Tuesday, November 24, 2009
Friday, November 20, 2009
Wednesday, November 18, 2009
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
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
Monday, November 9, 2009
“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
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.