Tuesday, December 29, 2009

A HUNDRED YEARS OF FLEXNER



When I find myself ranting that today’s healthcare is detached, impersonal, or even industrial, I sober up by recalling that its present style is only a hundred-year-old aberration.

At the turn of the last century, the enterprises calling themselves medical schools ranged from universities to carnival booths. The Illinois Board of Health reported in 1899 that while 179 American and Canadian medical schools featured some version of scientific approach, 26 taught homeopathy [evidently the Board didn't feel homeopathy was scientific], another 26 were “eclectic,” 13 “miscellaneous,” and 13 were outright “fraudulent.”

Industrialists Andrew Carnegie and John D. Rockefeller determined to convert this shaggy variety into a standardized vehicle suited to modern times. Rockefeller’s administrator of philanthropies, Rev. Frederick T. Gates, viewed the human body as the victim of virtual assault by disease. He wrote to Rockefeller,

“The body has a network of insulated nerves, like telephone wires, which transmit instantaneous alarms at every point of danger. The body is furnished with a most elaborate police system, with hundreds of police stations to which the criminal elements are carried by the police and jailed…The body has a most complete and elaborate sewer system…”
           
As a progressive of his time, Gates naturally recommended science as the basis of reformed medical education. Though he encountered little direct opposition, a few instructors expressed qualms. William Osler, professor of medicine at Johns Hopkins University and even today considered the historical patriarch of North American medicine, was one.

Though he revered science, Osler insisted throughout his career that human beings couldn’t be healed by science alone. (His best-known maxim is, “It is more important to know what sort of patient has a disease than what sort of disease the patient has.”) Osler cautioned against any change in medical education that might diminish attention to the patient. His warnings went largely unaddressed, and when he left Johns Hopkins in 1904 for Oxford University, he wrote to a colleague he considered too laboratory-oriented, “Now I go, and you have your way.”

Andrew Carnegie's Foundation for the Advancement of Teaching hired educator Abraham Flexner to critically examine American medical training. Competent and thorough, Flexner visited every medical school in the country. In his final report, issued in 1910, he recommended that curricula and methods be nationally uniform and based on science. Every medical student since then has learned during the first week of freshman year that the Flexner Report marked the birth of modern, scientific medicine, now sometimes called “biomedicine.”

After Flexner published his report, Dr. Osler, who had since been knighted, continued to predict that inordinate focus on science would likely eclipse concern for the patient. He wrote,

“The danger would be of the evolution throughout the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only human interest was research, forgetful of the wider claims of a clinical professor as a trainer of the young, a leader in the multiform activities of the profession, an interpreter of science to his generation, and a counselor in public and in private of the people, in whose interests, after all, the school exists.”

Bypassing such misgivings, money from Carnegie and Rockefeller—eventually over $100 million—established scientifically-based teaching chairs and facilities at America’s major medical schools. Unfunded institutions soon found competition difficult, and in a few years half of America’s medical schools closed. The industrialists effectively dislodged every competing style. Historically, this happened only yesterday: my own instructors received their training from students of the professors Carnegie and Rockefeller funded.

We’re in debt to Flexner for stupendous advances that ultimately helped devastate infectious disease and successfully treat other acute disorders. Yet if Flexner’s a rose, he bears the inevitable thorn, which I’ll describe in the next blog entry.


Sunday, December 27, 2009

PHYSICIANS WILL COME DOWN OFF PEDESTALS WHEN PATIENTS GET UP OFF THEIR KNEES


Dr. Martina Nicholson commented on my December 17 blog entry to the effect that she wants conversations with her patients to extend beyond the day’s chief complaint into what really matters, but there’s no billing code for that.

She resents the industrial style into which American healthcare has detoured, and I couldn’t agree more. During the past couple of generations, economic pressures have steadily morphed physicians into interchangeable cogs in a high-tech assembly line. You’ll get paid, Doc, after you’ve filled in all the blanks and fitted the patient into a billable code. And by the way, Doc, we’re reducing your reimbursements again. Healthcare’s economics are operated by distant agents who combine zero appreciation for the examination room’s subtleties with hefty incentives for augmenting profit.

Though Dr. Nicholson and I and a growing number of physicians want to "humanitize" healthcare, don’t wait for us, as the most necessary changes must come from patients. Robert S. Mendelsohn, a pediatrician, wrote in his 1991 book Confessions of a Medical Heretic, “We physicians will come down off our pedestals as soon as patients get up off their knees.”

We traditionally think of patients as passive. The doc’s the expert, and what could the patient possibly know? The doc’s the provider, the healing agent, the active principle; as the consumer, you need only to lie still in your paper gown.


If you still buy into that view, you’re short-changing yourself. Surgeon-author Bernie Siegel confirms that the feistiest patients (often labeled “difficult” by practitioners) fare measurably better than the most docile ones. “Feisty” means learning enough about your condition to ask important questions. It means demanding answers, getting second and third opinions, negotiating for exactly what you want, recruiting effective support, and continually asserting your dignity, unique selfhood, and ultimately control of your destiny.

Tuesday, December 22, 2009

THE IMPORTANCE OF FEEDBACK



Years ago, a physician I knew was in trouble with his medical staff. He wasn’t dealing with problems at home, and his consequent irritability was affecting his practice and beginning to alarm his colleagues. Many of his patients had already fled.

I asked him, “Well, what did you think when Jack S., who’s been your patient fifteen years, didn’t come to you anymore?”

“I figured he was cured.”

Healthcare practitioners can’t reliably gauge the quality of their relationship with their patients unless they hear from those very people. There’s nothing—I repeat, nothing—within standard medical practice that promotes that feedback. It's entirely up to patients. (There are exceptions, such as the Kaiser Permanente system, which bases physician remuneration partly on patient satisfaction surveys.) The general bottom line is that your relationship with your doc is largely in your hands.

This blog’s December 11, 2009 entry tells the story of a woman with an excruciating facial nerve irritation who was hoping an impending tooth extraction would relieve it.

The oral surgeon she consulted said, “No, it won’t make any difference.”

Shaken, the woman asked, “How do you know?”

The surgeon replied, “If I’m wrong, I’ll put on a cheerleading costume and wave pompoms.”

If you wondered about the rest of this story, it has since unfolded.

The woman returned home, depressed. When she told her dentist what had happened, he advised, “You can't have him do your surgery.” He helped her get an appointment with another oral surgeon, whom she found supportive. After this surgeon removed the tooth, the woman’s nerve irritation plummeted, and it’s likely she’s permanently cured.

The woman wrote two letters. One was a warmly commendatory one to her dentist, thanking him for his help and especially for his compassion.

The other letter, to the offensive surgeon, was politely critical. She wrote that when he entered the room he failed to introduce himself, that during their six minutes together she found him arrogant and demeaning, and that he ended the meeting by summarily leaving without a word. There was no way, she wrote, that she could let him lay a hand on her.

A week later, she received his consultation bill in the mail.

“Ha!” she said. “Pay him for that abuse? He’s gotta be kidding.”

Then, thinking it over, she decided maybe she would hand him a check if he’d show up at her door in a cheerleading costume, waving pompoms.


Thursday, December 17, 2009

THE REAPER BATS LAST



On a run this morning, I met an old friend. “Old” means he’s older than I am.

He said, “My wife and I have been struck by how many people we know are getting seriously sick or dying. I guess it comes with aging. Anyway, we’re beginning to talk with each other about our own deaths. You know—wills, powers of attorney, unfinished business.”

Good for them. And good for me, too. We’ve been discussing death and dying in our family for years. I’ve seen again and again that keeping it taboo begs trouble: family donnybrooks at the bedside, recriminations, litigation, misery no one needs.

Some part of each of us, I think, has bought into the notion that space-age medical intervention can snatch us perpetually from the grave. Add to that our personal, built-in, lifelong, tenacious denial of death, and little wonder we come to feel, however irrationally, that we’re entitled to immortality. William Saroyan’s last words were, “I know we all have to die, but I thought maybe in my case they’d make an exception.”

So it is that we conveniently ignore that The Reaper bats last, and direct our healthcare practitioners to apply heroic measures at the end of life, especially when we don’t pay for it ourselves. Medicare, the health insurance program for the elderly, spends nearly thirty percent of its budget on beneficiaries in their final year of life.

People who are dying are sicker than other patients, so spending more on their care is understandable. But for most reasonable purposes those efforts are futile, and predictably so. Medical science can indeed prolong life, but that too often amounts to prolonging suffering. In palliative circles, practitioners discuss this metaphorically, asking “whether the game is worth the candle.” In actuality, there’s usually no game left at all, since attention focuses exclusively on just trying to keep the candle lit.

Talking in advance about death and dying issues makes a tangible difference. Reporting last March in the Archives of Internal Medicine, investigators interviewed 603 advanced-cancer patients about whether they’d had end-of-life (EOL) conversations with their physicians. The researchers calculated the final week’s healthcare costs of patients who’d had such conversations, and compared them with the costs incurred by patients who hadn’t.

Those who’d had an EOL conversation had an average of $1,876 in health care expenses during their final week of life, compared with $2,917 for those who hadn’t, a difference of $1,041, or 36 percent. Higher costs—typically the result of more intensive, life-prolonging care—were also associated with a worse quality of life during patients’ final week. In addition, patients typically did not live longer if they received more intensive care.

Let’s go over that again: extreme medical intervention evidently results in lower quality of patients’ remaining days, doesn’t actually extend their life, and is hideously expensive. Wow, where does the line form?

A couple of months ago, I asked my cancer support group whether everyone had a Durable Power of Attorney for Healthcare. They all did, but I found to my chagrin that I couldn’t find my own. So my wife and I hustled up some new ones. We each named the other as our primary agent, authorized to make medical decisions if we're incapable.

Choosing an agent can raise fascinating questions. I imagined myself in an ICU bed, for example, apparently comatose but actually able to hear. My doctor tells my wife we’re in the home stretch at this point, so asks for her orders—whether to do even more, or, as popular terminology has it, “pull the plug?”

She answers the doctor, and I think, “Whoa! Wrong decision.”

But of course, I’m unable to speak. Scary.

But wait a minute. How do I know she’s made the wrong decision? I can’t know that I’m “right,” whatever “right” means; I know only my preference. Since I have nothing else to do at that moment, I review our history together. How many times has her judgment been superior to mine? Pretty damn often, actually. Haven’t I learned to literally trust her with my life? In addition, when, after all, can I simply let go?

Questions like these can elicit emotion and sometimes argument. They’re plenty meaty, extending as they do from the ultimate source of most fears, death. No wonder we shy away from them. One indication of how fearsome the subject can be is that in one national healthcare reform proposal, doctors would be paid to have EOL conversations. Many Americans came unglued at the prospect of discussing death, and chose to interpret the proposal's provision as "death panels."

Though doctors are increasingly trained these days in end-of-life issues, many don’t routinely initiate conversations in that area because, frankly, they’re not paid to do so. They get paid for procedures—spinal taps, liver biopsies—but not for just talking with patients. Paying doctors to hold these conversations would save millions if not billions of dollars and an untold amount of needless suffering.

Authentic healthcare reform then, needs to acknowlege, appreciate and address our widespread fear of death and dying.

Wednesday, December 16, 2009

MAKE THE OPENING


Commenting on my December 15 blog entry, a reader (something tells me not to publish readers’ email addresses) said...


“So good to hear your words. In the past 7 months I have had 3 surgeries (mastectomy, port installation, and breast reconstruction)and chemotherapy. What means most to me are the kind touches and words from the medical staff, and a hug I got from my plastic surgeon. I find that the medical staff do want to hug but I have to make the opening for that to happen, and I will continue to do so.”

As for the healing value of kindness, I rest my case.

The reader adds the point that some practitioners want to hug, but seem to need permission from the patient. I’ve written here about medical people feeling they need to maintain a detached, “scientific” persona, an attitude that opposes spontaneous warmth. That’s not healing for patients, and decidedly unhealthy for practitioners themselves. I’m reminded of a therapist in Berkeley some decades ago who stapled the poster for his men’s groups all over town. It displayed a photo of boys at the beach around 1900, vying to show off the hugest biceps. His caption was, “Tired of holding that pose?”

I think the reader raises another issue, too. Well-publicized and often justified litigation has left many of us afraid to touch one another. Teachers are wary of hugging their students, and bosses their employees. Physicians can fear that their warmth toward patients might be erotically misinterpreted, and so hold back.

Yet medical practitioners, fully as human as patients, need and deserve TLC. The reader writes, “…I have to make the opening for that to happen, and I will continue to do so.” Reader, you’re my Hero of the Day.

Tuesday, December 15, 2009

TWO ROADS DIVERGED IN A WOOD…



I embarked on the doctor path when I was nine years old. I was miserable for a week with a throat infection. In those days, doctors made house calls. Ours sat at my bedside that evening, took my temperature, peered down my throat. I had no way of knowing he was searching for enlarged lymph nodes when he palpated my neck; with my kid’s mind, I assumed doctors made people well by touching them. I don’t remember the penicillin injection I’m sure he gave me, but I clearly recall that when he touched me, my pain vanished. Magic! I had to learn this.

Medical schools wisely ask applicants about their motivations. The ones who answer, “I want to make heap big bucks” or, “I enjoy wielding power over naked people” don’t often make the short list. Nor do the ones who muse, “I want to learn magic.” Even as na├»ve as I was, I gave the preferred answer, also sincere, which was that I loved science and wanted to help people.

Orienting us on our first day, the dean listed the classes we’d take: anatomy, physiology, pharmacology, cytology, biochemistry, public health. Something wobbled inside me. Nothing but science? When do I learn how to touch people to make them feel better? Do they teach magic in the second year, maybe? Or on the wards? Before I was foolish enough to raise my hand, my guardian angel had me whisper my question to the student beside me.

“Magic?” He screwed up his face. “Did you say ‘magic?’”

Ooooo. “Well, er, maybe not, um, magic, but you know, like, well, ah, the doctor-patient relationship, and being with patients, and…”

Today that student is a successful psychiatrist who showed therapeutic promise that morning by telling me, “Hey, look, buddy: there’s no magic. It’s pure science. Get used to it.”

I got used to it. Along with my classmates, I absorbed the standard avalanche of information. Afterward, practicing in a variety of settings, from the National Institutes of Health to county hospital emergency departments, my silent question continued to pester me: where’s the magic?

Come now, I told myself, here you are, a grownup, a medical doctor, a trained scientist, longing for magic. Did I mean to dispense talismans and cast off curses? It was so difficult even to phrase a reasonable question that it crossed my mind that I was I losing it.

Providence intervened in the form of a film, “Diner” (I highly recommend it; rottentomatoes.com scores it 96%), about a pack of callow male adolescents in Baltimore. Two of them have lascivious designs on a wealthy young woman. She finds them repulsive and has twelve times their brains. She arranges for the guys to be stranded in a bleak, remote pasture late one moonless night.

Grimacing, one turns to the other and asks, “Didja ever think maybe there’s stuff going on that we don’t know about?”

Well, didja? I began asking questions: might there be more to medical practice than what I was trained to notice? Is there, say, some connection between the way people lead their lives and how they get sick? If there is, why don’t we examine their lives along with their lungs? Do people experience sickness uniformly or uniquely? How much can the sick contribute to their own healing? Can the placebo effect be initiated voluntarily? Is there actually a way to touch people so they heal? What do we mean by “healing,” anyway? When is it okay to die? All in all, what exactly is healthcare's mission—to diagnose and treat disease, or to treat the person, in addition? And what does “treat the person” mean?

You can't keep asking such questions without ultimately finding yourself in that bleak, remote pasture late one moonless night. But at least I could dimly see the “Two roads," as Robert Frost put it, that "...diverged in a wood…”

I left standard medicine in order exclusively to facilitate cancer support groups. There are no miracle cures here, nor raising of the dead. In fact, very little changes in the material world. What changes dramatically is people’s attitudes and, subsequently, their experience. It reminds me of when my doctor touched my nine-year-old aching throat. My fever and lymph nodes remained just as abnormal, but I’d felt better. Magic.

Friday, December 11, 2009

IF I’M WRONG, I’LL PUT ON A CHEERLEADING COSTUME


It never fails to astonish me that some clinicians don’t comprehend that they’re dealing with whole people, not sacks of deranged enzymes.

I hear of—and have seen personally—physicians, nurses, dentists, and others treat vulnerable sick people in styles that fall between insensitivity and abuse.

A couple of examples. I know at least three people with cancer who were told of their diagnosis by messages left on their answering machines—all, by the way, on Friday afternoons, leaving them to quake in anxiety and fear through the weekend.

Another woman, waiting in an emergency department for test results, was asked by a nurse, “How long have you known you have cancer?” Well, she hadn’t known she had cancer. Later, the nurse apologized, and weirdly added, “Gee, I do that all the time.”

A woman with an excruciating nerve irritation was hoping an impending tooth extraction would relieve it. Her oral surgeon said, “No, it won’t make any difference.” Shaken, the woman asked, “How do you know?” The surgeon replied, “If I’m wrong, I’ll put on a cheerleading costume and wave pompoms.”

I tend to believe these stories because I’ve acted that way myself. When you’re a young practitioner, insecure in your role, it feels important to know a lot and to be right. So you often give patients information without considering its emotional implications. That’s understandable, since young adults’ own suffering is usually a distant future abstraction. To them, advanced arthritis means walking twistedly, period. How can they appreciate the disease’s effects on relationships, energy, self-image, hopes? A friend recently told me, “I’d thought getting older just meant getting older. I didn’t know it meant disintegrating.”

So younger practitioners deserve the benefit of the doubt. But how about people who’ve been in practice three decades? Chances are they’ve been sick themselves, have had experience with depression, divorce, financial disappointments, deaths in their families. Most learn through their own suffering to treat sick people as they’d like to be treated. Thus the venerable archetype of the “wounded healer.” My favorite oncologist, when asked by patients whether they’re going to die from their cancer, answers honestly, “I don’t know. I do think you’re going to live with this cancer the rest of your life.”

A fact can be expressed in many ways. Some ways offer the strength to go on, and others can utterly destroy it. When someone says, “I don’t want to offer false hope,” I can’t help but suspect they offer false hopelessness in its place. Hope doesn’t have to be the promise of cure and immortality. As Vaclav Havel, the former prime minister of the Czech Republic, put it, “Hope is not the conviction that something will turn out well, but the certainty that something makes sense regardless of how it turns out.”

What, after all, is The Truth? The longer I hang around, the more surprises the world waves at me. Every year I’m less certain about predicting anything. But one thing I’m very, very sure of is that sick people ought to leave medical encounters feeling better rather than feeling worse.

Wednesday, December 9, 2009

CHEWING THE FAT



What does “preventive medicine” mean to you?

Most of us, I think, see it as periodic physical exams, routine blood tests, mammograms, colonscopies, and so on. But those procedures aren’t actually preventive; they’re worthwhile attempts to catch diseases in early stages.

Though illness can seem to just happen, much prevention resides in the way we live. Our diet, exercise habits, stress management, relationship skills, social support, and other factors—most of them under our control—are the major determinants of health. A large number of people are saddled with poverty and ignorance, and some with pathogenic genes, but many, many of us can effect healthy choices.

Let’s take as one example obesity, a major risk factor for early death from a variety of causes. Obesity is determined by a formula, “body mass index” (BMI), which compares the body’s weight to its surface area. “Overweight" is defined as a BMI above 25 kilograms per square meter, and “obese” as a BMI  greater than 30.

You probably expect cynical old me to slight my fellow Americans as world-class fatties, but the fact is that we’re relatively svelte. According to WHO estimates, more than 75% of women older than thirty are overweight in countries as diverse as Barbados, Egypt, Malta, Mexico, South Africa, and Turkey. Estimates are similar for men, with over 75% overweight in Argentina, Germany, Greece, Kuwait, New Zealand, Samoa, and the United Kingdom. In the Western Pacific islands of Nauru and Tonga, nine out of ten adults are overweight.

Even so, American figures are no cause for a confetti parade. The U.S. Center for Disease Control reports overweight incidence of 57% among adults, and, more disturbing, 32% among children. Beyond overweight, the CDC finds 16% of American children obese, and an unfortunate 11% “extremely obese.” Should current trends continue, 75% of American adults are projected to be overweight and 41% obese by 2015.

Considering the propensity—indeed, the virtual certainty—of long-term obesity blooming into serious disease, we’re headed toward a major train wreck. In my October 22, 2009 rant in this blog, "Healthcare Reform? In Your Dreams," I tried to make the case that whatever current reform package Congress adopts, from “Single Payer” to “Enrich Industry CEOs Beyond Their Wildest Dreams,” healthcare costs will eventually bankrupt our nation. Unless, of course, we individuals amend how we choose to live…

Monday, December 7, 2009

PAGING DR. TRUDEAU


A hundred years ago people mattered in healthcare. They had to, since we knew so much less about medical science.

The leading incurable disease of that day was tuberculosis. A prominent specialist, Dr. Edward Livingston Trudeau, having long pondered what could be done for these people, developed the first sanitarium. There, on the shores of Lake Saranac, New York, he gave his patients standard contemporary treatment and also offered them respite from cities’ crowded tenements. Residents benefited from clean air, decent food, and a serene environment. My own aunt’s two years at Trudeau’s establishment granted her another seven decades of life.

The sanitarium is now a research facility. Vines partly cover a statue of Trudeau. A brass plaque at its base commemorates his treatment motto:

“Cure sometimes,
Relieve often,
Comfort always.”

After Trudeau’s era, tremendous scientific advances treated tuberculosis so effectively that sanitoria closed. Antibiotics saved thousands or even millions who would previously have died from other infections. Immunizations and public health measures fairly wiped out polio, and smallpox now exists only in vials in a few laboratories. We’ve learned to sew on limbs and transplant most vital organs. Scientific success has been so brilliant, as a matter of fact, that sick people’s softer requirements can appear rather dull and mundane in comparison.

Scientific success has a curious shadow, though: in reducing deaths from acute infectious diseases and trauma, it’s created a sea-change in disease demographics.

I mentioned in an earlier blog entry that the proportion of short-term to long-term diseases reversed during the past fifty years. Whereas two-thirds of medical visits had been for short-term problems, now two-thirds are for long-term problems. That’s pretty dry info until you realize that long-term problems are long-term only because we can’t cure them.

Most cases of today’s leading diseases—arthritis, cancer, and cardiovascular, autoimmune, and metabolic disorders—are entities people need to live with the rest of their lives. We docs can ameliorate symptoms and probably extend survival, but we can’t cure these diseases. In other words, tuberculosis is under far better control than it was in Dr. Trudeau’s time, but now we’re confronted with equivalents just as frustrating.

It makes sense, then, to revive his motto,

“Cure sometimes,
Relieve often,
Comfort always.”

Thursday, December 3, 2009

GEE, DO YOU LOSE YOUR PUBIC HAIR, TOO?



Yesterday a friend told me, “I’m on my way to see my cousin. He’s dying of cancer. What can I say to him?”

People ask me that often. They want to say something not only to comfort, but to feel they’re being useful. But really, what can you say? Certainly not those platitudes that sound unhelpful or even hurtful, like, “Well, hang in there,” and, “I just know everything’s going to turn out fine.”

I suggested to him my usual: don’t say anything. Just ask, “How are you doing?”

But I thought about it more later. That question means something different to me than it does to those who don’t employ it a lot.

“How are you doing?”

“Fine.”

Now what?

That question can be the cork in a bottle of unknown contents. If you’re going to ask it seriously, you need to be ready to deal with those contents once the bottle’s opened.

When I first got into cancer counseling over thirty years ago, hardly anyone else was doing it, so there was nowhere to study it, and no one with whom to compare notes. It was scary, especially for a non-psychiatrist physician unaccustomed to raw emotion. I worried that people might “lose it,” that I might rip open a Pandora’s box I couldn’t close, or spring someone into a psychotic break.

People did indeed fall apart. They cried, screamed, and spewed anger at cancer, God, and whoever was handy, including me. And I found to my amazement that I not only could witness it all and survive, but increasingly remain centered. What I feared I’d lacked wasn’t professional training, but familiarity with intense intimacy.

I suspect that in this age of specialization we assume intimacy is the exclusive domain of licensed psychotherapists. An otherwise excellent oncologist told me, “I ask my patients how they’re doing emotionally with their cancer and treatment. If they say they’re doing okay, I leave it at that. If they say they’re not handling it well, I refer them to a psychiatrist.”

That is, he doesn’t feel adequate to deal with their emotions. He doesn’t say that though; he says he doesn’t have time. That’s too bad, since his patients’ cancers and emotional discomforts can be treated simultaneously.

A few years ago some wag published a list of smartass answers to the dumb questions people with cancer get asked.

One question was, “Gee, when you lose your hair with chemotherapy, do you lose your pubic hair, too?”

The answer is, “How badly do you want to know?”

So before you ask someone who’s sick, “How are you doing?”, ask yourself, “How intimate are you ready to get?”

Tuesday, December 1, 2009

ILLNESS ISN’T WHAT IT USED TO BE


If you’re of a certain age, you’ll remember Yul Brynner in “The King and I,” singing,

"When I was a boy
World was better spot.
What was so was so,
What was not was not.
Now I am a man;
World has changed a lot.
Some things nearly so,
Others nearly not."

Me, too. When I was a young teen, Dr. Ben Casey took me under his strong, kind wing. Every week on television, this chief neurosurgery resident drained the brain abscess just before it popped, grabbed the obscure diagnosis that eluded his smug house staff (“Phil, do you mean you didn’t even think of a metastatic pheochromocytoma?”), and secured housing, jobs, and dates for his indigent patients.

Dr. Casey was actually heir to an honorable lineage that included Dr. Christian, Dr. Kildare, and Dr. Konrad Steiner, and would serve as a model for Dr. Marcus Welby and today’s scalpel-sharp tele-docs. Whatever the catastrophe, these physicians yank heaven from the jaws of hell, then take a break at the coffee machine.

One of our central healthcare myths is that we get sick and then a doctor makes us well. That was generally valid through the 1950s, when two-thirds of medical visits were for short-term, cleancut problems like infections and trauma. But since then, as Brynner noted, “world has changed a lot.” Today two out of three visits are for chronic conditions. Chronic, meaning long-term, is actually a euphemism for incurable.

All Dr. Casey can do today for your chronic condition is to moderate your symptoms, perhaps prolong your life. But he can’t often make the disease go away. Believe me, this isn’t easy on him. He’s as frustrated as you are—not only at his inability to cure you, but that healthcare isn’t living up to its legendary heritage.

And now comes an even greater nuisance, “MUPS.” Within mainstream healthcare, recently coined entities that may or may not be actual diseases are called "Medically Unexplainable Physical Symptoms." Chronic fatigue syndrome, fibromyalgia, candida allergy, multiple environmental sensitivity syndrome, and a host of other labels describe conditions for which diagnostic physical signs are between controversial and frankly absent.

You break your leg, you can jolly well see it in an x-ray. Pneumonia is visible pus in the lungs. You can remove and weigh a tumor, but how do you prove CFS or ADD? What can’t be measured is considered outside traditional medical jurisdiction. (Although the pharmaceutical industry has a definite interest in challenging that limit, and ultimately defining human life itself as a condition treatable with drugs.)

When I think about whether MUPS, these “shadow diagnoses,” are “real,” I soon fall into linguistic angst, wondering what "is" is. I have enough trouble deciding what’s real in my daily experience, for God’s sake, without taking on this one. But I’ll tell you: taking a firm stand for either the validity of these entities or their falsity bothers me.

I know a doc who “diagnoses” tumors by microscopically examining peripheral blood. Then he obliterates the tumors with what he calls nucleic acid extracts. His patients swear by him. “He’s the one who finally found my cancer,” a friend told me, “and he cured it.”

I know another doc who, upon hearing his patient complain of chronic fatigue syndrome, simply walked out of the room.

Both these docs are attending to the disease to the exclusion of the person. Whether an illness is curable, incurable, or even of questionable existence, at least we know this person is suffering. Are we docs to restrict our mission to biochemical (or, if surgeons, structural) engineering, or can we treat suffering, too?

A friend told me he’s had four sessions with his acupuncturist, and every time leaves feeling better. “I have no idea how acupuncture works, or if it works at all,” he said. “But this guy talks with me, listens to me, and touches me. Afterwards I don’t feel like a sack of enzymes. Whether what he ‘does’ works or not, I’ve feel like I’ve been deeply noticed.”

Sometimes, then, it really doesn’t matter what the diagnosis—or prognosis—is. We simply ask, “What ails you, my friend?”

Tuesday, November 24, 2009

THE SUNSET MAGAZINE KITCHEN MODEL



I admit I entered medical school with a few surreal fantasies.

One concerned patient contact. Recall photos from Sunset magazine’s 1960s kitchens: perfectly coiffed and composed chefs in dove-white aprons conjured never-fail souffles. I imagined myself like that in practice—the white-coated scientist who, floating above worldly concerns, dispenses cures to ever-grateful patients.

It didn’t take extensive ward experience to reveal that image as not only arrogant, but impossible. I learned that the juice in this career I was taking on lay in precisely the opposite direction, getting fully into it with sick people. Each successive year I found myself more enthralled with people’s stories: the meanings they made of their sicknesses, the coping strategies they crafted, the lessons they learned.

At some point I completed my leap across the chasm. Whatever medications or advice I supplied, it often felt in essence like I was operating a high-tech turnstile, patching folks up so they could return to their same-old same-old. Now, having chosen to have no medical responsibilities, I can listen to people fully, without physician filters in my ears, and I love it. Of course, I’ve noticed that my role has changed, from objective scientist to, well, friend.

That’s why I got rattled when a psychologist buddy sent me a column from one of her professional journals. Written by the journal’s resident ethicist, it responded to a query from a Dr. T.

Dr. T. is a psychologist in a small town, and also happens to sing with a band. One of her clients is Ms. G., a woman in her eighties with cancer. During one of their sessions together, Ms. G. leaned over, placed her hand on Dr. T.'s, and said, “It would mean so much to me if you sang at my funeral. Would you do that for me?”

Touched, Dr. T. wanted to say yes, but a little voice inside her said that might constitute what’s called in psychotherapy a “dual relationship,” defined as contact outside the office. I’m your psychologist, say, but what would it mean if I also played tennis with you? How might that affect our therapy’s dynamics? Can we go to the movies together? Can we date? You see where I’m going. Dual relationships can be hazardous, especially given the perceived difference in power between the two people. Are our transactions outside the office by genuine mutual consent, or is one of us simply acceding to the other’s power?

Listing several potential issues, the ethics columnist advised Dr. T. to think about it carefully before answering Ms. G. One issue he explored was confidentiality: is it alright with Ms. G. for her friends and relatives to learn, as they will, that she was seeing Dr. T. for psychotherapy? Another was consistency: how will Dr. T. respond to future requests to sing? And what about transference and countertransference?

My psychologist friend and her partner, who together have a century of experience counseling people with cancer, wrote to the journal that they disagreed with the ethicist’s advice. They said he failed to note Dr. T’s commitment to the client. “In this situation,” they wrote, “you enter into the relationship wholly or not at all.”

I agree with them. As Wavy Gravy famously observed, “We’re all bozos on this bus.” Sometimes the most stainless chefs need to get a little butter and chocolate on their hands. I’ll be in Ms. G’s shoes soon enough, and when I am, whom would I like around me, those who love me unconditionally or people behind starched aprons?

How would you answer Ms. G.'s request?

Friday, November 20, 2009

HOW DOES AN ELEVEN-YEAR-OLD WEIGH 220 POUNDS?


A few years ago, TIME magazine featured a cover story on type two diabetes. The cover photo was of an eleven-year-old girl who suffered from the disease. Type two diabetes is traditionally a disorder of overweight, middle-aged people, but recently more children have joined its ranks. The article mentioned that this girl weighed two hundred and twenty pounds when she was diagnosed. Then it blithely proceeded to a discussion of diabetes’ physiology and treatment.

Hang on, I thought, wait a minute. How does an eleven-year-old come to weigh two hundred and twenty pounds? Why is this article about diabetes rather than pathogenic behavior? This latter subject, after all, has been evading us. Even though we medical types know something about the roles of social pressure, genes, poverty, ignorance, adverse experiences, and neurotic intent in generating sickness, we’re still painfully ineffective at preventing it. We’d love to intervene before the person’s biochemistry has irreversibly gone south, but as things now stand, we’re limited to leaving American Heart Association flyers on the waiting room table and replacing them when they turn yellow.

Health education undoubtedly detours pathogenic behavior over the long haul. When I entered medical training, for example, a couple of my professors occasionally stepped outside for a cigaret, and now, forty-five years later, I don’t know a single physician who smokes. Every quantum of health education, though, is opposed by a score of clever seductions that push for even more consumption. Magazine ads, TV commercials, infomercials, and the very tone of pop culture all tend to encourage heedless glitz and gluttony.

There’s impressive talent behind these sales pitches, as literally billions of dollars ride on soft drinks, cheap fats, high-fructose corn syrup, and various legal addictions. On the other hand, no one gets rich encouraging people to think critically about their lifestyle.

Twenty years ago, Dr. David Spiegel and his colleagues at Stanford University published a study in the prestigious British medical journal Lancet which concluded that women with advanced breast cancer who participated in support groups survived twice as long as women not in support groups. (Since then, this conclusion has been in contention, but that’s not my point.) Afterward, Spiegel noted a conspicuous professional disinterest in his findings. He commented, “If…my intervention was a new chemotherapy agent, every hospital in the country would be doing it by now.”

In a private conversation he continued, “If it had been a drug, the manufacturer would promote it left and right. But the medicine in this case is only conversation, so who’ll promote it, chairmakers?”

Please forgive me, as it’s cold and rainy today, so maybe my mood’s a little dark. Still, I can’t help but hear the constant din of standards crumbling. Yesterday I read this headline: “Road Rage Incident Gets Out of Hand.”

Wednesday, November 18, 2009

ON LOOSENING UP

A few years ago, a dermatologist spoke at a medical education lunch at our local hospital. Given his specialty, his talk was a series of color slides depicting skin lesions. Some photos, of course, challenged the audience’s appetite, but that comes with the territory.

He showed a slide and said, “This is the typical kind of lesion you get with Type A skin.” With the next slide, he said, “This one, though, is more characteristic of Type B skin.”

And on and on, Type A and Type B. Finally, one physician said, “Excuse me, but I’ve never heard of Type A and Type B skin. Where is this in the medical literature?”

The dermatologist seemed shocked. He said, “It’s not in the literature. It’s my fantasy.”

Several physicians, outraged, pounded the table and stormed out. The presenter called after them, “What’s the matter? Don’t you fantasize?”

I guess not. They wanted facts, by God. Call me deviant, but I was delighted by the presentation.

Where would science be without fantasy? Every disciplined investigation begins as a fantasy. We have no idea what to look at until we say, “I wonder…” Albert Einstein, arguably the archetypical scientist, hardly ever entered a laboratory. His deepest revelations came to him while he was lying on his back in his sailboat on a Swiss lake, daydreaming. He wrote, “The most beautiful experience we can have is the mysterious. It is the fundamental emotion which stands at the cradle of true art and true science.”

I admit it: I fantasize continually, often about healthcare.

For example, is illness always an unmitigated misfortune, or, by temporarily evicting us from our regular habits, does it offer us the opportunity to alter our lives?

For example, is pathophysiology (what goes “wrong” in the body) sometimes a form of body language—our deeper selves expressing an encoded message?

For example, does pain exist not just to torture us, but also to get our attention?

For example, when is it okay to die?

Saturday, November 14, 2009

WHITE COAT HYPERTENSION

You’re probably familiar with the term “white coat hypertension,” an abnormal rise in a patient’s blood pressure that occurs only when a nurse or doctor pumps up the cuff. That is, it’s nervousness due to medical presence.

But have you considered the reciprocal phenomenon, physicians getting anxious around patients? They do, you know. I don’t think their blood pressure rises, but they rapidly shift their persona, the self they exhibit, from standard human being to scientist—the upright, knowledgeable, competent, confident, objective physician.

Well, shouldn’t the doctor be a scientist? After all, that’s been our ideal during the past century, and a sensible choice it’s been, given that our greatest medical advances have been scientific. We justifiably think so highly of science that it’s arguably our secular culture’s religion, and the physician its priest. My parents’ generation took the word of doctors as gospel. If, when I was a child, my doctor had recommended sewing my elbows together, my mother would have acceded enthusiastically.

But only half of medicine is science. As our professional elders universally advised, it’s a science and an art. That maxim always sounds grand, but the fact is that docs aren’t taught the art, only the science.

I’m not even sure the art can be taught as much as modeled, and that requires intent, time and experience. Until we develop it in ourselves, an entire profile of sick people remains invisible to us. We don’t appreciate, and so can’t treat, their suffering. We comprehend them instead as intellectual challenges, disordered physiologies begging resolution. That’s when we act as technicians rather than healers.

I know physicians who do both. That feat is tangibly therapeutic for their patients, but even more so for them. Think about it: how would you manage wading in suffering for a living? Imagine having some responsibility to guide people through hyperemotional life-and-death situations at least forty hours weekly. What would you do with the suffering you can’t help but absorb?

Not long ago I witnessed an encounter between a young woman with severe rheumatoid arthritis and her physician, whom I know personally as a gentle, loving human being. Describing her pain, the patient cried. I watched the doctor. If I could see the thought balloon over his head, it was something like this:

My God, this poor young woman is suffering something awful; I want to get up and just hold her; on the other hand, that’s not very professional.

He literally wrung his hands, as though his left and right sides were struggling with one another. In the end, he stayed put, resumed a straight face and wrote her a prescription for a more potent painkiller.

Afterward, I couldn’t help but ask the doctor how he felt. He said, “Ripped in half.”

Good, I thought: the beginning of a conversation. “Ripped in half? Can you tell me more about that?”

“No,” he answered. “I don’t want to talk about it now. I have more people to see.”

This suffering that’s part of the medical stock-in-trade continues to inhabit us like a slowly growing abscess. Without periodic, conscious draining, it’s not healthy. Look up physicians’ rates of divorce, drug dependence, alcoholism, and suicide. Our health statistics don’t amount to a great advertisement for the exclusively scientific medical style.

So when you notice your doc’s caught a case of white coat hypertension, please understand what’s likely on his or her shoulders. Treat him or her by insisting on humanity along with science in the examining room. You might ask, “How are you doing today, doctor?” Believe me, you’ll be thanked.

Thursday, November 12, 2009

CANCERITIS



“Canceritis,” a perennial subject in cancer circles, is an informal diagnosis of cancer anxiety.

Say you’ve had cancer, you’re in remission, and you get a headache. What’s the first thing you think of? Despite the fact that 999 out of a thousand headaches aren’t from cancer, and that people who’ve had cancer can still get plain old headaches. Because of your history, it’s natural that you go to this worst-case scenario first.

Canceritis bedevils almost everyone who’s had cancer, and it seems to be permanent. Sure, every time it happens you get a little more used to it, so a little less anxious, but it persists anyway. Where once you were relatively carefree, now this invisible little mischief-maker rides constantly on your shoulder.

“I don’t think that’s a bad thing,” said a friend who’s lived with active metastatic lung cancer almost twenty-two years now. “I co-exist with my cancer. If it wants to go away, that’s fine with me, but if it stays, that’s something I accept, too. It reminds me that I’m always vulnerable. With or without cancer, as a matter of fact, we’re all mortal, and we don’t know when we’re going to shuffle off. Knowing that in my bones, I don’t put anything off. And I suspect that consciously living with mortality is somehow therapeutic for me.”

That’s how she deals with canceritis. Others find other strategies. I heard of a man with prostate cancer who lived at the edge of his chair in regard to his periodic “prostate-specific antigen,” or “PSA,” blood tests. Slight, medically insignificant variations in the result would send him into emotional frenzies. One evening he decided to calm himself by taking a drive through the city. Never mind which city, but a stray bullet passed through his car window. Now he doesn’t worry about his PSA so much.

Monday, November 9, 2009

WHEN PATIENTS COMPLAIN…

I have an unusual practice. All I do is listen to cancer patients and their family members in support groups. I don’t diagnose or treat; I only listen. Generally I hear praise from them about their healthcare. Sometimes I hear criticism. When these people complain, though, it’s never, never, about medical technology. It's uniformly about human interaction.

“All I see of my doctor is the back of his head while he enters data into his laptop,” one said.

“How is it,” another asked, “that we can put people on the moon but we can’t send a fax across town?”

“They lost my chart,” marveled another, “simply lost it.”

“I’ve been going to this medical office for six years, and the receptionist still doesn’t know my name.”

“The doctor didn’t asked me how I wanted to handle this, just made a surgery appointment.”

A friend summed up all complaints, I think, when she said of her hospitalization, “I was poked and probed and ultraviolated, but never touched.”

In the old days, maybe the 1960s, the medical examination room held only a doctor and a patient and the pain and suffering and intimacy and hope that emanated from their transaction. Gradually, third parties—insurance companies and government agencies—invaded the room and pruned it of emotion. What had been a temple became a factory. The examining room, once an existential crucible, the very nucleus of healthcare, devolved into a sterile counter over which a “provider” passes a product called “healthcare” to a “consumer.” That bothers me enough, but what totally shivers my timbers is that we stood by and allowed it to happen.

So when we finally get to talking about what “health” actually means, let’s consider including responsibility, the skill of paying attention and then acting accordingly.

Tuesday, November 3, 2009

HOW TO HEAL SUFFERING

In an earlier posting I mentioned the seemingly outrageous proposition that people with cancer don’t often suffer from their tumors. True, sometimes they have pain. More often, they have symptoms resulting from their treatments. But most of their suffering comes from their own normal, understandable emotions—their anxiety, fear, anger, depression, and frustration.


This being true of other diseases, too, it leaves us practitioners with a problem: we’ve been trained to treat tumors and other physical manifestations, but not to treat suffering. In fact, that disparity has been healthcare’s atmosphere so long that many of us feel it’s beyond our jurisdiction.


Yet our professional elders from Hippocrates to Sir William Osler have encouraged us to treat the person along with the disease. Osler advised,


“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with powders or potions…”


Poet and pediatrician William Carlos Williams wrote,


“To treat a man as something to which surgery, drugs and hoodoo applied was an indifferent matter; to treat him as material for a work of art somehow made him come alive to me.”


Sounds right, but how do we get there? Simple, really. Explaining the source of his own wisdom, pitcher Satchel Paige said, “I just let ‘em talk.”


Just let ‘em talk. No kidding.


It’s simple, but not easy, as the task especially challenges the medically trained: can you just listen without trying to fix?


(An aside, examples of fixing:

“I know how you feel.”

“Have your looked into clinical trials?”

“I’m sure things’ll turn out okay.”

“How about acupuncture/herbs/homeopathy/crystals/prayer?”

“Just stay positive.”)


Suffering can’t possibly be fixed, only experienced. Novelist Marcel Proust advised, “We are healed by suffering only by experiencing it to the full.” But we don’t like it, of course, so we try to avoid it, which actually perpetuates it. As a cancer support group member said, “Buried suffering is always buried alive.”


We practitioners can help by accelerating the person’s passage through suffering. In her now-classical book, On Death and Dying, Dr. Elisabeth Kubler-Ross wrote of emotional “stages” in the dying process. These stages—denial, anger, bargaining, depression, and acceptance—are examples of suffering. When we learn we have any irretrievable loss (not just disclosure of our mortality, but an impending divorce or drop in stock value), we first deny it, then get angry, and so on. These “stages” don’t necessarily happen in Kubler-Ross’ order, and suffering may include emotions she didn’t name, but once we’ve expressed them, there’s nothing left, and we’re in the state she calls “acceptance.” Acceptance is the same as serenity, the absence of emotion.


In short, here’s how to treat suffering: ask, “How are you?”


Let ‘em talk. Listening, ask yourself what their suffering consists of. Ask them questions in order to clarify. Don’t interrupt. Don’t interpret. Don’t fix.


There’s magic here. When we avoid suffering, it remains an amorphous unknown. When we enter its heart, however painful that is, we find the route to the way out. Here’s an abbreviated version of a conversation that occurred over several weeks:


“How are you?”


“How am I? I’m dying, that’s how I am.”


“How is that for you?”


“Well, I’m damned angry about it.”


“What part of it makes you angry?”


“I’ve wasted so much time. I’m angry at myself. I could’ve done so much more.”


“What haven’t you done that you could still do?”


“Well, reconcile with my kids, that’s one thing.”


Here is alchemy before our eyes. Someone has transformed her generic, undifferentiated suffering into behavioral advice. She knows now what she needs to do to approach serenity.


This work doesn’t require training in psychotherapy because there’s nothing abnormal in the situation. Nothing is wrong. Intervention here amounts to simple compassion. In other words, this is friendship.