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The Other End
Of the Stethoscope:
Physicsican As Patient ROBERT 0. STEPHENS, MD
HAVE YOU ever wondered what it
would be like to be on the
receiving, rather than the giving, end
of a needle, or a plaster cast, or a
stethoscope, or a cystoscope? As a
practicing physician, such thoughts
have often crossed my mind, and I am
sure they have yours.
But it was not until this past
summer that my questions were
answered as I was suddenly and un-
expectedly hospitalized for nearly two
weeks. The investigation and treat-
ment of my illness and its complica-
tions resulted in my receiving firsthand
experience as a patient in many of the
departments of a large metropolitan
hospital. What were my impressions,
my fears, my conclusions? Did I learn
anything that would be of value in my
ongoing relationship with patients?
Let me try to answer some of these
questions.
Visits by Physicians
I had a number of physicians and
surgeons examine me during the
course of my illness. Although I had a
very good idea of what was going on,
it was most reassuring to be carefully
examined and to have the physician
share with me his diagnosis and treat-
ment plan. I looked forward to the
daily visits by the physicians and
found them very reassuring. Even
though a physician might have nothing
new to report, a short friendly call was
greatly appreciated. I found myself
thinking, often at night, of the ques-
tions I would ask on the next visit. At
this distance, many of these questions
appear trivial, and probably were, but
they seemed important to me at the
time and it felt good to have them
answered.
In this connection, there has been
continuing discussion over the years as
to the value of "supportive care" by
the family physician. The whole
validity of this concept has been re-
peatedly challenged. On the basis of
my experience, I would staunchly
support the worth of such care. Even
though the family physician is not
writing orders he still has an effective
role to play in the total support and
care of his patient.
In hospital, I was surprised how
quickly the ordinary worries and
concerns of daily living and practice
were forgotton - or perhaps were
elbowed out by new concerns which
were much more basic in character and
related in a greater or lesser degree to
my survival as an individual. My con-
cerns became whether I would hold
the next meal down, if I would have
another chill, when I would become
free of pain, what was the basic cause
of my illness. In a way, I suppose it
was good to be reminded of my basic
needs as a person. It certainly helps,
much as does a holiday, to put one's
daily professional problems into focus
and perspective.
Experience of Pain
My illness involved considerable
severe pain lasting for several days -
again a first-time experience for me.
As a result, I have a new respect and
appreciation for the value of anal-
gesics. The relief of pain is a worthy
and worthwhile segment of the whole
practice of medicine! As a result of my
experience, too, I feel I will be more
sympathetic - and quicker to act -
towards the person in severe pain.
Physicians tend to measure the
success of their treatment by param-
eters which can give mathematically
expressed results. We speak of cure
rates, mortality rates, five-year cures
etc. Obviously, these do not tell the
whole story. Who can measure the
value of the relief of pain, the amelio-
ration of anxiety or the reduction of
fear and frustration? Family physi-
cians in particular must remember how
important these aspects of medical
therapy are.
And talking about pain, I was agree-
ably surprised by the lack of pain in
regard to the intravenous that was
running in my hand for several days.
The IV team started it smoothly and
easily. I found that I could move in
bed quite easily and freely without
pain in my hand. I was surprised that I
hardly knew it was there after a while.
I would sleep quite comfortably with
it.
Improvements in Anesthesia
While on the topic of needles, I
found the induction of a general
anesthetic for a cystoscopic examina-
tion and biopsy of the prostate to be
very pleasant and smooth. My only
previous experience in this connection
was as a child having a T and A. I have
bad memories of being held, of the
ether smell, of a mask being clamped
over my nose. But my recent induc-
tion was something else - which has
left me with only pleasant memories. I
found the nurses in the recovery room
to be reassuring and helpful during
that dreamy, half-awake stage. Even
though I couldn't bring their faces into
focus, I found their voices and their
presence reassuring.
High Quality of Nursing Care
As a matter of fact, I would give
very high marks to the great majority
of all the types and grades and sexes of
nurses who attended me. Contrary to
some public opinion, there are still a
great number of nurses who can care
for patients with skill and compassion.
I would comment further, however,
that the frequent changing of shifts -
coupled with days off etc. - makes it
difficult for the patient to get to know
the nurses, but I suppose this is un-
avoidable in our present day setup.
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1972 73
Sinequan
25 mg tid
The tranquilizer that is
an antidepressant.
The antidepressant
that is a tranquilizer.
Indcatlons-The antidepressant and anxiolytic properties of Sinequan
have been found to be of value in the drug treatment of:
1. Psychoneurotic patients with anxiety and/or depressive reactions;
Anxiety neurosis associated with somatic disorders;
Alcoholic patients with anxiety and/or depression.
2. Psychotic depression, including manic-depressive illness
(depressed type) and involutional melancholia.
Clinicel Use-Controlled clinical trials have confirmed that Sinequan
is an effective psychotropic agent with antidepressant and anxiolytic
properties. Sinequan has been found useful in alleviating manifest
anxiety in neurotic patients including those with somatic disorders. It
has also been found useful in patients with neurotic depression in-
cluding those with mixed anxiety and depression. Patients with endo-
genous or psychotic depression including manic-depressive illness
(depressed type). and involutional melancholia. have also been re-
ported to respond favourably to Sinequan. As adjunctive medication,
it appears to benefit some alcoholic patients with chronic anxiety and
depressive reactions.
As with most psychotropic agents, some patients with these condi-
tions who have failed to respond to other appropriate medication, may
benef it from treatment with Sinequan. In psychoneurotic patients the
following symptoms have responded significantly to doxepin: anxiety,
tension, depressed mood, somatic concern, guilt feelings, insomnia.
fear, apprehension. and worry. Its anxiolytic effect occurs promptly,
while onset of the antidepressant effect is delayed and can usually be
expected atter 10 days or more of treatment.
Dosgeand Administration-An optimum daily dosage of Sinequan
depends on the condition which is being treated and the response of
the individual. Some patients respond promptly: others may not res-
pond for 2 weeks or longer. An initial dosage of 25 mg. t.i.d. is recom-
mended in most patients. This dosage should be increased as required
by 25 mg. increments at appropriate intervals until a therapeutic
response is obtained. The usual optimum dosage range is 100-150
mg. per day. n some patients, up to 300 mg. per day may be required,
but there is rarelyany benef it to beobtained by increasing thisdosage.
In elderly patients it is advisable to proceed more cautiously with
dosage increments and to initiate treatment with a lower dosage.
Once a satisfactory therapeutic response has been obtained, it is
generally possible to reduce the dosage and still maintain this effect.
ContraIndicatlons-Sinequanis contraindicated in individuals who
have shown hypersensitivity to the drug.
It is not recommended for children under 12 years of age, since suf-
ficient data on its use in this age group is not yet available.
Becauseof itsanticholinergicactivitySinequan should not bead-
ministered to patients with glaucoma or a tendency to urinary
retention.
Tricylic agents are generally contraindicated in patients with a history
of blood dyscrasias and severe liver disease.
Sinequan should not be administered concomitantly with MAO inhi-
bitors, since such a combination may cause a syndrome of intensive
sympathetic stimulation. Drugs of this type should be discontinued
at least two weeks before instituting therapy with Sinequan.
Procautons and Warnings-Although animal reproductive studies
have not resulted in any teratogenic effect, the safety of use of
Sinequan in pregnancy has not been established and therefore it
should be used in pregnant women only when, in the judgment of the
physician, it is essential for the welfare of the patients.
Since drowsiness may occur with the use of this drug, patients should
be warned of the possibility of this occurring early in the course of
treatment, and cautioned against driving a car or operating machinery.
Combined use with other drugs acting on the central nervous system
should be undertaken with due recognition of the possibility of poten-
tiation. The response to alcohol may also be modified.
As with other antidepressant agents, the possibility of activation of
psychotic symptoms should be borne in mind.
Appropriate supervision is required when treating depressed patients,
and alternate forms of management should be considered in treating
severely depressed patients because of the inherent suicidal risk.
Tricylic agents may lower the convulsive threshold and should there-
tore be used with caution in patients with convulsive disorders.
Sinequan should be used with caution in patients with cardiovascular
disorders. At doses of 300 mg./day or above, it may block the anti-
hypertensive effect of guanethidine and related compounds.
Adverse Reactons-Sinequan is generally well tolerated. The fol-
lowing adverse reactions have been reported.
Behavioral Effects: agitation, restlessness. excitement, activation of
psychotic symptoms and toxic confusional state.
Anticholinergic Effects: dry mouth, blurred vision, constipation, and
genitourinary disorders.
CentralNervousSystemEftects:drowsiness, insomnia,extrapyramidal
symptoms.
Cardiovascular Effects: dizziness, hypootension, tachycardia.
Miscellaneous: fatigue, weight gain, increased sweating and other
secretory effects, nausea, heartburn, rash and pruritus, paresthesia,
edema. flushing. chills. tinnitus, photophobia, decreased libido.
Supply-Sinequan is available as hard gelatin capsules containing
doxepin hydrochloride equivalent to 10. 25 and SO mg. of doxepin in
bottlesof 100and 500.
ltrademar.k authorized user
f PHARMACEUTICAL DIVISION
60 PLACE cREMAZIE.MONTCEAL 351. OttEEC
But it did seem that new faces and
voices were forever replacing those
which I had just begun to recognize!
Sense of Abandonment
There was only one occasion when
I had the uneasy feeling that I was left
'in limbo' by the hospital staff. This
occurred when I was taken for X-rays.
In pain, I left the nurses who had been
attending me and who, I felt, under-
stood my condition and situation and
was taken by an unfamiliar attendant
to the X-ray Department. Here I
became a numbered patient in a sort
of staging area (which was really a bay
in a busy hallway) in a line-up of
patients awaiting attention. There was
a 20 minute wait during which time I
began to feel depersonalized. Was I
just another IVP on a production line?
When my turn came and I was wheeled
in to find the radiologist and his
attendants, I felt like a real person
again. I would suggest as a result of
this experience that departments such
as radiology and laboratory would do
well to take a hard look at their
reception procedures. A gaily deco-
rated staging area, with soft music in
the background, and away from the
gaze and bustle of the public and staff
would be a great advance. This could
be attended by a pleasant volunteer or
nurse who could do a great deal to
allay fears, explain delays and attend
to simple, basic needs.
I also had a first-time experience in
being introduced to the use of the
bedpan. All I can do here is to re-echo
the comments we all have heard so
often from our patients - that the
bedpan is a kind of necessary evil, like
taxes, which is inevitable and painful
but must be faced with equanimity
and fortitude and then forgotten as
quickly as possible!
I found it very difficult to order
food 24 or more hours in advance. To
be able to judge one's appetite that far
ahead in health is in itself quite a feat,
but it is immeasurably more difficult
in time of illness. In this connection, I
found it almost impossible to eat in
the face of severe pain and nausea. As
a result, I feel I will be a little less
likely to push my patients to eat what
is on their trays without first investi-
gating the immediate reason for their
non-eating. There are some good
reasons for complete loss of appetite.
Companionship
I was glad that I was in a two-bed
room during my hospital stay. I
enjoyed the companionship. Beyond
this it gave me opportunity to com-
pare treatment procedures and the
attitudes of medical staff, and also to
gain some insight into the thoughts of
a non-medical person facing the same
problems as I was.
I was not aware of receiving any
special attention because I was a physi-
cians, nor did people seem wary of me.
In fact, on one or two occasions, I had
to ring more than once for attention -
just like anybody else! The roommate
I had for most of my stay was a bank
manager who ultimately underwent
surgery for a ruptured intervertebral
disc. Despite his good educational
background, I was most interested to
note how little he understood the
meaning of such terms as myelogram,
spinal fusion or degenerated disc. I am
not certain whether my explanations
in answer to his many questions
decreased or increased his fears.
Incidentally, I did not introduce
myself to him as a physician, but when
he found out a few hours later, he
seemed quite amazed that a doctor
could be a patient in hospital. Some-
how he believed that doctors could
not or should not ever become serious-
ly ill. This same concept was very
frequently expressed to me by visitors.
I wonder in this connection whether
people regard physicians as some sort
of supermen with special immunity
factors, or whether they believe that
the medical profession possesses some
secret magic potion which is reserved
for use among its members. It is
comforting to know that in an era of
public witch hunts against the medical
profession, some of the mystique of
medicine may still remain.
The Healing Team
I enjoyed immensely the many
visitors I had and they did boost my
sagging morale at many crucial times.
To a lesser degree so did cards, letters
and flowers. Visits by the hospital
chaplain were most helpful - he is a
real member of the healing team.
It was fascinating to watch this
healing team operate. At times it
seemed ponderous and inflexible, but
more often it was obviously efficient
and competent. It became alive and
had warmth because of the human
touch which was evidenced in so many
ways. I learned anew that medicine -
like nursing -is at once a scientific
discipline and a rare art; a careful
blending of highly-developed skills
with the touch of compassion. 4
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1972 75