“The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter.” -Malcolm Gladwell, Blink
The question Tim asked was simple. “Am I going to get this infection on my arm again after treatment with the antibiotics?” Tim was a long distance truck driver who had been admitted to the hospital because of poorly controlled diabetes, morbid obesity with a BMI of 57 (obesity is defined as a body mass index greater than 30 and morbid obesity as greater than 40), and redness and swelling of his right arm. Cellulitis is a common and debilitating problem in patients with obesity and diabetes. He had responded well to the intravenous antibiotics during his hospital stay and anticipated discharge home. His seemingly simple question posed an opportunity. Should I briefly explain that the inflammatory response comes from compromised blood flow and elevated sugars in the setting of the typical bacterial flora of the diabetic’s skin or should I delve into the actual cause of his cellulitis and begin the process of healing by helping him understand the connection between his behavioral choices and his physical illness? At the most basic level, it was a question of time. My scientific answer would be an acceptable response as I convinced my patient of my physiologic understanding of his problem. That could take me less than five minutes given that most patients zone out while physicians spew an array of polysyllabic words with little meaning to them. My trauma informed answer of the patient’s underlying causes of his behavioral choices leading to his morbid obesity could lead to a discussion of his emotional health. There was no telling how long that might take.
Like all patients, Tim’s story was unique. He told me a story of a personal trauma when he and his girlfriend found out that they were going to have a baby. They were sixteen years old. They both agreed that it was the right thing to bring the baby into the world. The trauma came when both families emotionally abandoned the two expecting parents. Tim remembers feeling completely isolated from his support system. Because of their ages, the court appointed a guardian for the case for two years until they reached eighteen. Tim readily understood the difficulty placed on both families with the circumstance posed by the pregnancy. However, he never imagined that he would be left alone to start his family without any help from the ones that he thought were his base. He and his girlfriend remain married to this day. Their lives had additional trauma when they lost a young adult son from sudden death. The son also suffered from obesity. Tim and his wife supported each other in the loss but thoughts of abandonment crept back into his life. He readily accepted the fact that eating was his means to manage his emotional trauma. His insight came quickly. I gave him a few simple goals regarding his dietary choices as a long-distance truck driver. I shared my cell phone number and asked him to text me with his progress over the next few weeks. Our conversation took about twenty minutes.
Once we made a connection based on trust, his mind was engaged. He believed he could regain the self-respect that he lost during his periods of abandonment. He was glad to know that he had the tools to make better choices about his dietary discretion on the road. He was excited that he had a chance to stay in contact with me about his progress. He was down eleven pounds in two weeks. With a few words of encouragement and an open invitation to stay in touch, we agreed to text again soon. I got a message from him three weeks later that he was down thirty-three pounds. He used no medications for his weight loss. He had made the connection between his emotional health and the behavioral choices leading to poorly controlled sugars and cellulitis. It wasn’t my knowledge that changed his course. He had gained understanding. Our society has developed institutions of knowledge. There are few better examples than the profession of medicine. However, given the impact of understanding, shouldn’t we cultivate that as well? Do we have institutions of understanding? We have all heard that time is money. We all know about the limitations of time in our healthcare delivery system. Nevertheless, if understanding comes, in part, with time and a lack of understanding creates chronic, costly health problems, we need institutions of understanding. Like Tim, I have a simple question as well, “Can we afford not to?”
About the author:
Dr. James H. Mooney, M.D. is a Hospitalist physician in central Ohio who explores the connection between a person's emotional and physical health.