Jarrod Shapiro, DPM
Patient Heal Thyself

Remember that old proverb, "Physician, heal thyself"? I was interested to learn this phrase comes from the New Testament, specifically Luke 4:23.

The omniscient Wikipedia states, "The moral of the proverb is counsel to attend to one's own defects rather than criticizing defects in others... "¹

It’s fair to say that there is also an alternative modern interpretation that pertains in a more literal sense to doctors. In Latin Cura te ipsum urges physicians to maintain our own health prior to treating patients. I picture this as similar to what the airline flight attendants tell us about securing our own air mask before that of our children in case of emergency.

Recently, though, I had one of those weeks with a confluence of events that made me think about this phrase in a different sense: we doctors need our patients to heal themselves, to help us to help them. I can’t help thinking about a much less profound source for a different quote, the movie Jerry Maguire. Tom Cruise’s character, Jerry, a down-on-his luck sports agent is trying to convince his one and only client, Rod Tidwell (played by Cuba Gooding, Jr.) to do what he needs to do to make them both successful. "Help me help you," Jerry desperately yells at Rod.

Sometimes as a physician, I feel just like Tom Cruise’s character, imploring my patients to "help me help you." Let me give you an example of what I mean.

A while back, I performed an emergent amputation on a diabetic patient. After an uneventful recovery, I referred the patient back to the primary care physician for a referral to a new podiatrist (due to insurance issues). Almost six months later, I was called to see the patient again in the hospital with a new infection. During my patient’s time away, he did nothing to improve his own condition: not following up with a podiatrist, failing to keep appropriate blood sugar control, doing recreational drugs, and waiting almost a month with a brewing foot infection to see the primary care physician. The patient required a more extensive emergent amputation this time. If this patient had only taken steps to help himself, he wouldn’t have ended up in dire straights again.

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Here’s another example. I recently met a very nice patient with a stress fracture. Due to a desire to remain active, this patient experienced delayed healing and prolonged pain as a result of continuing to walk several miles per day and refusing to wear a fracture boot as prescribed. The delay in healing may have been minimized if only this patient could have adhered to prior instructions.

What about the diabetic patient with prior 5th metatarsal osteomyelitis and plantar ulcer that successfully underwent a 5th metatarsal head resection, but then experienced delayed healing of the original wound due to noncompliance with offweighting. After 15 minutes of negotiations, the patient finally acquiesced to converting his cam walker to an instant total contact cast. Within two weeks of preventing removal of his boot, the wound was completely healed.

...Or the patient with a toe wound and severe pain that continues to smoke, despite successfully undergoing an extremity bypass procedure.

There are two consistencies about this group of patients. The first is that they are not helping their doctors to help themselves. The second is that there is a reason these patients are behaving in this manner. Whether it’s hopelessness, addiction, the desire not to be inconvenienced, or something else, it’s up to us as their healthcare providers to figure out why these patients don’t help themselves. Dean Harkless of Western University’s College of Podiatric Medicine calls this the psychosocial determinants of disease.

I’ll admit that this is the single most challenging part of medicine. I can sit and listen to a patient’s story and empathize with them. But I have a much harder time converting that understanding and empathy to improved patient adherence.

I’ll end this discussion with a somewhat philosophical example. I had a diabetic patient on whom I did an emergent partial first ray amputation. As he was recovering, he used this experience to motivate him to change his behaviors. He successfully stopped smoking, controlled his blood sugar (to an incredible HbA1c of 5.5), and started exercising and eating better. It was wonderful to see a patient who took a terrible experience and used it to empower himself to make positive life changes. I have actually seen this repeatedly with partial foot amputations. I think the common podiatric amputations are just bad enough to motivate a change while not being so bad as to excessively disable patients.

Perhaps instead of making it a priority to convince our patients to do what we want, we should let their disease complications evolve in whatever way is necessary (within reason) for that patient’s own personal life path, while helping guide them to that same realization and empowerment that my successful patient found.

There’s only so much we can do and only so much control we have. I suggest we consider allowing our adult patients to make whatever decisions are necessary for them, while taking the opportunity to empower them to make positive changes whenever those opportunities arise. In this way, we are helping our patients to help themselves to help us to help them.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
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