The “Somatization” Cardiologist

Posted: June 7, 2013 in Uncategorized
Tags: , , , ,

The appointment started well, he asked me where I was from and I told him the entire east coast, as I’ve moved many times.  I jokingly told him if my accent changed mid-convo he’d have to excuse it since I’ve lived so many places.  We got a laugh and he said he wouldn’t make any judgments at all.  He asked me why my doctor referred me and I explained that I was there for more than just palpitations and said I’d had cardiac testing before and it seemed to be more my autonomic nervous system.  He sounded open to the idea.  I explained my symptoms, those weird ones (a list I brought with me and just rattled off).

He asked about previous cardiac testing and I told him I’d had a holter (heart) monitor strapped on for 24 hours before, but that they hooked me up on a day when I was having fewer symptoms and of course they didn’t catch the palpitations – I was not having any that day.  I’d also had an echocardiogram in 2010 which came back unremarkable (which is good!).  But I reiterated that if you felt like passing out each day like I do, you’d be somewhat distressed about it!  He agreed.  He asked if I’d actually passed out and I told him I had and that I’d been to the ER a number of times in 2009 and 2010.  He seemed less than impressed when he found out I had not needed stitches after hitting my head, which I found weird, but…  We kept going.

He asked about exercising at the gym and I described my routine there and why I exercise due to the CRPS.  He asked what limits me when I workout at the gym.  I told him it was a combination of things that limits me – I fatigue much quicker than most people, I don’t progress with exercise, burning pain, exhaustion, balance, and muscle tightness.  He asked a bunch of demographic and social questions…you know – family and friend support, employment, drug use, family history.  He asked about the asthma, and I also gave him my normals for resting heart rate, blood pressure and oxygen sats.  I’ve tested these things in the last year myself, trying to figure out what’s wrong since my doctors have all been buffaloed [sic].  I kept hoping each time I bought a new meter (blood pressure cuff, o2 sat meter etc) that it would hold the answers…it never did, but I at least learned my normal ranges and can reassure myself I’m not going to keel even when I feel like I am.  Evidently giving doctors this info isn’t always seen positively, however….

He checked out pulse points and listened to my heart.  I warned him not to touch my legs due to pain.  He asked if I have belly pain.  Really?  No duh, dude…did you just hear me list my GI disorders?  I played along and told him again that I do and here’s why.  I told him about my diet, that I make all my foods from scratch using about 25 main ingredients to help manage the GI disorders.

He asked if I feel like passing out every day.  I said I don’t, some days I’m fine, other days it’s awful, and there’s no rhyme or reason to it.  The longest stretch I had was daily for five months, and now I’m cycling faster than that, but on bad days I have to drop things from my calendar.  Adrenaline can help me for a little while but afterwards I crash.  I told him I perk up for doctor’s appointments due to adrenaline, but when I get home it’s NOT pretty, so doctors don’t tend to see me when it’s really bad.

I was supposed to ask him for a referral to psychiatry because it’s been almost impossible to find a psychiatrist who will take my insurance.  So my doctors and psychologist told me to try to get in at Duke through my cardiologist.  So I did.  Bad move.  Bad, BAD move.  Lesson learned:  when you don’t yet have a rapport built up with a new doctor, DO NOT – I repeat – DO NOT bring up anything related to mental health!!!  Shaking head.  He asked about why I had been on Wellbutrin and I told him I was depressed and had suicidal thoughts because I was in extreme pain every single day, had not eaten for nearly three weeks, not sleeping, doctor’s would not help me, and I just wanted relief.  Of course the Wellbutrin made me psychotic.  I told him I was on Lyrica now and that I was having difficulty at night, so I needed a psychiatrist to help manage the side effects of medications I’m taking for pain management.  I have good reason to be very careful about which meds I choose to take.  He told me to take up the issue with my primary care doctor, and I explained that we’d already tried that and nobody took my insurance.  He said he couldn’t write a referral and there needs to be a “captain of that ship” to steer the direction of my healthcare, that he’s considered a consultant so he can’t consult another consultant (i.e. refer me to someone else because he’s already been referred to by someone to begin with).  I told him my pain management doctor was the captain of my ship and I’d address that with her again.

He said his Gestalt (which he said meant “recognition of patterns” as I wasn’t sure what he meant – think those black and white ink blot cards) was that I don’t have severe cardiac problems.  “I say that not trying to minimize all the symptoms you have; I recognize you have many and that they are really disturbing you and I’m not saying they aren’t there.  But after doing this for 24 years, you get input from what patients describe and what has been done in the past.  You get a sense…is there a major heart issue here or not.  My sense is that there’s probably not.  That said, I would like to help you by obtaining objective data that would support my clinical impression.  Today I’d like to get an ECG and a 48 holter monitor to see if there are any markers for advanced cardiac arrhythmia.  And then finally, even though you’ve had an echocardiogram a few years ago, we can revisit that and make sure the pump chamber is strong, the valves are okay, though your valves sound ok when I listen to you, and make sure we actually look at the heart structure and function.  So what I can tell you is this – IF we don’t see any markers of high-grade arrhythmia and the heart structure appears normal, that your chance of having a serious cardiovascular problem that would explain your symptoms approaches zero.”  I nodded and mmm hmmm’d appropriately as he spoke.  “And that’s really what you’re here today for.  Obviously with that and all your problems, I won’t be able to shed light on things that will get rid of all those problems and you don’t expect that.  My segment here is to come back and tell you and tell your referring doctor is there a major cardiac problem or is there not.  That’s my limitation.”  I asked who would help with circulatory problems, like peripheral issues.  He said he didn’t examine my periphery because I didn’t want him to touch my legs, and that he didn’t hear things that would suggest PVD, and PVD doesn’t come out of the blue.  At this point I thought to myself, “I’m not talking about PVD!” but I realized he’s a cardio and it’s his job to think cardio so he was stuck in his little box.  “PVD usually occurs in older patients who have been smokers and have a lot of other risks for atherosclerosis, so you don’t have any of those risks.  If you wanted me to examine your legs…” and I said, “I can tell you how to do it.”  I asked to borrow his arm.  I touched his arm in several different ways explaining, “You can touch me like this, but you cannot touch me like this…or like this…or like this…” hoping he’d get the point and showing him that using an increased surface area for contact would cause less pain.  He said it made sense and the nurses would get me on the table, we’d do the ECG and examine my extremities.

The whole reason I agreed to have him touch my legs and check the circulation was because my legs turn blue and all kinds of unhealthy colors, especially my left.  I didn’t know where to test the pulses myself, otherwise I would have.  And looking back, I wish I’d asked him to instruct me in doing it myself.

I told him I’d brought two research papers and he said he’d be honest – he wasn’t going to look at them.  I wasn’t quite sure what to say so I thanked him for his honesty though it was a major mark against him in my book that he wouldn’t read solid research.  I mean…really?  They weren’t long studies either (and for the lazy doctor, almost all studies have a Conclusion/Discussion section at the end!).  “This stuff really doesn’t impact what my role is here,” he said.  “Wow,” I thought to myself.  I got the impression that this doctor, while probably very good at Hearts…was just that – ONLY really good at HEARTS, and nothing more, which would limit him even in his own boxed-in world of hearts because EVERYTHING IS CONNECTED.  Those studies might be the very link to the ANS issues I said I was thinking were driving my symptoms.  Anyhow, he left the room and the nurses came in to help me up on the table.  I warned them very sternly NOT TO TOUCH MY LEGS!!!  The ECG was boring, which is good.

The cardio came back to check my pulses in my legs.   My stress level was very high but I was trying not to show it so I took the otoscope down from his wall to amuse myself and check out my wristwatch.  The cool thing about looking through one of those is that close-up objects look magnified, but farther-away objects look smaller.  It helped me pass a few very high-stress minutes waiting with a harmless distraction.  “Are you checking out your ears?” he asked.  “No, just my watch,” I said as I goofily tried to return the otoscope to its home on the wall without dropping the thing.  “Are you hypersensitive from the knees down?”  Yes, I explained.  I reminded him to use a broader surface area when touching my legs.  He talked about where he was going to touch me and took his time.  I understood that he wanted to prepare me but I was already at that point where I was ready to get this part over with!  Femoral artery first…I’m okay with that…abdominal aorta…all’s well.  He asked, “When you’re in the gym, do you ever get on like the stair-climber or anything like that?”  I thought he’d had to be crazy to ask…stairs?  “No,” I said.  I mean, I wasn’t going to tell him I thought he was weird for asking.  He was stalling in getting the leg-touching done; I wasn’t in a mood for any more conversations!  Popliteal artery (behind the knee)…didn’t bother me too badly but I was nervous and tense as all get-out.  He started talking about veinous insufficiency.  Looking at my legs, I knew the color wasn’t bad today because the temperature had been PERFECT for me.  I interrupted him (again to hurry the process along) and said, “My legs often turn gray, blue, purple, mottled, red…but right now my legs are the right color,” and he said “they are” (again…no duh, Shirlock) and I continued “but when I get cold by even a couple degrees they get blue and if I get hot they get red and swollen”.

Posterior tibial pulse…he told me where it was and said he couldn’t use his palm but he’d use the pads of his fingers.  I showed him again what would work.  NOW THIS ONE HURT LIKE THE DICKENS!  I felt mad because though we’d covered adnauseum how to touch and not touch, he forgot about his dumb thumb!!!  He told me he’d use the pads of his fingers, but he didn’t mention his thumb.  His thumb was pushing like a knife into my leg because he was squeezing to feel my pulse and he didn’t think to do it with just his other fingers and no thumb!  I wanted to deck him with all my fingers, including my thumbs!!  I held on.  He still had to do the other leg, so I didn’t complain even though I was mad and wanted to run away.  I felt that trying to explain what he was doing wrong was only going to drag out the process.  Dorsalis pedis…oh crap! there’s another one to test?!!!  Yep, there is, and it’s in one of the worst parts of my legs – just before the toes.  I didn’t say anything.  After he felt there too he said I had very good pulses.  “So what does that tell us?  It just tells us that for one it doesn’t look like you have veinous problems and arterial flow appears normal so it really answers that question.”  He talked to a nurse while I tried to gather myself together mentally – the touching was over though I still had pain from it.

I told him I had two questions for him.  The first was whether he wanted to wait to strap me up to the holter monitor until I was having a bad day so he can see it.  He said when you look at the data on cardiac arrhythmias, if a person has severe arrhythmia, it’s not like there is not going to be a marker for that.  In other words, that you have absolutely nothing and suddenly you have V-tach or a problem that needs to be treated with medication.  I reminded him that on bad days I can have the palpitations happen several hundred times and on good days it won’t happen at all.  He reiterated his sense that I probably have a little palpitation but that just ruling out high grade arrhythmias is adequate and doing at least due diligence.  (I thanked him for that, as I appreciate thoroughness.)  Some people may look at the chart and see it was done before and ask why I am doing it again and I’d say it’s because these things are really bothering you and you’d like to know whether it’s an issue or it’s not an issue.  I explained in a sense it didn’t matter if I agreed or not with him (since he’s the doctor who knows about hearts and I’m not, so I trust his expertise…though I’m not sure he understood what I meant when I said the former), I DO happen to agree that it’s not a heart thing and I’m not especially concerned about my heart in particular.

You see, at this point, I was wondering about the oddity of some of his questions (stair climbers?  – I almost thought that was a joke) and responses (telling me again and again what I don’t have…like…I wasn’t even worried about PVD or V-tach, for example) towards the later part of my first visit with him but for some reason I still didn’t expect he was a big bad wolf.  I was annoyed that he didn’t see himself as being a “team player” in the broader scope of my healthcare management, and I knew his unwillingness to even skim a small research paper was a bad sign.  Yet I appreciated that, all in all, he spoke at a medical level that I understood (not too advanced, not too dummied-down) and he explained himself and his reasoning well.  Whether or not I agreed with him was a separate issue in my mind – he was good with communication as a whole.  I wish he’d left it there, however.

The second question I asked because I realized other than doing some tests to rule out heart problems, he couldn’t help me either because he really didn’t know enough about what I’m experiencing (not necessarily any fault of his own) or because he’s chosen to box himself in so tightly that he could not think any more globally than “HEARTS HEARTS HEARTS” as if I’m just some disembodied heart without, well, a body of parts that work as a whole including that heart.  Anyways, I said “If you’re not the right person for me to get answers from regarding the suspected autonomic nervous system problems, who IS the person whom I need to see next?  What is the next step here?”

He had not been slow in answering my previous questions.  This time, however, he stumbled.  “Well…right…uhm…”  I figured he was just narrowing down the choices and trying to help me get to the best person who could help me with my physical problems.  “How do I get in to see that ‘magical’ person?”  “Uh, right, well…” he continued stammering.  “I’ll be honest with you,” he said.  “Please,” I responded.  (whoops)  He continued, “I’m not sure there is an autonomic issue here.”  “Ok,” I said, curious as to what the alternatives might be.  If he was telling me it was not something that he’s already said wasn’t in his specialty to evaluate or diagnose, then surely he must have some other idea.  “I mean, I’ve been doing this for a couple of decades.  Autonomic dysfunction patients are, in my experience, have a different constellation [of symptoms].”  I thought “Oh great, he’s pulling out his resume, and I have a feeling it isn’t to comfort me in his experience as much as it is to assert his knowingness.  This is either the second or third time in this visit that he’s mentioned how many years he’s been doing this.”  “So you know…this is a difficult…you’re asking me this question and I’m going to be as honest as I can be and you may even think brutally honest, but you had asked me if I could send you to a psychiatrist within the Duke system…and I told you that I would feel more comfortable with you arranging that through your primary care doctor, and I think that’s the right way to go.”  “Ok,” I said, absorbing what he’d just said.  I knew what it meant already.

“So are you telling me that you think it’s in my head?” I asked almost immediately.  “I think that you have a lot of somatization, soma-ti-zation means that a lot of symptoms and a lot of concerns that are focused inward to your body.  You had papers on that and I already know about the pain cycle sort of thing…” OH MY!  NO!  THOSE PAPERS WEREN’T ABOUT PAIN AND IF YOU HAD JUST SKIMMED OVER THEM OR ASKED ME FOR THE 5 CENT TOUR, YOU WOULD HAVE SEEN THEY WERE ABOUT THE CORRELATION BETWEEN CRPS AND AUTONOMIC DYSFUNCTION!!!!!  I didn’t say that though.  “But I think that, uhm, and maybe it’s because as physicians when we don’t understand something exactly, we…” I cut him off to add “blame it on the brain” and he kept going “and I understand that; maybe that’s what this is, and maybe I’m guilty of that as well – I’ll be honest”.  I wanted to say “yeah, you’re guilty alright!” but I didn’t.  “But, uhm, you asked me and that’s my guess.  But that’s not to say that we’re not going to look CAREFULLY at your cardiovascular system and I have today – I’ve listened carefully to your complaints, your symptoms, your physical exam, and you know things look normal from a heart standpoint.”  The tears began rolling down my eyes.  I had stopped saying “ok” or nodding, but I was listening carefully.  I was grateful that he could admit some doctors are butts that blame it on the patient when they can’t figure something out.  I have no way to know how sincere he was in admitting he might be a mugshot doctor as well, but I don’t think I need to know really.  I knew what somatization was before he spelled it out in syllables – while it’s not the same as hypochondria, to most medical professionals it might as well share the same pea pod.  As expected, doctor mugshots came back to my mind – that long list of people who haven’t believed me.

I took the calm approach as the tears rolled and I tried to keep my voice as even as it had been.  “Well, I guess from the patient’s perspective (I pointed to myself), when a doctor tells you it’s in your head, it hurts.  But yeah, I am tired of feeling like I do typically.” “I see that,” he said.  “I had chosen to go into the medical field, in part, because I have worked so hard all my life to manage my health problems and now I work on my diet and exercise, and I WOULD NOT do all this unless I actually HAD to because this really IS NOT the kind of life that I anticipated or wanted or would choose.”  “I understand that,” he said.  “Uhm, but I would, you know, really like you to try if you can help figure out what someone does when they feel like this…what the PHYSICAL causes are as well (rather than just the mental ones) because I really want to be well.”  “I see that, and that’s why I am going to go around this block again to make sure we do what kind of heart and cardio testing we can.”  The tears were really rivers, but I was still keeping it real with him though you couldn’t miss the fact that I was crying now.  “There’s GOT to be SOMEBODY who can help me!”  He said, “It’s hard for me to know who that person it; it really is.  I have the tools that I have to see whether a person has cardiovascular disease.”  I answered, “I understand, like you mentioned earlier, that I can’t expect any doctor to have all the answers.  I didn’t have all the answers when I had my own patients.  But I think the best thing a doctor can do is to do as much as they can, and that sometimes takes them beyond the call of duty perhaps, to try to find the person who can help.”  He said, “If I knew the answer to who might help you, I’d be right there.  I would.  I just don’t know who would have the abilities, the capabilities, the knowledge, to answer your questions.  I’m sorry.”  Though I didn’t say it, I wish I had asked, “Then could you consult with other physicians to see if THEY might have ideas about who can help me?  It doesn’t have to be all about what YOU know!”  He continued, “Sometimes being a doctor means realizing what your limitations are.”  “Right,” I said, because I agreed – we all have limitations and it’s better to understand and accept them rather than pretend they don’t exist.  Sometimes accepting them, however, means we also accept help in our areas of deficiency and we capitalize on the strengths of others…and in this case, I think that means a doctor who doesn’t know who to recommend I see next can reach out to his or her medical social network and ASK.  “But we will check this out, okay?”  “Alright, thanks,” I said, in my squeaky and trying-not-to-bawl voice.

The nurses and doctor left saying they would get me hooked up to the holter monitor.  Once the door shut and I had a few extra tissues, I cried more but I knew I couldn’t let it get out or I’d not be able to reel it back in before they came back, and I didn’t want to be a blubbering mess.  After a few minutes, they returned.  There was a new nurse to help along with the other two.  I couldn’t transfer or step off the table myself without potentially landing on my face, so I really did need some help (respecting my own limitations and seeking help for my area of deficiency!).  The nurses were problem solving the best way for me to get off the table without falling and I was telling them how we could do it when the new nurse suddenly grabbed my legs as she asked if she should lift them!!!  Oh, I nearly had a heart attack and then the cardiologist probably could have done something for me!!!  It’s one thing for me to touch my own legs, it’s another for someone else to touch because I have no control over when or how they will touch but it can be tolerable when I am expecting it…it’s a much worse situation when someone else touches and I wasn’t anywhere near expecting them to do so!!  I shot my hands down to my legs to remove her hands in self-protection as I let out a small yell.  The touch hurt.  “You can’t touch her legs!” the other nurse said hurriedly as she began to apologize to me, “Are you okay?  I’m so sorry, we forgot to tell her…”  I felt a little snappy but said as calmly as possible, “Yes, you sure did forget to tell her.”

And people wonder why I hate being touched, why I hate doctor’s appointments, why I don’t trust doctors or medical staff anymore, why this is so bloomin’ exhausting?

This was just one medical appointment I had last week.  But I have specialist doctor appointments EVERY DAY of the week plus medical tests.  So all the emotion and energy packed up into this one appointment is magnified and repeated many times each week and it’s very hard.

The experience reopened up that can of worms I’ve been trying to seal shut – questioning whether it really is in my head.  So I talked to my psychologists about it last week and this week.  My psychologists, both of them, plus my other specialists confirm it’s not all in my head.  I really am sick, I really am having problems.  There are things I wish I had possessed both the time and mental energy to tell the cardiologist during this visit.  Plenty of things I wish I’d done differently.  I wish I had time to process through all of that, but like I explained in my previous post, the processing doesn’t typically happen when I’m in survival mode.  I just have to move on to the next thing and keep going.  Ditch the docs who don’t believe and get help from those who do (because they are ultimately the only ones who are going to be helpful anyways).

If mental/emotional energy exists for me to write a post about what I think caused this doctor to conclude I was primarily suffering a mental health issue, I’ll write it out.  I also want to write out what I would have done differently and what I wish I would have told him if he still believed it was in my head.

In the end, I wish he had not mentioned the mental health stuff, but I did still appreciate his honesty.  Better to know a doc thinks you’re mental on the front end that to see him several times before realizing he thinks he’s got this inside scoop on your mental health and now you’re surprised.  If he feels that way, then he can’t help me and I probably should not waste my precious energy resources on trying to convince him otherwise.

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Comments
  1. Hi hon, well done for getting through it. The cardio’ I saw was a hearts-and vascular-only guy, too. The best things are that the heart is healthy (hurrah!) and that you have psych’s who are supportive of you. At least they can write a letter to your doc if the cardio’s leanings send him/her off in the wrong direction. Have you seen DINET’s autonomic physician list? I found an appropriate specialist from their list, and went to see my doc armed with papers, graphs of my symptoms, a list of my symptoms etc and presented the case for possible autonomic dysfunction. My doc’ couldn;t refer my direct to a tertiary levels specialist so he contacted a local neuro, wrote him a letter about me and included my graphs and symptom list as extra info’, and the outcome was that the neuro replied in a letter saying that it was too specialist an area for him and that they don’t have the testing equipment required, so he said that yep, the patient’s suggestion was appropriate. Then my doc’ could use the neuro’s advice in the written letter as a way to refer me forwards to the autonomic specialist. It was some out-of-the-box thinking on the part of my doc, and it worked. Here’s hoping your doc can be persuaded to think outside the box too.
    Big hugs from me, rest well after all that appointment hassle, love from me, xx

  2. Sarah Bosse says:

    Thanks! Right now I am trying to get scheduled with yet another neuro and a doctor at Duke who do the tilt table and some autonomic testing. Not the same as going to a guru, I understand, but I feel it’s a good start. From what I hear, these two docs are incredibly thorough…one has NO bedside manner, and the other has enough to make up for three docs who have none. LOL. That doesn’t bother me; if they’re good at what they do and they do not think it’s in my head, I’m fine. 🙂

    Would love more info on the kind of graphs you kept, what variables you measured, how often each was tested. Do you have a link to that information on your blog?

    I have a little more testing through this current “somatization” cardiologist and then I plan to drop him like a hot potato. 🙂

    Yes, I looked through DINET and the other website too that was provided, but neither had physicians in my state. In fact, the ones they had listed for my state had shut down = doctors were no longer working (one retired, another went on “permanent” maternity leave). So Duke will be my first bite at this with any hope of promise. If that doesn’t work, I may really end up needing to travel.

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