Does Invisible Suffering "Count" in the Doctor's Office?

You can also listen to this episode on Spotify! Human suffering is impossible to fully measure. It includes our core values and beliefs. It encompasses our tolerance for pain. If medical decision-making is about avoiding risk, who gets to decide what’s even worth risking? If avoiding one risk means adding another, when are we doing “no harm”? Doctors can measure blood pressure, blood sugar, liver enzymes, and white cells; we can even run genetic profiles to look for elevated risks for cancer (like the BRCA gene mutations). But there is no blood test for depression, no MRI for chronic pain, no line in the sand separating worry from debilitating fear. In this episode, Dr. McBride discusses how modern medicine tends to discount things it cannot see — and how to better advocate for ourselves in the doctor’s office. Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast. Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome Please be sure to like, rate, review — and enjoy — the show! The transcript of the show is here! Dr. Lucy McBride: Hello, and welcome to my home office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription". Today, it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, peeling back the layers of everyday medical problems I see. In clinical practice for over 20 years, I've found that patients generally want the same things. A framework to evaluate their risks, [00:00:30] access to the truth and the courage to face it, and tools and actionable information to be healthy mentally and physically. So, whether it's managing weight, cholesterol, cancer, or mental health issues, we all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today, and how to be healthy from the inside out. Let's go. Today, dear listeners, I'd like to talk to you about how we do [00:01:00] such a bad job in the modern medical landscape at addressing the invisible suffering people experience. What do I mean by this? I read this article that you probably read in the New York Times, on February 1st, 2023. It was a fantastic article, written by Susan Dominus. The title, "Women Have Been Misled About Menopause." When I first read the article, I was honestly speechless. I was delighted but I was also kind of shocked that the mainstream media are finally recognizing [00:01:30] the invisible toll on women from the absence of hormones. I'm gonna get to the substance of that article in a minute. But the takeaway from that article, which I really encourage you to read, and I'll link it in the show notes, is not so much that women should be given nuanced information about hormone replacement therapy around menopause. They should. It's more that this article represents another example of modern medicine's inability to countenance things we cannot measure, [00:02:00] things we cannot see. In other words, as I talk about commonly, there are lots of things we can measure. We can measure cholesterol, we can measure blood pressure, we can measure genetics, you know, we can measure predispositions towards genetic phenomena. What is harder to quantify but no less important is the everyday suffering that people experience. And it's not just about menopause. Let's think about other subjects in which we cannot quantify suffering. Let's talk about mental health. There's no blood test, there's no MRI [00:02:30] for depression. There is no line in the sand that separates anxiety that's unhealthy from anxiety that is "normal". Let's talk about COVID-19 and our response to it. We, for good reason, protected, at all costs, against COVID-19 in 2020, when we didn't know what was going on, we saw people dying, vulnerable people in nursing homes particularly vulnerable. But we also, [00:03:00] in my humble opinion, failed to acknowledge, over time, as more information and data was collected, and as we had extraordinary vaccines, we failed to zoom out and recognize that health is about more than the absence of COVID-19. In other words, not having COVID is great. But health is also about being in the classroom, seeing the faces of your teachers, participating in social activities. Particularly for young minds and for older people, [00:03:30] social interaction is crucial. But those are not measurable. There's no PCR test for despair. In other words, it's much easier to defend against the enemy that we can see than it is to protect against the things we can't see. Here's another example of where we don't do well in this department. By the way, this is not gonna be a depressing podcast episode, although if you're depressed, you know, fine. I have lots of thoughts and ideas on how we can mitigate this problem, [00:04:00] from a societal level and on an individual level. But another area in which we see this problem where we don't countenance the invisible is in conversations about death and dying. I have the honor of being part of these conversations. My patients who have terminal illnesses, my patients who are elderly and infirm, they have accumulated medical conditions, none of which is going to necessarily take them, but we know that given their age and their comorbidities, that they have, you know, less than two years, less than five years to live. [00:04:30] The way I approach these conversations with families and the patient is not by helping them decide on a menu which medicine, which medical procedure they want, at which time and which day, because guess what? We can't predict the future. We don't have a crystal ball on how everything is going to go in the last days, months, years of life. So, instead of asking people, "Do you wanna be on a ventilator? Do you want dialysis? Do you want aggressive measures, you know, at the end of your life?" I instead frame the question in a different way. What gives you meaning in your life? [00:05:00] In other words, let's center life in the question instead of death. Let's center your values as a way to pressure-test our decisions moving forward about interventions like feeding tubes or dialysis. Let's take an example. And my friend Eleanor Tanno, who's a physician in the D.C. area, and a good friend of mine, has written me a guest post for my newsletter about this very issue. As she says, you know, when she's talking to patients and families about end-of-life decisions, how can you decide on what you want for dinner [00:05:30] when you don't even know what's on the menu? In other words, when we're thinking about end-of-life decision-making, planning ahead, we wanna ask the patient, what is it you live for? And what are the things that you consider a bare minimum for a quality of life? And if your quality of life is contingent on being able to read the New York Times, listen to Beethoven, or know your grandchildren's names, any medical intervention that we're deciding on that's not gonna restore those faculties [00:06:00] is something we should spare you. Because at the end of the day, we do harm by prolonging life that's not quality. Then this gets back to my original point that we don't do a good job of measuring things we cannot see. It is harder to measure the value someone places in the ability to identify music they hear on the radio than it is to quantify their EKG, their heart rate, their blood pressure. Whether we're talking about menopause, and the absence of hormones, [00:06:30] and the unmeasurable suffering, like hot flashes and night sweats, sexual dysfunction, low sexual desire, loss of muscle tone in the pelvic floor, or whether we're talking about the despair that existed during the pandemic and that still does, or whether we're talking about people's core values or the way they value life, we have to do better as doctors, and as a … This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit lucymcbride.substack.com/subscribe