The Doctor and the Kidney Stone

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Must doctors follow their own advice?

The issue often comes up when the obese doctor or the doctor who smokes advises a patient to lose weight or stop smoking. But I recently got to ponder the issue more personally when the severe pain of a kidney stone hit. Despite the extreme discomfort, I continued to work. But would I advise my patients to do the same?

The pain of kidney stones is distinctive because it is excruciating yet intermittent. A mixture of salts and minerals, stones form in the kidneys of susceptible individuals and often stay put, causing no symptoms. But they can cause severe pain — as severe as that associated with childbirth — when the body decides to send them out of the kidney and into the long, thin ureters that connect with the bladder.

As is often the case, the first sign I had a stone was blood in my urine. Within hours, though, I was having “10 out of 10” pain in my left flank area. I went to an emergency room, where doctors gave me intravenous fluids and increasing doses of pain medications. A CT scan revealed, as I suspected, a stone stuck in the middle of the left ureter.

It was very small, only three millimeters in diameter. This was good news. The stone would most likely pass by itself, and I would not need extracorporeal shock wave lithotripsy, a technology that uses high-energy sound waves to break up larger stones, say five to 10 millimeters in diameter, that won’t move.

But there is a downside to waiting. Even when patients drink lots of fluids, smaller stones may not pass for quite a while. In the meantime, periodic bouts of severe pain are likely to return.

This is exactly what happened to me over the next four days. Out of the blue, my flank would begin to hurt again. Although I immediately took pain pills, they took a while to start working. In the meantime, I would be moaning in agony, writhing on the floor, trying desperately to find a comfortable position.

My family was perplexed and, it should be said, a little irritated at my decision to stay the course. “Why don’t you just get it taken care of?” my wife asked.

I had my reasons. Being a physician, I always first think, “Do no harm.” I knew that as long as I did not develop a complication from the stone — most likely an infection above the obstruction — I was in no great danger. And while lithotripsy is well established and largely safe, it nevertheless has side effects, most notably bleeding, infection or, should the stone shards that are left come to obstruct the ureter, more pain. Nevertheless, I consulted with a family friend and urologist, who was willing to do the lithotripsy – just in case.

I also continued to work. Between bouts of pain, I felt totally fine and very productive. Fortunately, the pain hit only once when I was seeing a patient, and it was toward the end of the session. And on two other occasions I was able to close the door to my administrative office until the pain subsided.

I experienced my last bout of pain six days after the episode began. It was mild and in my groin, suggesting that the stone was moving down the ureter into the bladder. When I saw what looked like grains of sand in my urine, most likely the remnants of a stone that had broken up by itself, I knew the episode was over.

So was it crazy for me to go about my work and pretend to lead a normal life, when I could have gotten rid of the stone much sooner? I don’t think so. After all, 80 percent to 90 percent of kidney stones pass by themselves. In the end, I judged that avoiding lithotripsy was a huge success.

But I’m not so sure I would realistically recommend to my own patients that they wait it out and continue to work. Pain medications can dull one’s ability to think, and though I never saw patients after taking them, not everyone has a job in which it is possible to take pills, shut the door and even take a quick nap. The pain, along with the medications, can also make it dangerous to drive to and from work.

I would advise my patients with kidney stones to find a good urologist, one who is skilled at lithotripsy and surgery, but not too eager to use them. And I continue to keep myself well hydrated in the hope of avoiding a recurrence. But should another stone develop, I may again end up being another doctor telling his patients to do what he says — but not what he does.

Barron H. Lerner, M.D., a physician and historian at Columbia University Medical Center, is the author, most recently, of “When Illness Goes Public: Celebrity Patients and How We Look at Medicine.”

For more information, see The Times Health Guide: Kidney Stones.