Is that so hard for a patient to say? Just for…let’s see, like saving their life…or maybe relieving them of excruciating pain? But nooo. How many times has one of your patients actually come back to say thanks for what you did for them?
I guess I actually learned this dark side of emergency medicine a long time ago when I saw a man collapse in a back hallway in the hospital where I was the ED director. Finding him pulseless I called for help and began one man CPR. Within a few minutes he awakened and was complaining of the pain of chest compressions. So I stopped and within seconds he became pulseless and unconscious again. I would resume CPR and he would awaken and start complaining again. This went on through several cycles of chest compression as I tried to explain to him that I wasn’t trying to hurt him, rather I was keeping him alive. But he continued to complain nevertheless.
The code team eventually arrived and took over, placing an external pacer and moving him to the ICU. After placing a permanent pacemaker his outcome was uneventful without any neurological sequelae to his cardiac arrest. I was rather proud of the fact that I had literally kept him alive. But I was shocked to find that he displayed not the slightest hint of gratitude to the bystander who saved his life.
I came to understand that this was the rule rather than the exception. While it is true that some patients are thankful for their care, the majority of them are oblivious to the sacrifice and caring of the staff that are awake and alert on a holiday night just in case they have a real or just perceived medical emergency. This is made painfully obvious in the numerous patient satisfaction surveys that I have seen over the years. While most people are “satisfied” with their care, their response is little more than a shrug. It is the unhappy campers that make all the noise. Not the hundreds who received great care.
Our pastor referenced this phenomenon in people recently when he talked about the story of Jesus healing the 10 lepers. Following the miracle only one of the 10 returned to thank Jesus for their health. I feel like that sometimes.
“Stop!” my wife almost shouted as she looked over my shoulder while I was writing these paragraphs. “Stop whining about your ungrateful patients, you big baby. ‘Oh, Dr. Plaster, you are so wonderful. How can I thank you for saving my life?’ she said dripping with sarcasm. “And believe me ‘O Great One’, you ain’t Jesus”.
Well actually, none of this happened. The CPR story is true. But the rest is a fictional construct meant to set you up for my real story. The truth is that, while it is great to be appreciated, and I suspect all of us are fully aware that we are much more appreciated than my sniveling story would suggest, the real benefit from thankfulness comes to the one who shows it, rather than the one receiving it.
While I’ve known this intellectually for years, my work with opioid dependent patients has really driven the concept home. Research has shown that opioids have two main areas of effect. First, the area that we are most familiar with in emergency medicine is the spinal cord where opioids block pain. But the second area, and this is the part that presents the most problem, is the locus ceruleus in the midbrain that secretes norepenephrine when stimulated by opioids that in turn causes a dopamine rush in the frontal lobe. This is often termed the “high.” But I think the term often causes us to misunderstand what the sensation really provides.
I got a little insight into this after hearing a young person relate how they got into recreational opioid use. His life wasn’t going well. His family life was unstable and his parents eventually split. The back and forth between the parents had hampered his ability to learn in school so he wasn’t doing well. He wasn’t athletic to start with, but the floating parenting had lead to poor eating habits and eventually early obesity. Combined with all this was the sexual frustration of puberty and unsightliness of severe acne. The end result was a young man who didn’t see anything good in his life. So when he was offered an opioid pill by another similarly failing student he made an interesting observation. He said that that was “the best I’d ever felt about myself.” In no time he had a full on addiction that ended up lasting a decade before coming to me.
As we started to wean him off his artificial contentment, joy and purpose in life I saw in his personality what I had seen in functional MRIs of opioid dependent patients. The years of opioid abuse had literally rewired his frontal lobe to, in effect, short circuit his ability to experience real joy, contentment and purpose. I had seen those FMRIs of “this is your brain and this is your brain on drugs.” But now I was seeing the person. Just getting him off opioids was just the beginning of his healing. Even if we were able to get him off opioids, if we didn’t reactivate his frontal lobe to experience real joy he would have nothing. Or a life that was dull, colorless and lifeless. And he would eventually return to his artificial sense of well being. His former life was only a virtual happiness. But it was better than nothing.
So we began the arduous task of rebuilding his sense of joy and contentment that came from real life. And nothing sparked that neuroplastic regeneration of his experience of joy and contentment quite so successfully as the exercise of thankfulness. First, I explained the process of how we were going to replace his artificial joy with real joy by looking for it and spending time reveling in all the contours of it. “Just make a list of 10 things, people, or experiences that you find interesting, beautiful or satisfying — 10 blessings so to speak. No matter how small or seemingly insignificant,” I told him. Over the months I saw his dull face start to light up as he saw me and pulled out his list of amazing things and experiences. But the greatest effect was when he could connect these experiences to himself with a sense of gratefulness.
At first his gratefulness was for artificial experiences such as his favorite team winning. But then he started to extend that gratitude to small things in his daily life that were not dependent on anyone else. And that’s when we knew he was rebuilding his intrinsic sense of real joy that could displace the craving for an artificial sense of contentment. His brain was literally being healed by experiencing real thankfulness. And as a physician I am aware that true healing from a cynical sense of ungratefulness from my patients comes from my own practiced awareness of the people and things for which I’m deeply grateful.
The truth be told, I get a lot of thankful expressions from my patients. On a late night shift recently I was taking a routine history from a fellow veteran. After asking if he drank alcohol, he responded that he loved to drink a good bourbon. Without thinking I blurted out, “Did you bring any for me?” We had a good laugh and a long talk about how when I was in Iraq the Navy SEALs would follow up after bringing their wounded to me with a “gift” from town, where I was not allowed to go. As he left he asked when my shift ended. I told him, but I didn’t understand his curiosity. About an hour later the front desk called back to say that someone up front had something for me.
Peeking in the bag I saw a bottle of some very fine bourbon. “You didn’t see anything,” I said to the security guard standing nearby. He just shrugged and gave an “I know nothing” look. “Semper Fi,” I said to my former patient.
So is this story another fictional construct to show patient gratitude? I’ll let you decide.