Mary, I just wanted to say how impressed I am by your ability to contextualise complex medical concepts for us all to understand in this storytelling. Your explanations translate what many doctors don't have time to walk through, whether it's an EKG or GFR, kidneys and blood work. Thank you.
My Dad had congestive heart failure and when it was destabilised in 2015 he had a complex case of oedema, compounded by effects of his rheumatoid arthritis meds on his kidneys..I massaged his legs, but he constantly felt like he had 'ants under his skin', as the oedema fluctuated. We're lucky to have your empathetic explanations.
I love how you always sneak in a good extended metaphor...this one being that the kidneys were feeling slapped around and bullied into doing something and that Lilly didn't respond well to that kind of approach...so you took the opposite. You are a highly intuitive doctor and a sensitive soul who reads people exceptionally well.
Your opening comment about asking Lily how she was doing and her being a little bit snippy really resonated with me. I volunteer at a clinic where I am the front desk receptionist. I’ve learned not to ask people how they are doing. I just say “ welcome Mr. so-and-so it’s nice to see you today. “. Otherwise I get a litany of issues for which I have no answer. 🤪
It's funny because I really do want to know how my patients are when I ask, Evie! I'm not just being polite, but I can imagine it's really hard to hear a list of problems you can do nothing about!
I look forward to hearing more about Lily. I appreciate the way you have to stop yourself from saying what you are thinking in order to phrase things in a way she would be more likely to accept. It really is an art to be able to do that. You are also helping me to understand things I’ve either long forgotten or have never known, like GFR. As we age, it helps to have clarity on what’s happening -or not-to our bodies.
Loved this article and was surprised at your very vulnerable post on Sensible Medicine. Being a cancer survivor, I cried a little when I read it. Blessings to you 🙏🏻🥰
Well now I’m hooked…I have cautious hope for Lilly - she reminds me of many former patients, except I treated chronic non cancer pain and addiction - contrary to the “experts’” opinions back in the days of Porter and Jick, pain treated with opioids does not exclude addiction in many cases. Your quote “Giving her water pills without understanding her kidneys was a bad idea.” is as true for opioids, especially in this day of “opiate replacement” (I call buprenorphine millennial methadone due to the fact that it’s given with no treatment these days…bad idea). Giving any med without education has likely caused a great many problems over the years! I love how you educate to the patient at hand; that’s an art and a gift.
I have following the saga of Lilly. Every post I read I find myself wondering if she would be as “contrary” if you were a male doctor? Of course she might not have gotten such understanding care.
Lilly is fictional. I can attest that Mary's editor has pushed her to make Lilly contrary. Giving the fictional patients difficult personalities allows Mary to highlight what she must do to have successful interactions with patients, and it makes the short stories more engaging.
We ensure that there is no direct correspondence between the fictional patients and any real patients. The fictional patients are amalgams, not only of patients, but also of some other people Mary knows. Furthermore, their specific actions are carefully crafted to illustrate common medical issues and what it's like to be in the doctor's shoes, while also being entertaining. While Lilly is Mary's invention, some of her contrary behaviors have been my suggestions to make not only Lilly more interesting, but also what Mary has to do for a patient like Lilly more interesting.
Either it's Mary's excellent writing or your excellent editing or both, but the patients feel very real. I suspect that's why we all want to know what happens to them, even though we know they are an amalgam. Thanks to both of you for the lovely informative posts.
The patients feel real because Mary has lots of experience with patients, but they are carefully crafted to be fictional. One cannot post information about real patients on Substack and keep one's medical license.
As the patients are fictional, Mary doesn't quite know what they're going to do next. I asked her last night what was going to happen to Lilly, and except for a couple of things, she hadn't decided yet. I probably won't see a rough draft until Thursday.
Doug, I'm also a physician of several decades, so I completely understand and agree re:patient confidentiality. Mary has such a talent for creating the fictional patients that make them enjoyable to follow. They would be awesome case studies for a medical school...brings the learning to life, as it were.
It's so nice to know you take the time to explain her condition in a way she can understand. Renal failure can be a hard concept. My dad had kidney failure, on hemodialysis. One Sat he was very sick needing emergent dialysis. When I brought him in, he was coughing a lot with SOB. He told them it was a sinus infection, and they prescribed a decongestant. I couldn't believe they did that. Even I knew many years ago as a nursing student it was HF. But, after the CXR, they knew. And , yep, 1st thing my dad did after dialysis was head to his neighborhood tavern for a couple of beers...and the cycle started again.
I agree, Kathy, renal failure is a tough concept to explain and it's not helped by the fact that kidneys can fail quietly with no specific symptoms. I could tell an interesting story or two, but will hold on to them for future essays.
This is medicine at its best. Taking time with a patient, explaining how things in a way they can understand, treating the whole person not just the symptoms and listening to what they say (and don’t say) is rare yet essential. You’re lucky that you work where you do and your patients are lucky to have you.
Thanks for this. It’s helpful in understanding what’s happening to my body.
Ever since I started a diuretic, my GFR has been declining. I’ve tried to skip it in the past, but the “bloated” sensation which results makes exercising (and just moving) uncomfortable.
I’ve been a jock all my life, but in the past six months I just haven’t had the energy. When I manage to force myself to exercise, my heart beats too fast and I can’t seem to catch my breath. As a result of being inactive, my BNP has doubled (830).
The diuretic definitely makes me feel and function better, but now I understand that it’s wrecking my kidneys.
Please, please, have this discussion with your doctor! You can't extrapolate from Lilly taking a very large dose of a water pill she had around the house and injuring her kidneys to what your doc is doing with you. Ask your doc how much, if any, of Lilly's situation applies to you.
Your primary care doc knows you, your medical history, your resources, your preferences, and beliefs all of which are probably different from Lilly's. Doctoring Unpacked is not medical advice.
The heart/kidney relationship is infinitely more complicated than you've laid out and than we have described for Lilly so far. The short description is that it's all a balance. As you've probably already figured out, this situation is difficult to treat, with many nuances.
It is tough to go from being a jock to feeling like you've described. I am confident that your doc can help!
Everyone knows the "kill your darlings" line, but it's painful when it's your own darlings, especially your darlings that you've worked very hard to make clear.
Mary, I just wanted to say how impressed I am by your ability to contextualise complex medical concepts for us all to understand in this storytelling. Your explanations translate what many doctors don't have time to walk through, whether it's an EKG or GFR, kidneys and blood work. Thank you.
My Dad had congestive heart failure and when it was destabilised in 2015 he had a complex case of oedema, compounded by effects of his rheumatoid arthritis meds on his kidneys..I massaged his legs, but he constantly felt like he had 'ants under his skin', as the oedema fluctuated. We're lucky to have your empathetic explanations.
I love how you always sneak in a good extended metaphor...this one being that the kidneys were feeling slapped around and bullied into doing something and that Lilly didn't respond well to that kind of approach...so you took the opposite. You are a highly intuitive doctor and a sensitive soul who reads people exceptionally well.
YIKES!!!!!!
Thank you, great explanation. I can certainly use this to explain a few things to my other half.
I really enjoy your work, thanks for sharing it. We don’t hear enough from regular doctors working with regular folk.
Thank you for continuing the story. I await the next installment.
You are welcome, Ree Gee. I'm so glad you enjoyed it!
Your opening comment about asking Lily how she was doing and her being a little bit snippy really resonated with me. I volunteer at a clinic where I am the front desk receptionist. I’ve learned not to ask people how they are doing. I just say “ welcome Mr. so-and-so it’s nice to see you today. “. Otherwise I get a litany of issues for which I have no answer. 🤪
It's funny because I really do want to know how my patients are when I ask, Evie! I'm not just being polite, but I can imagine it's really hard to hear a list of problems you can do nothing about!
Yes in your position it is much more appropriate than for the front desk receptionist, for sure.
I look forward to hearing more about Lily. I appreciate the way you have to stop yourself from saying what you are thinking in order to phrase things in a way she would be more likely to accept. It really is an art to be able to do that. You are also helping me to understand things I’ve either long forgotten or have never known, like GFR. As we age, it helps to have clarity on what’s happening -or not-to our bodies.
Thank you, Cindy! I had a long explanation about GFR and creatinine in the deleted one thousand words, lol.
I read once that pediatricians and veterinarians are the only doctors whose patients don’t lie to them.
That's funny, Tom. I've never heard that before, but it does make sense.
Loved this article and was surprised at your very vulnerable post on Sensible Medicine. Being a cancer survivor, I cried a little when I read it. Blessings to you 🙏🏻🥰
Thank you, Donna. I'm so glad you're enjoying Lilly. She seems to have struck a chord with a lot of people.
And thank you for letting me know about the Sensible Medicine post.
Thank you and you, too!
Well now I’m hooked…I have cautious hope for Lilly - she reminds me of many former patients, except I treated chronic non cancer pain and addiction - contrary to the “experts’” opinions back in the days of Porter and Jick, pain treated with opioids does not exclude addiction in many cases. Your quote “Giving her water pills without understanding her kidneys was a bad idea.” is as true for opioids, especially in this day of “opiate replacement” (I call buprenorphine millennial methadone due to the fact that it’s given with no treatment these days…bad idea). Giving any med without education has likely caused a great many problems over the years! I love how you educate to the patient at hand; that’s an art and a gift.
Thank you, Jim. I'm excited that you're hooked! I am worried about Lilly and also hopeful, too.
Having an addiction *and* chronic pain is at least ten times more complicated than either condition alone and both are very complicated on their own.
I have following the saga of Lilly. Every post I read I find myself wondering if she would be as “contrary” if you were a male doctor? Of course she might not have gotten such understanding care.
Interesting question, Martha. I suspect Lilly would not have returned to the care of a male doctor, but I don't know.
Lilly is fictional. I can attest that Mary's editor has pushed her to make Lilly contrary. Giving the fictional patients difficult personalities allows Mary to highlight what she must do to have successful interactions with patients, and it makes the short stories more engaging.
Well, yeah, of course. The doctor has said that. But I’m making a wild guess here that the stories are based on real patients…
We ensure that there is no direct correspondence between the fictional patients and any real patients. The fictional patients are amalgams, not only of patients, but also of some other people Mary knows. Furthermore, their specific actions are carefully crafted to illustrate common medical issues and what it's like to be in the doctor's shoes, while also being entertaining. While Lilly is Mary's invention, some of her contrary behaviors have been my suggestions to make not only Lilly more interesting, but also what Mary has to do for a patient like Lilly more interesting.
Either it's Mary's excellent writing or your excellent editing or both, but the patients feel very real. I suspect that's why we all want to know what happens to them, even though we know they are an amalgam. Thanks to both of you for the lovely informative posts.
The patients feel real because Mary has lots of experience with patients, but they are carefully crafted to be fictional. One cannot post information about real patients on Substack and keep one's medical license.
As the patients are fictional, Mary doesn't quite know what they're going to do next. I asked her last night what was going to happen to Lilly, and except for a couple of things, she hadn't decided yet. I probably won't see a rough draft until Thursday.
Doug, I'm also a physician of several decades, so I completely understand and agree re:patient confidentiality. Mary has such a talent for creating the fictional patients that make them enjoyable to follow. They would be awesome case studies for a medical school...brings the learning to life, as it were.
It's so nice to know you take the time to explain her condition in a way she can understand. Renal failure can be a hard concept. My dad had kidney failure, on hemodialysis. One Sat he was very sick needing emergent dialysis. When I brought him in, he was coughing a lot with SOB. He told them it was a sinus infection, and they prescribed a decongestant. I couldn't believe they did that. Even I knew many years ago as a nursing student it was HF. But, after the CXR, they knew. And , yep, 1st thing my dad did after dialysis was head to his neighborhood tavern for a couple of beers...and the cycle started again.
I agree, Kathy, renal failure is a tough concept to explain and it's not helped by the fact that kidneys can fail quietly with no specific symptoms. I could tell an interesting story or two, but will hold on to them for future essays.
Thank you for reading and commenting!
This is medicine at its best. Taking time with a patient, explaining how things in a way they can understand, treating the whole person not just the symptoms and listening to what they say (and don’t say) is rare yet essential. You’re lucky that you work where you do and your patients are lucky to have you.
Thank you, Susan.
I do love my employer (most days, lol).
Thank you for laying out the components so nicely. What they say (and don't say) is very insightful. It's what's missing that often tells the story.
Thanks for this. It’s helpful in understanding what’s happening to my body.
Ever since I started a diuretic, my GFR has been declining. I’ve tried to skip it in the past, but the “bloated” sensation which results makes exercising (and just moving) uncomfortable.
I’ve been a jock all my life, but in the past six months I just haven’t had the energy. When I manage to force myself to exercise, my heart beats too fast and I can’t seem to catch my breath. As a result of being inactive, my BNP has doubled (830).
The diuretic definitely makes me feel and function better, but now I understand that it’s wrecking my kidneys.
This feels like a slow, sure death.
Thank you for reading and commenting, Jim.
Please, please, have this discussion with your doctor! You can't extrapolate from Lilly taking a very large dose of a water pill she had around the house and injuring her kidneys to what your doc is doing with you. Ask your doc how much, if any, of Lilly's situation applies to you.
Your primary care doc knows you, your medical history, your resources, your preferences, and beliefs all of which are probably different from Lilly's. Doctoring Unpacked is not medical advice.
The heart/kidney relationship is infinitely more complicated than you've laid out and than we have described for Lilly so far. The short description is that it's all a balance. As you've probably already figured out, this situation is difficult to treat, with many nuances.
It is tough to go from being a jock to feeling like you've described. I am confident that your doc can help!
Please keep writing. That’s what we writers do. We write.
Thank goodness you have an editor. It’s easy to get too attached to our carefully crafted phrases.
You gave a very good explanation to Lilly. Just remember, writers need good editors.
Thank you.
Everyone knows the "kill your darlings" line, but it's painful when it's your own darlings, especially your darlings that you've worked very hard to make clear.