A second opinion

One doctor's enlightenment through pain.

Published July 9, 1999 4:00PM (EDT)

In March, I wrote an editorial questioning most present-day treatments for
back pain. I quoted the New England Journal of Medicine. I relied upon my
own history of minor self-resolving bouts of sciatica as back-up experience.
My advice: exercise and time. Stay away from the surgeons.

Apparently the article was overnighted to the gods of irony and retribution.

A week later, while on a working vacation in Manhattan, I awakened with a
fiery stabbing pain in my back and left leg. For three days I literally
couldn't move.

I could hear myself asking my patients, "Could it be stress?" I ran through
the circumstances of my life, passed my own psych evaluation, though I knew that self-awareness in such matters is often nothing but self-delusion. No, I chided myself. The problem was definitely anatomic, a ruptured disc, not some frayed moral fiber. I knew stress, and this wasn't stress. Not me.

How to describe the pain? "It's killing me," came to mind, but I didn't want
to sound like a complainer. Doctor to doctor one must always be stoic. But
my back was killing me, and I wouldn't mind saying so, though I was fully
aware that obituaries seldom listed sciatica as a cause of death.

Cut out the sickbed hyperbole. No need for panic. You'll be just fine. The
neurologist in me reminded me that 80 percent of people have an episode of acute back pain. The majority heal within a few weeks to a couple months, even if they have a disc protrusion.

But what if I was wrong? I practiced saying, "It's nothing," while trying
not to contemplate the worst.

Look tough, act tough. Be macho in small things; keep your appointments. I
had my wife tug on my socks and pants, in a chilling rehearsal of ... no,
let's not go there, not even in silent print. I am superstitious. I step
around ladders and cracks in the sidewalk, worry what might happen as
counterbalance if I won the lottery. Let's not talk about what not being
able to move reminds me of. I do confess to having tried swimming laps with
my eyes closed, just to imagine what it might be like to be blind. But never
have I pretended to be paralyzed with pain.

A brief digression. The unspoken operant word driving many physicians is
counterphobia. Ask anyone who treats M.D.s as patients. I can't imagine a more anxious, fearful group, yet these are the same folks who poke fun at
cadavers, perform amputations and autopsies to rock 'n' roll, who strut and
swagger as though granted diplomatic immunity from mortality. Most normal people, who are repulsed by sickness or frightened by illness, simply stay away and go into other professions. They do not consider getting used to
gruesome pathology a measure of strength.

One might argue that physicians make bad patients because they know too
much, know what might go wrong or what might be wrong. True, but I suspect the anxiety came first, the squeamishness and mortal fear hidden beneath layer upon layer of denial. I know firsthand. Illness has always seemed incomprehensible. I might know the pathophysiology down to the molecular level, but never have I understood what illness actually is. All I know for sure is that pain and suffering are personal and lonely, existential in dimension.

I was stuck in the worst of predicaments -- I was a metaphysically uncertain
physician trying to reassure a frightened patient.

I went out, my lips sealed, hoping others would understand by my limp and my hand at the small of my back. Let my body language cry out for me. Tough doctor who has seen it all. This is nothing. Others have had the same.

After three weeks I was no better. My foot went numb, a block of ice where
nice pink toes once wiggled like small children at bedtime.

"How do you know that it's not a tumor?" my wife asked.
"Because it's not. The scan will show an L5-S1 disc, but so what?"

MRI scans are of very little value in the assessment of acute back pain.
Nearly half the general asymptomatic population will have disc bulges,
protrusions, herniations. Correlation with pain is questionable. So says my
article. Yes, but ...

I phoned my primary care physician in San Francisco. He started by telling
me that most disc problems get better on their own, as though forgetting
that I was a neurologist, and that he often referred his back patients to
me. I had been struck dumb by a disc in my back, an aberrant bit of
physiology if there ever was one. He went on to explain that most of his
patients didn't need scans, but that, of course if I was really worried, he
would order it.

My doc is truly decent, one of the most compassionate men I have met in
medicine. Yet he sounded condescending simply because he was telling the
truth. He was saying what I would have said had the tables been reversed.
The pain had not only made me brain dead, it had made my skin tissue-paper thin. Every comment was filled with innuendo, harbored deeper meaning.

I was pathetic, embarrassed, yet grateful when he phoned the HMO and ordered the scan. He knew what was best.

And now I had to decide what to root for. A negative scan would imply that
the pain was all in my head. I would creep out of the scanner as embarrassed as if I had become incontinent while giving grand rounds. A negative scan would mean that I had soiled my psyche. But a positive. How bad did I want it to be? A minor abnormality wouldn't explain much, would leave me in limbo. A major extrusion would mean that my pain was justified, but might also be one of the few reasons for contemplating surgery. Whoa. Surgery? Not me. Not this skeptic.

I canceled the scan.

The pain persisted. I rescheduled a few days later.

"I'm a neurologist," I told the technician when he asked me to undress. He
nodded, helped me into the MRI scanner. The top of the tube loomed
millimeters from my nose, like a coffin lid. Why hadn't the technician
warned me, prepared me? Because I told him I was a neurologist. He presumed that I knew, which I did, which still didn't excuse him. I didn't want to be treated as a mere patient, yet I wanted everything that patients got. The young lady before me had been given a brochure and an explanation of how the machine worked. I got nothing. The technician was presumptuous. Of course, if he had said anything, I would have interrupted and said, "I know." And he knew that, too.

Which meant that I couldn't say anything about the creeping claustrophobia
and the chilling knowledge that total strangers were getting the first look
at my innards. Maybe they would see something in addition, some yet-to-be-announced catastrophe of the flesh.

"You want to see the pictures?" the technician asked when we finished. If
the technician saw nothing worse, and was talking to me like a colleague,
then it couldn't be that bad. But he was looking away, didn't make eye
contact. "The official report will be ready tomorrow." What did he mean by
that? Please look at me and smile. Instead, he muttered, "It looks mainly
like L5-S1, though a little at L3-L4." I went from a feeling of apprehension
to one of relief and a simultaneous sense of having been scooped. My 30
years' experience wasn't necessary. Nor the yearly MRI seminars. The tech
had casually, like an indifferent physician, told me what was wrong.

I looked at the pictures, found myself agreeing. I focused in on the L5-S1
level, saw the disc nudging the nerve root, tried to compare it with the
thousands of scans I'd reviewed in my own practice. My experience labeled
the protrusion as moderate, not surgical. Briefly I wondered if I was
entitled to this much pain. I felt unsure, as though my judgment were OK
for others but not myself.

"It doesn't seem that bad," I said to the tech.

"I wouldn't want it," he countered.

What did he know that he wasn't saying? "Could I speak with the
radiologist?" I asked like a little child.

"She's busy. I'll lose my job if I interrupt her." He scowled at me as
though I had asked for a second opinion.

I took a copy of the scan back to the apartment and showed my wife.

"Couldn't they cut it out?"

"I already told you. Surgery is worthless."

"I was just asking."

Maybe she was right. I went onto Medline, reread the same articles that I
had used to write my editorial, as though the words might have changed, some emphasis shifted, some new slant interjected. I read with renewed interest, alternating between moments of self-deceiving hope and the realization that I was revisiting already-formed opinions. "No," I eventually concluded.

I am getting better. The pain is nearly gone. I guess this Dr. Burton knew
what he was talking about. Still, he could have been a little kinder, a
little gentler, not so straight to the point. And the way he looked at my
scan, as though it was nothing, or something that we all get. He could have
made me feel that he cared. Though I have to confess that, in the end, it
probably made no difference. I got better in spite of him, not because of

Remember that, I tell myself.

By Dr. Robert Burton

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