What is Reality?

I have realized in my 10th year of practice that a significant part of what I do, or at least try to do, is see reality for what it is. Making a proper diagnosis in the shoulder is simply the ability to see what is causing someone’s pain. Recommending reasonable treatment options is simply a process of seeing the possibility of a better future and identifying ways to make that possibility a reality.

The problem is that people do not like reality. People want to continue living in their fantasy land, where there is no such thing as pain and you can eat ice cream without gaining weight. I really hate being the guy that has to introduce people to reality, despite their insistence that I join them in their fantasy world and treat their shoulder problem based on the metaphysical laws that govern their world.

Seeing reality is hard. Accepting reality is even harder. It is most likely a reality that a rotator cuff repair takes approximately 6 months to heal. After repair, patients spend 6 weeks in a sling doing nothing with their arm. After coming out of the sling, they are allowed to “move it but not use it” — this means no pushing, pulling, or lifting anything for 3 months after surgery. At 3 months they START going back to light daily activities, and if they have regained their full motion they can start adding some resistance exercises to their rehab. This is why it is so important to be as judicious as possible with our recommendations for surgery — it is no fun to recover from a rotator cuff repair.

It is not unusual at all for me to have to talk to patients both before and after surgery about the difficulties of their reality. I think this is an important part of what I do because it is so tempting from their perspective to reject reality. It is much easier to think that you can get a rotator cuff repair and go back to your physically demanding job after a month or two. This is not reality. Reality is that “feeling good” may be the reason that you end up overexerting yourself and compromising the integrity of a tendon repair that could have healed if you took it slow.

One of my patients reminded me recently that there is a difference between compliance and adherence. The first one is the patient’s willingness to do as they are asked, and the latter is the patient’s ability to actually follow through. My friend and PCP, Dr. Ehab Sorial, can attest to the fact that I am poor at both. This is one of the reasons I am sensitive to my patients’ needs to be walked through the undestanding gap, the motivation gap, and the action gap that must be closed before compliance and adherence are likely to become a reality.

Before we get to a list of things that keep us from seeing reality more clearly, I want to share a metaphor that helps me to conceptualize clarity in the face of complexity. I like to think of reality as a giant stadium, but instead of sitting in a seat you have to look through a porthole approximately the size of your face. It’s made of a kaleidoscope lens through which you get to see what is happening inside the stadium. Perhaps you are trying to watch the best soccer match of all time, and you are barely making out the motion of the players on the field, constantly turning the kaleidoscope trying to track in your mind a 3D image of what is happening based on fragmented pieces of a 2D projection.

One way to see reality better is to make your window into reality more clear by trading out your kaleidoscope for one with better optics or larger fragments. Another way to see reality better is to ask other people what they see through their kaleidoscope. It is very very hard to look through someone else’s window, and even if they describe it perfectly, it is hard to truly understand what they are seeing. Their viewing angle of the stadium is different. The pattern of their kaleidoscope is different, so just as you were getting used to yours, they were getting used to theirs, and neither of you is able to quickly adjust to each others way of seeing reality.

Perhaps this comes to a shock to some of you that your idea of reality is not infallible. Perhaps this serves as a gentle reminder that even if you are an expert on something, your idea of reality is still an approximation. You can resist this reality, but just because you have a fantasy of infallibility, this does not make you infallible. This brings us to our list of things that we confuse for reality:

1. Our Ego — we do not see reality for what it is because we do not want to; instead, we want to live out our fantasy in which we are invincible and everyone else is weak. “Yes, yes, someone else might need 6–12 months to recover from a rotator cuff repair, but I’ll be back at work in 2 weeks.”
2. Money — we think that money is real, but it is simply an medium of exchange for more meaningful needs. “I cannot be out of work for 6 months, I need to make money” is a tangible concern for many people that live paycheck to paycheck. However, the 55 year old manual laborer that intends to work for another 10 or more years needs the shoulder to be great for 9.5 years, not just the first 6 months of those 10 years. If their shoulder problem was not affecting earning potential, they probably would have not seen me in the first place. What it comes down to is that money in this person’s case is a proxy for self worth. “If I am not earning money, then I am useless.” I do not at all mean to trivialize the financial challenges of undergoing surgery, but these difficulties have to be extracted from the false idea that you are less of a person when you are recovering from surgery because you are not being productive.
3. Pain — we think that pain is something that can be measured and put on a scale from 1 to 10. Pain is actually an abstract notion and more of an experience than a piece of data. This is why a pain scale is unreliable, since one person’s 6/10 is another person’s 15/10. Yes, patients do tell us their pain is 15/10, and no, this does not make sense. This is what I mean when I say that pain is something that you experience not something that you measure. We have to translate what people say about pain as a piece of a larger puzzle because context is what helps to make sense of any complex experience.
4. Frustration — we think that frustration is something that needs to be treated, but it is actually a function of dwelling in the past. Oftentimes, I’ll be talking to the patient about what their problem is and what we could do about it, and all they want to do is relive and recite the litany of their traumatic event. We have to be sensitive to this and offer a compassionate ear, since sometimes your shoulder surgeon is the first person to ask “have you actually sat down to process the emotions of what happened to you?” Having at least planted the seed of the need to heal emotionally as well as physically, we must move on to recognize that there is nothing I can do physically to your shoulder that will alleviate the frustration you have about what happened.
5. Anxiety — just as frustration is a function of dwelling in the past, anxiety is a worry about what will happen in the future. I had this conversation with a patient just yesterday that the only thing I can do is treat his shoulder in the present. I cannot foresee or prevent what may happen to him in the future. Are there preventive measures that we can take that minimize the chances of failure? Sure. Are there best practices and ways to optimize someone’s great result to “future proof” it as much as possible? Sometimes. Is it possible to guarantee anything? Definitely not.

This is not an exhaustive list of false realities, and each of these can be its own separate article. Maybe I will add to the list. Maybe you will make suggestions on what I can add. Maybe we will see reality better together.