love you more for it...and if they feel better and more confident about _you_, those intangibles may lead to a better surgical outcome.

 

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