He was a tough guy. The bad cop to my good cop. He went by different names, including Director of Rehabilitative Services, and he certainly had a given name, but I always thought of him as the Hammer.
The Hammer was very polite, well mannered, and friendly. He was the kind of person who, when someone entered the room, would always rise, extend his hand in friendship, and smile. He could not tell a good joke, but always laughed heartily at a funny story well told. The familiar doctor’s white coat was not formal enough for him; he preferred the corporate business suit. Professionally, I did not know a more helpful and friendly individual, and we were reasonably good friends.
But to my patients, the Hammer was altogether different. The Hammer was old school. He believed that what the doctor says goes. His curt, sharp manner inspired confidence at first but often alienated patients at last because he seemed too matter-of-fact and cold. And he made one thing perfectly clear: If you did not abide by his rules you needed to find another doctor.
When he examined a patient, he was very thorough, and in assessing pain syndromes he usually did a better neurological exam than our staff neurologist. I confess that when I wanted a careful neurological evaluation on a patient whose diagnosis eluded me, I would often pass on the neurologist and reach for the Hammer.
The Hammer's world was black and white, full of hard edges and sharp corners. I would sometimes gaze into his eyes to see if I could glimpse the mind of a cubist. When he made a diagnosis, that was it. He had a plan, and he was sticking to it. He felt he could judge if a patient was is pain or just faking it, and on more than one occasion I have seen him flatly accuse someone of malingering or of drug seeking behavior.
Even more disconcerting, though, were his rehab evaluations. As head of the Rehab department, the Hammer decided who was admitted into the hospital’s Rehab unit. Rehab, not to be confused with Drug Rehab, was an inpatient facility devoted to physical therapy. There, patients underwent multidisciplinary therapy to overcome stroke, massive heart attacks, major surgery, or weakness from severe chronic illness. The Hammer did his job well. Rehab was hard work, and he cracked the whip. If a patient was not willing to put in the hard work of rehabilitation, out he went. The Hammer had no patience for slackers.
When he evaluated patients for his unit, the Hammer was very clinical in his approach. If a patient was not strong enough, not devoted enough, or too ill to tolerate two 3 hour rehab sessions a day, the Hammer had no intention of allowing him in his door. To be fair, this was of necessity, because rehab is expensive, and insurance companies were very parsimonious about approving rehab stays. If he did not get patients in and out on schedule, his unit would quickly start losing money. A careless Rehab director could easily end up with a unit full of ill patients making no progress to speak of.
His strict interpretation of the facts sometimes caused me problems, though. I might have an elderly patient in the hospital who suffered a severe stroke. Good cop that I am, during my treatment I would encourage the patient and family, telling them that Rehab is a possibility and may result in great improvements. Without distorting the truth, I would try to give them a ray of hope, a reason to go on. Without this hope in the eyes of my patients, I would find the daily practice of medicine very dreary. My patients need hope. I need them to need hope.
But as I said, the Hammer was old school. If he did not think he could help the patient, he would tell them matter-of-factly that he thought nothing could be done. I have known him to be as blunt as to say, “I have examined you and reviewed the facts of the case and I cannot do anything for you. I suggest you consider a nursing home.” Then he would walk out.
The first time he did this I was aghast, but I got used to it. I am quite skilled at talking people off of ledges, and I was usually able, with effort, to smooth things over. Over time, I came to expect that this might happen from time to time, and I developed a set of ready-made options in case the Hammer turned the case down. These options included home health, outpatient physical therapy, and placement in intermediate-term facilities that could do limited rehab before sending the patient home.
As I got used to this recurrent experience, I began to see a value in his ways, artless as they may be. The Hammer was calling it as he saw it. No varnish, no dishonesty, just plain opinion. Though he did not handle situations as smoothly as I would have liked, he was telling the patients the truth as he saw it, almost all the time. I am not sure I can make the same claim myself.
When I was a resident, I had a professor I admired greatly who used to ask his students, “When is it appropriate to lie to your patients?” He never asked if, it was always when. In the question he was implying the answer. Sometimes it is not necessary to communicate the whole truth to patients. My professor always used the word lie, but I understood that by lie he did not mean we should falsify the facts, only that there is value in packaging the truth in a way the patient can handle.
If I diagnose a patient with lung cancer, for example, I do not have to follow the bad news with the statement, “and lung cancer has an 85% five year death rate in the United States,” even though that statement is true. There is no harm in saying, “You have lung cancer, but there are many treatments for it, and many lives are prolonged with the treatments we have and some are even cured.” The word cure may be an element of a lie for some patients, since a cure is not always possible. But hope is so terribly important, and if focusing on the minority that are cured rather than the majority in the graveyard encourages the patient to carry on, then I say do it.
The Hammer, with his methods, sometimes squelched hope. But there was some good to be had from his unvarnished opinion. From time to time all doctors have the experience of treating patients who are not doing well, patients who subsist on unrealistic hope. Unrealistic hope can be harmful if it drives the patient to seek out aggressive treatments and measures that are not going to do any good. This attitude can be abetted by a row of doctors who just want to say nice things and give words of encouragement rather than spill the truth. In such situations, the Hammer was a godsend – he would break the magic spell and force patient and family to face reality.
Too often, I find that patients come to me looking for a solution, rather than a treatment, for their problems. There is not always a solution. Many patients come to accept this, but some resist. It is one of life’s hardest intellectual feats, accepting things as they are. That was the Hammer’s specialty, and he took some pride in it. I do not think he enjoyed hurting people, but from my conversations with him I definitely got the impression that he thought the pain of facing the truth is a necessary part of medicine.
He is right, but not completely. Hope is not about ignoring the truth. It is about fixing on the best possible outcome, and striving for it. Imagine a hundred people entering a competition that can have only have one winner. Each participant has hopes to win. Mathematically, each of the hundred has only a 1% chance of winning, but if the participants looked at it that way, most would drop out. There would be no winner. Realism may be a means dealing with things as they are, but hope is the core element of a champion.
Over time, I came to appreciate the Hammer’s role with my patients. The Hammer brought the truth. He offered a clear opinion, for good or for bad. If the patient reacted negatively to him, I would move in afterward and help rebuild hope. Most people are so willing to hope that rebuilding it is not hard to do. When I rebuilt, however, I took care not to completely erase the Hammer’s handiwork. I would remind the patients that their options are limited, since rehab is now out, and that they may have to accept something less than a full recovery.
A hammer, after all, is a tool. For some jobs, it works beautifully; for others, not so well. The carpenter has to be the judge when to use it, how long to use it, and when to set it aside.
I wonder who uses me that way?