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?”