Thursday, October 29, 2009

WHAT DOES TOLSTOY HAVE TO DO WITH E. COLI?

I’ve been asked to help organize a “literature-in-medicine” course for a medical school. That doctors relate to patients more compassionately when they’ve been tutored in the humanities is a notion so obviously valid that many schools have already adopted such programs. In New York, Mount Sinai School of Medicine conducts an art appreciation course. Yale, Stanford, and Cornell offer similar curricula. The University of Minnesota even features a Center for Spirituality and Healing.

There’s one huge hurdle in teaching this subject, though. I came across it forty-five years ago, when I took the humanities course my medical school offered. It was incredibly progressive for its time. We read some of the classics, attended art history slide shows and talks on classical music...and it was totally lost on me.

Look: I was a kid. I hadn’t been out in the world much. Aside from birth and adolescence, I hadn’t sipped life’s other sacraments. Marriage, children, suffering, aging, and death were only abstractions to me. What was real was the microbiology final I needed to study for.

Things haven’t changed much. Despite the humanities’ subtle incursions into medical education, the primary and almost exclusive focus remains hardnosed, objective science. A few years ago, on a whim, I visited Dr. Eric Cassell in his Brooklyn home. Dr. Cassell is an emeritus professor of medicine and public health, author of The Nature of Suffering, and widely considered the grandfather of the movement to augment compassion in healthcare. I asked him whether he thought his goal might be attained during his lifetime. He chuckled, looked me up and down, and asked me how old I was. I told him. He chuckled again, and said, “Not in your lifetime, either.”

Ah, well. Still, we must do what we must do.

So here’s my current Burning Question to you: as we teach humanities to medical students, how can we convince them of its central, undeniable relevance to their life’s work? Operators are standing by.

Tuesday, October 27, 2009

HOW DO YOU KNOW YOU LOVE YOUR WIFE?

Many years ago, my wife Ronnie and I heard Norman Cousins hold forth at UC San Francisco Medical Center. His popular book, Anatomy of an Illness as Perceived by the Patient, described his experience with a galloping case of ankylosing spondylitis, a painful savaging of the spine. Cousins wrote that he was dissatisfied with his hospital-based treatment, so moved to a five-star hotel next door (at a fifth the price) and got his doctors to agree to see him there and to restrict blood-drawing to a single stick a day. He discontinued most of his medications, and instead treated himself with megadoses of vitamin C and laughter in the form of Marx brothers and Candid Camera films. Under this regimen his spondylitis gradually evaporated, a fact corroborated by his doctors’ testimonials.

Cousins told his story to this audience of physicians, nurses and students, and then asked for questions. A white-coated man stood and asked, “Mr. Cousins, laughter is no doubt a positive thing, but how could we devise a double-blind controlled study in order to know objectively whether it aids healing?”

Ronnie has frequently been nominated for the Nobel Manners Prize, but this was too much even for her. She stood up and said, “If you don’t know right now that laughter aids healing, I'm afraid there’s something seriously wrong with you.”

I must have had her comment in mind years later when an oncologist at a medical center where I facilitated cancer support groups challenged the validity of my work. The kindly old chief of medicine summoned me to his office. “Dr. T. claims you’re doing witchcraft,” he said. “Go see him and calm him down, willya?”

So Dr. T. and I met. He said he didn’t approve of support groups because there was no way to measure their efficacy. “Give a hundred patients with strep infections the right ‘cillin,” he said, “and eighty-five will get cured. That’s solid numbers. But can you apply anything like that to cancer patients in a support group?”

Glancing at a photo on his desk, I asked, “How do you know you love your wife?”

He frothed and tossed me out. I can only hope that little seed has taken root in him, and grown into the operant notion that we’re composed of more than meat.

Anyone who’s ever experienced sickness, for example, recognizes its simultaneous heads and tails. Heads is the disease process itself—the infection, the tumor, the physical and chemical derangements. Tails is feeling like hell.

Heads and tails are dimensionally different. Physical disease occurs in the physical world, but our emotions are admittedly subjective. Disease can be seen, touched, measured. Suffering can’t. When I ask conference participants, “Who here has experienced the most suffering?”, they laugh because they know suffering will never been seen under a microscope or reported in a blood test. Yet along with love, humor, and other feelings, it’s an undeniable ingredient of life’s juice.

We’ll know the healthcare reform discussion is finally getting real—instead of just focusing on who’ll pay for what—when we accept that diagnosing and treating sick folks’ disease alone is exactly half of what’s needed.

Saturday, October 24, 2009

SICKNESS AND SUFFERING

When I entered my medical training in the early 1960s, disease demographics were undergoing an oceanic change we still haven’t fully addressed. Before then, most patients saw doctors for “acute,” meaning short-term, conditions such as infectious diseases and trauma. Now a full two-thirds of medical visits are for “chronic” conditions.

As the name implies, chronic means longterm, often lifelong. Most cases of hypertension, diabetes, arthritis, autoimmune diseases, cancer, and heart disorders are chronic. They’re chronic because we’d cure them if we could, but we can’t: that is, “chronic” is a euphemism for incurable. Despite the media’s relentless touting of “breakthroughs,” most patients can’t reasonably expect cures. They can reasonably expect relief from some symptoms and a limited prolongation of life.

And if people actually matter in healthcare, they can reasonably expect relief from their suffering.

Chronic diseases differ dimensionally from acute ones. An acute disease visits temporarily. In a relatively short time we either get over it or it does us in. A chronic one moves in as a troublesome roommate. It sets up house for the long run, and we have to learn how to accommodate. Over time it changes who we are, and our relationships with others as well.

Having facilitated cancer support groups some three decades, I can tell you that people only rarely suffer from their tumors. Sure, there’s pain sometimes, and we’re learning to treat that rather well. But most of cancer’s suffering is emotional. Try going through this disease without experiencing anxiety, depression, anger, disorientation, and isolation. That’s what actually bedevils people, and it's a normal response to having cancer.

Medical training is built around finding what’s wrong and fixing it. You can “fix” a tumor by removing it in various ways, but since you can’t fix emotions, they’ve been essentially excluded from consideration. This deficit leaves most physicians unprepared to deal effectively with suffering. (Still, I know a few docs who are existential masters--a result of their personal development, not their professional training.)

Authentic healthcare reform must include considering what we can do to help our patients live with incurable diseases. Part of that is alleviating their suffering. It’s not hard to do. It doesn’t require a specialist. Virtually all of us are already competent, having led a human life. More to come.

Thursday, October 22, 2009

HEALTHCARE REFORM? IN YOUR DREAMS

I recently participated in an online healthcare reform chat group. I’d expected a passionate discussion, but instead found people drily exchanging statistics and prices. Deflated, I looked up the group’s roster. Of sixty-two members, almost all were administrators or economists. In fact, I was the only one identified as either a patient or medical practitioner.

What can we possibly be thinking when we omit healthcare’s obligate participants from the reform discussion? The current Congressional hearings involved numerous representatives from the insurance, hospital, and pharmaceutical industries, but hardly any patients or practitioners.

Evidently Congress is convinced that the healthcare crisis is purely economic. If policy makers were to ask plain old citizens who are sick and those who treat them, they’d learn that at its core, healthcare isn’t just another business. It’s as subtle as it is complex, a blend of suffering and science, hope and compassion. Seen through the narrow lens of economics, though, doctors and patients are simply agents engaged in the transfer of a product: health has become a commodity like pork bellies and winter wheat, what a “provider” sells to a “consumer.” Shame on us. Hippocrates is spinning in his grave.

It is that gross misperception, not economics, that is the nucleus of our healthcare crisis. Surgeon-writer Atul Gawande explained this incisively in the June 1, 2009 edition of The New Yorker. In an article that’s become required reading for White House staff, Gawande demonstrated that we pay too many bucks for too little bang because we simply overuse medical care.

We demand more than we need, encouraged by the perennial avalanche of press releases about the latest breakthrough, that medical miracle just over the horizon. Most of these wonders don’t pan out, yet relentless publicity persuades us that there is or soon will be a pill or procedure for virtually anything that can go awry. We understandably want to believe this, and genuine advances do occur, but most of what we hear is flat-out sales pitch. Consider the magazine ads and TV commercials you’ve seen by the score: “Nervous? (Insomnic? Depressed? Itchy?) Ask your doctor if this is the right medicine for you.” Sadly, some of these hawkers are physicians who, having noticed the rushing river of healthcare dollars outside their window, lean out to dip their ladles.

Mesmerized by unrealistic but pervasive promises, too many of us don’t take care of ourselves. Assuming doctors will heal us no matter what, we eat processed foods that bestow weight without nutrition, we ingest noxious chemicals, lack tools to handle stress, tolerate abusive relationships, and don’t exercise. When I ask my medical colleagues what fraction of their patients are being treated for self-caused problems, they uniformly answer in the majority. We’re talking here about most cases of obesity, hypertension, type two diabetes, atherosclerosis, accident proneness, emphysema, cirrhosis, and so on, the results of sick-making lifestyles.

Cheaper—and even empowering—approaches are available. More than a decade ago, cardiologist Dr. Dean Ornish and his staff at the University of California San Francisco showed that clogged coronary arteries could be cleared with a simple but intense program combining diet, exercise, meditation and support, the cost of which was a few thousand dollars. Compare this to a four-way coronary bypass operation costing a quarter million dollars. Yet who’s going to push lifestyle change when entire industries, many thousands of jobs, depend on bypass operations? Maybe it’s easier to just get the operation, especially if someone else pays for it.

But sooner or later, we’ll need to rethink that strategy because as costly as healthcare is now, you ain’t seen nothing yet. In 1960, one dollar of every twelve spent for anything in the United States went toward healthcare. By 1980, healthcare’s share was one of every seven dollars. Today it’s close to one in five. At this rate, we’ll eventually buy nothing but healthcare: we’ll live in packing crates and shop in dumpsters, but at least some of us will have access to the most opulent healthcare technology in world history.

No matter what reform scheme emerges from today’s Congressional pipeline—single-payer, government-subsidized private insurance, or something else—we’re headed toward national bankruptcy unless we alter the conversation. Instead of just debating who’ll pay for what, we need to begin discussing personal responsibility, effective health education, and exactly what we as members of a democracy owe one another.

- Jeff