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.