Thursday, December 30, 2010

ONE THOUSAND CHARACTERS


The NY Times’ “Well Blog” often presents juicy morsels of medical issues, and today’s (http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/?pagemode=print) is worth reading.

Internist Dr. Danielle Ofri writes about a difficulty she’s encountered with electronic medical records (EMR). Certainly EMR is an improvement over paper records, as it’s universally accessible and pages don’t tear, crumble and get lost. But the folks who control its use, like so much within healthcare administration today, aren’t medical people. With little idea of what occurs between patients and doctors, their main concerns are with their own technologies. So one parameter they place on EMRs is word count: docs can write only so much in a medical record entry.

Dr. Ofri reports, “…in our electronic medical record system there is a 1,000-character maximum in the ‘assessment’ field.” She felt she needed to write more about one patient, so in desperation she phoned the help desk. A techie told her, “Well, we can’t have the doctors rambling on forever.”

Dr. Ofri good-humoredly concludes, “For my next medical evaluation, I think I will use haiku.”

I once knew a medical resident who understood his patients’ situations so thoroughly that his writeups rarely exceeded two elegant sentences. I worship such graceful brevity. But he’s a rare doc, and in any case the issue here isn’t about doctors rambling on forever. It’s about still another entity coming between patient and doctor.

As if insurance carriers, government agencies, and the consequences of reduced reimbursements didn’t crowd the examining room enough, now information technologies are limiting the transmission of all-important information.

We have a boiling frog here. You know the story. Put a frog in a pot of water, and if you heat it slowly enough the frog won’t notice until it’s boiled to a turn. In the same way, the patient-doctor relationship has been eroded almost imperceptibly over decades. The parties feel increasingly uncomfortable and angry, but aren’t clear about why. One wonders when they’ll finally tell the interlopers, “No. I'll write all the characters I need, and as for you characters: out.”   




Monday, December 27, 2010

HANGING-OUT AS PANACEA

In the back-to-the-land days of forty years ago, I lived in a redwood forest hamlet east of San Francisco Bay. It was an untamed place, and its two hundred residents were people who welcomed challenges. They characteristically built their homes from seconds and from what they found in the forest.

I bought an old examining table from a funky movie studio whose owner told me it had been used as a prop in a film of dubious repute and then abandoned. I ordered supplies and common drugs and began seeing neighbors in a closet-sized micro-clinic. Most were on Medi-Cal, state medical assistance. It paid nada, and that hasn’t changed. (I treated two-year-old Starwater, submitted my remuneration paperwork, and received a rejection fourteen years later.) On the other hand, patients stopped by with a quart of soup or showed up to help me fix my plumbing, which led to a good deal of hanging-out time.

One sleety winter night a woman named Little Lulu roused me from my comfort to ask me to come see Butch the Rapper. I got my boots on, grabbed my little medical bag, and followed her over a hill and down a goat path to Butch’s place, a sheet-metal lean-to. Despite ice on the walls, Butch was undressed and sweating profusely. As a future nurse friend would have said, he was "looking puny." One of his lungs, it turned out, was packed with pneumonia. Since Butch refused hospitalization, I gave him a massive injection of penicillin then and again over the next three days. He survived, and the following summer delivered me an unsolicited cord of dry oak, followed, of course, by hanging-out time.

This was the way much of medicine was practiced a century ago, and even now in various crannies. A current best-selling book is Cutting for Stone by Abraham Verghese, born in India and trained as a physician there and in Ethiopia, and who now teaches at Stanford. It tells a fascinating story, but I think Verghese’s forte is memoirs. His previous book, My Own Country, describes his experience predominantly treating AIDS in Johnson City, Tennessee, beginning when the disease was a total mystery. Soon confronting a second pernicious condition, endemic homophobia, Verghese found that his practice required enhanced discretion, so many of his contacts with patients were in their homes, in more intimate encounters that afforded hanging-out time.

Hanging-out time isn’t idleness. It’s the vehicle of intimacy.

Today’s average medical consultation lasts, depending on which study you check, five to ten minutes—not exactly hanging-out time. I hear patients regularly complain that from the moment their doctor enters the room, it’s as though his or her hand is stuck on the doorknob. Ten minutes, I submit, isn’t enough time even for an accurate and comprehensive diagnosis, let alone genuine healing contact.

Face it: conventional healthcare is a factory. It short-changes patients and, over decades of practice, devastates doctors. Confided a colleague, “Here I thought I was entering this sacred calling, the path of Hippocrates, Galen and Osler, and I find myself drudging away on an assembly line. There’s gotta be more to medicine than this.”

She’s correct. There’s much more. Practice as though people matter, and you find yourself in their homes and their lives, entranced by the astonishing kaleidoscope of humanity and its inherent magic. Of course, you might not make as much money, but it’s worth remembering that while a certain amount of money is necessary, there are more important currencies.

Monday, December 20, 2010

DRUG PUSHING


I’ve written here before (see the April 23, 2010 entry) about pharmaceutical companies paying medical school faculty members to promote their drugs to other doctors. You might think that when this shoddy practice is exposed it would dry up, but no such luck.

The journalism website ProPublica (http://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit) today revealed that this chicanery is as robust as ever. In 2009 and early 2010, medical school faculty members in my state alone, California, were paid $28.5 million to peddle their patrons’ products to colleagues.

Some institutions, like Stanford University, clamped down. In 2006 Stanford evicted drug company reps from its halls, stopped the free lunches and trinkets emblazoned with drug names, and forbade its physicians from giving paid promotional talks for pharmaceutical companies. Just one problem, though: it forgot about enforcement. ProPublica found that more than a dozen of the school’s doctors had continued on as paid speakers in violation of the policy, two of them earning six figures since last year.  

What’s wrong with this, after all? Aren’t these talks truly educational? Don’t physicians need to keep current with pharmaceutical advances?

No argument with that, but we already know that when we go to buy a car, the Ford salesperson wants to sell us a Ford. Plenty of independent sources, such as The Medical Letter (http://secure.medicalletter.org/), offer unbiased analyses.

But there’s a more crucial issue. The relentless, ubiquitous pushing of drugs creates the atmosphere that healthcare is about drugs, period. That’s the way most physicians come to see their work, especially younger ones who’ve had no contact with the family medicine style of a half-century ago. Despite abundant recent research showing the impressive therapeutic effect of non-drug treatments—diet, meditation, support, and exercise, for example—docs and patients continue to reach first for drugs.

I’ll know things are changing when a meditation school offers us docs a free lunch of stir-fried tofu and brown rice.

Thursday, December 16, 2010

DEATH ISN’T AN OPTION


After a man undergoes surgery to remove a lung tumor, the surgeon reports to the man’s wife that he came through the operation beautifully and now needs just a few hours in the recovery room. The wife says she needs to see him, and now. The surgeon says he’ll be cleaned up enough in a few minutes. She cries, saying she needs to see him immediately to verify that he’s alive. The surgeon tries to reassure her that indeed he’s alive and doing well, but she doesn’t buy it. When she gets more upset, the surgeon allows her to visit.

Certainly a loved one should have access unless a visit is predictably dangerous, but there’s another issue here: the woman is concerned to a disturbing degree. It’s not unlike how I felt after our first child was born, when I continually tiptoed to her crib to be sure she was breathing. After several weeks, I realized I couldn’t continue doing this into her thirties, say, without considering myself neurotic.

The woman’s husband learned of her deep worries as he convalesced. Surprised and concerned for her, he recommended she attend a caregivers’ support group. She learned in the group that her anxiety wasn’t at all uncommon. Many of us worry about our mate dying, often to the extent that it replaces the current joy of being together with the worry that it won’t last.

I suggest a little radical surgery here. Begin with the ultimate, undeniable truth: death isn’t a possibility or an option; it’s a sure thing. It may be unpleasant or inconvenient to consider, but we will all die. That means every relationship will dissolve. We are certain to lose one another. Try that on. If it feels depressing or morbid at first, that’s because our culture has chosen to define it as such. Other cultures around the world see death and eventual separation as natural, normal.

Once we accept that, we realize that the only time we have with one another is right now, so we’d best take advantage of it. Right now…and now…and now…

Monday, December 13, 2010

WHEN SMOKING IS OUTLAWED, ONLY OUTLAWS WILL SMOKE

An article in today’s NY Times (http://well.blogs.nytimes.com/2010/12/13/the-elusive-smoke-free-home/#more-42267) relates a recent research finding that children in apartments in which no one smokes actually absorb nicotine that drifts in from other apartments.

So here’s another reason why smoking restrictions will steadily tighten. As things are now, you can’t smoke on air flights. Or in most restaurants. Or even in bars in many states. 

Indeed, other recent studies found that rather than asserting a calming effect, cigarettes actually cause longterm stress levels to rise. That’s little wonder, considering the mounting stigma smokers experience. Those who feel the crunch fight back as they can, but the handwriting’s on the wall: healthcare is out to end smoking, period.

It won’t succeed, though, any more than Prohibition did. When smoking is outlawed, only outlaws will smoke. Even when cigarette packs are festooned with the most dire, graphic warnings, as the FDA now plans, smokers who harbor secret and not-so-secret death wishes will enthusiastically puff away.

Smokers are people like anyone else, but caught up in a habit that does no one good but Philip Morris. As they feel the public health screws tighten, they suffer. They’re more apt to examine their behavior in an atmosphere of compassion than condemnation. You want to light up? I love you, but not around me, thanks.

Tuesday, December 7, 2010

MISUNDERSTANDING POISON


The FDA has approved new warning graphics for cigarette packs which could be more explicit only if manufacturers splashed bloody sputum onto the box. Here’s a sample:
WARNING: Cigarettes cause fatal lung disease


One wonders why people pay good money for a potentially suicidal product. It’s easy to rationalize, of course, that cigarettes aren’t sure to kill you, only skyrocket your risk. (Matter of fact, ten to fifteen percent of lung cancers occur in nonsmokers.) But a more compelling reason is that people don’t generally understand how poisons work, and that’s a serious public health hazard.
We popularly think of poisons as working instantly: Socrates sips his hemlock and falls over dead. True, there are a few poisons, like cyanide, that are that fast, but most toxins we’re exposed to are slow-acting and cumulative.

We navigate a sea of these slow-acting, cumulative toxins. They pervade almost every aspect of consumer culture, including food flavoring and preservation, cosmetics, sunscreens, and pesticides. Many are synthetic organic molecules, of which there are now hundreds of thousands. Some are heavy metals. Some are the breakdown products of plastics. Together, they’re implicated in a range of disorders from birth defects to asthma to cancer.

Socrates could drink any of these and not be affected because a single exposure is almost innocuous. Almost. But regular assault by hundreds, year after year, can and does evolve disease. And when you eventually get sick, you can’t point to one causative agent, since there were so many and over so long a time. For those who produce and distribute these chemicals, this phenomenon is a liability dream. In very few cases can anyone prove who injured them.

Don’t believe for a moment that the government protects you from these agents. Of the massive number of potential chemical offenders, only a few have ever even been tested for hazard, and of that number a handful have been banned. One obstacle to more universal testing is expense. The cost of thoroughly evaluating every compound would occupy the entire federal budget. It would make sense, then, to compel manufacturers to test their products on their dime…but you see the quandary here: manufacturers tend eternally to find their products not only harmless, but boons to humankind. Funny how that works. So the FDA labels most untested chemicals “Generally Recognized As Safe,” or GRAS, meaning we haven’t the slightest idea, but what the hell, we’ll give them a pass.

That’s why our family reads labels carefully. We don’t buy any body care product that contains parabens. We don’t eat meat treated with nitrates or nitrites. We avoid plastic containers made with bisphenols. I chronically appeal to our local school boards to avoid Roundup on school lawns.

Are these chemicals really carcinogens? It’s hard to know. Research sponsored by independent groups casts abundant suspicion on them, but that’s countered by the chemical industry’s opposing publicity plus the effect of its lobbyists on legislators. The impasse is why so many chemicals are labeled GRAS. I suppose that’s a way of applying our judicial “innocent till proven guilty” ethic to inanimate products.

Canada does it a little differently. Through its “precautionary principle,” chemicals are considered harmful until proven harmless. Earlier this year I took walks around neighborhoods in Ottawa and Montreal. Official-looking signs on lawns here and there announced that those homeowners were using pesticides. They couldn’t just flop a few bucks onto the counter at Chemicals-R-Us and walk out with a tub of Roundup. They had to get a permit and put up the sign to inform their neighbors, and yes, there is some social stigma attached.

For those of us who abhor government intervention, there’s always the marketplace. Read labels. Learn what’s harmful in food and body and landscaping products. For a start, take a look at http://www.preventcancer.com/consumers/cosmetics/Tables_cospcp.htm
Don’t buy anything with ingredients that look like a high school science project. Today I read a canned soup label that listed—I counted them—fifty-one ingredients. Only a few were edible; the rest were shelf-life extenders and artificial doodads. In his book The Omnivore’s Dilemma, author Michael Pollan advises against buying any food whose ingredients you can’t explain to your grandmother.

I take the title of this blog seriously. People do matter. Shelf life extenders don’t. Whatever we buy and apply and ingest is a vote for a particular way of living, and at the same time assertion of personal responsibility for our health.

Friday, December 3, 2010

A WRENCH IN THE MACHINE

Are caregiver issues becoming more prominent, or am I just getting more sensitive to them?

The connection between sick people and their caregivers is as complex and unique as any relationship, and believe me, there are some strange ones around. Think of a coupleship, for example, that makes your jaw drop. You’ve asked yourself what these people get from one another, or how they can stand to live together. Like me, you eventually concluded that people scratch where they itch, and relationships are attempts to integrate itches and scratches. These attempts, these machines we evolve, strange though they may look to others, can work well. But throw in a serious illness…

Several years ago, Hildegarde told her support group that her doctor said her chemo was no longer working, that they’d need to change her treatment. When she returned home, her husband, Ken, asked her how it went. She said, “The doctor said the chemo’s not working.”

Ken flew into a rage. “That’s an awful way to tell me,” he said. “How negative! What a thing to do to me!” He advised Hildegarde to see a therapist. “There’s something wrong with you, to act like that,” he said.

After Hildegarde related this event, another member, Lisa, suggested that there was nothing wrong with her at all. Hildegarde had told Ken the simple truth, she said, and he acted as though he’d been somehow victimized. “You don’t need a therapist. Ken does. Or maybe you should see one together.”

Hildegarde described Ken as characteristically busy—with golf, fishing, his lodge, volunteer work and hobbies—to the point of distraction. She suspected he coped with stress around her cancer by refusing to take a break long enough to think about it.

One of many reasons for continually improving communication skills is that we have no idea what’s in someone else’s mind unless they express it. I don’t care whether you’re a stranger or my best pal of decades; unless you come out and tell me, I can only guess your feelings.

That isn’t the problem, though, since we’re actually pretty good at guessing others’ feelings. We notice their body language—their face, their posture, inflections, and so on. The problem is that while the body can’t lie, the mind can indeed.

So when my wife asks, “What’s eating you?” I respond, “Nothing. Why?” Suddenly, a wrench in our machine.

Monday, November 29, 2010

YOU NEEDN'T HIDE YOUR "PEOPLE" MAGAZINE ANYMORE


A news item in the NY Times (http://www.nytimes.com/2010/11/30/health/views/30mind.html?_r=1) reported that “Narcissistic personality disorder” is going to be deleted from the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, due out in 2013.

NPD isn’t the first entity to get bumped from the DSM. In 1973, homosexuality was deleted after years of debate. It finally happened when enough gay psychiatrists came out, causing their straight colleagues to observe, “Gee, I know those people and they seem fine. So maybe they’re normal.”

Psychiatric diagnoses rise and fall from a show of hands: it's no more scientific than that.

If you wonder why NPD, of all behaviors, no longer looks abnormal, take a look at Facebook, where hundreds of your “friends” can’t wait to tell you they bought a jar of Skippy this morning. Take a look at television, where people ache so much for their fifteen minutes of attention that they wait in line to make fools or felons of themselves. Notice that we gaze into one another's eyes less than at our cell phone screen’s display of messages, messages to US. 

Yup, narcissism’s getting relieved of its “disorder” burden because a significant number of psychiatrists have had the courage to admit that they, too, have become navel-gazers. Narcissism is now officially normal. What gets rehabilitated next, greed?

Friday, November 26, 2010

CANCER AND PTSD

Thanks to our interminable wars, we hear regularly about returned veterans suffering Post-Traumatic Stress Disorder. PTSD is characterized by hypervigilance, nightmares, mood swings, and inexplicable emotions, including emotional numbness. In sum, PTSD is a frightening derangement of feelings.

We’re beginning to realize, though, that PTSD isn’t limited to war veterans. It’s shared by people who, having been through any situation that threatens their sense of self and who didn’t consciously process their consequent feelings. For example, one study found the rate of PTSD in adults who were in foster care for one teenage year was higher than that of combat veterans.

Is it any surprise, then, that PTSD is common in people with cancer? If you haven’t been through cancer yourself, then imagine that your doctor just spoke the C word. Your hearing failed immediately after that, but later you remember the doctor saying you need some diagnostic studies, and the sooner the better, since cancer cells are anything but patient. You undergo a variety of mystifying scans and other tests, learn about the stage and intensity of your cancer, and are encouraged to begin treatment, chemotherapy, say, immediately. The treatment is no picnic. It fatigues and nauseates you, and changes your body image. Meanwhile, your relatives and friends conduct their own confusingly mixed choreography. A few separate from you, a few infantilize you, and conversely, many show you loved you’d never dreamed of.

In other words, your life as you knew it is utterly gone, and at this point there’s no reliable replacement. Is that a bit unsettling? Would that all these changes had occurred more leisurely, with enough time for you to emotionally digest each, but that’s a rarity. New cancer can demand an urgency that leaves emotional health in the dust. Yet as one member of a cancer support group advised, “Buried emotions are always buried alive.”

Sooner or later, like stones in a farm field, they surface, and can do so in distorted, baffling ways: PTSD. Part of my work in facilitating cancer support is to convey two items of hope to new patients and their families:
    1. The emotional roller coaster they’re riding does NOT mean they’ve gone nuts. It’s not abnormal. It’s a common, even expected aspect of cancer.
    2. It’s transient. The emotions patients had to stuff temporarily in order to survive are now finally accessible, and can be gently drained away.

Wednesday, November 17, 2010

WE'RE MUCH MORE THAN WE'VE BELIEVED

Finnish researchers recently found that exercise doesn't carry predictably results. Some people benefit, some don't, some decay a little more.
 
That finding parallels experience with diet, too, and with personal response to medication.“…the actual mechanisms involved are complex,” says the article. Indeed: maybe we aren’t as knowledgeable as we claim. In a story that may be apocryphal, a medical school dean told his graduating class, “I’m sorry, but about a third of what you’ve learned here is incorrect. We just don’t know which third.”

When we view any human being, we need to know that this flesh we see is only the tip of something invisible and far larger. Each of us is a universe of perception, emotion and meaning, which inevitably informs our every activity. 

The mornings I run, I of course observe others running. Some look blissed out, some look as though The Reaper’s chasing them. My fantasy—though not yet borne out by science—is that we squirt out hormones specific to our emotions: some runners bathe themselves in cortisol, others in endorphins. That is, consider that it’s not about exercise, but the meaning that exercise holds for us.

One can postulate similarly about diet (and any other function, as a matter of fact). Imagine gobbling a half-pound of bacon. Tastes good, right? But it might also generate a guilt pang, meaning certain as-yet-undiscovered brain cells emit guiltotonin, a hormone with nasty cardiovascular consequences.

As long as we wish to see ourselves primarily as physical beings, we’ll attend just to that aspect. We won’t learn much about who we really are until we significantly appreciate our subjective elegance.

Tuesday, November 16, 2010

THE PRINCESS INDEX

As I pay attention to developments in the world of cancer, I see a particular aspect gaining justified prominence: caregivers.

Just a couple of years ago, caregiver issues were considered almost ancillary, a sideline to the major phenomenon, the patient and his or her tumor. It’s increasingly apparent, though, that the quality of care patients receive is inevitably dependent on the condition of their caregivers.

In my experience, caregivers (usually spouses, but sometimes other relatives or friends) often suffer more than the patient does, beset by anxiety, depression, sleep deprivation, fatigue, and underappreciation.
And if you’ve ever been a patient, you know that at times you can be a real pain in the butt.

A scientist friend is currently caring for his wife. Normally easygoing and pleasant, she’s on a steroid, Decadron, that leaves her wired, sleepless, tired, and uncharacteristically irritable and demanding.

My friend says, “Her intensity around being sure I have done obvious things gets annoying, but I am trying to find words to convey my position without getting upset. It gives new meaning to the idea of your spouse acting like a ‘princess.’ Get me this, do that, do it THIS way, and do it NOW. Weird. But it is something I need to be tolerant of, especially because it is clearly not due to a previously un-manifest personality flaw, but is a pharmacologic side effect of euphoria. We have had to develop a sense of humor about it, so I came up with the idea of a a quantitative measurement, the ‘Princess Index.’” 

PRINCESS INDEX =  PRESENCE OF CRISIS (0 OR 1) TIMES DECADRON  DOSAGE TIMES DECADRON DURATION DIVIDED BY FUNCTIONAL LEVEL (0 TO 10)

So if you’re sick and it seems your caregivers regard you as Mr. Hyde, consider that there's nothing wrong with you. It's just that your Princess (or Prince) Index is temporarily elevated.

Tuesday, October 26, 2010

RESPONSIBILITY


Research published in this month’s American Journal of Preventive Medicine indicates that when a physician advises a patient to lose weight, the patient does or doesn’t depending on the physician’s counseling style.

The most successful style is a back-and-forth conversation. E.g., “What are your feelings about your weight?” The least successful is where the doc alone speaks. E.g., “You know, you really need to knock off twenty or thirty pounds.”

If you’ve been reading this blog, I guess this conclusion isn’t earthshaking news.

The lead researcher, Dr. Kathryn Pollak, an associate professor of community and family medicine at Duke, put her finger on it when she said, “When it comes to behavior change, the patient is the expert, not the doctor…The whole point is to help the patient solve the problem himself…Doctors are hearing the message that they need to do something. They’re trying, but they’re not doing it right.”

It’d be nice if they were doing it right, but really: whose job is it to motivate the patient to change, anyway? 

My physician friends tell me the majority of their patients suffer from diseases—including emphysema, obesity, type two diabetes, and hypertension—that arise from pathogenic lifestyles. Docs can clean up some of the damage, but that approach essentially enables self-destructive behavior. It’s an expensive, high-tech turnstile which certainly keeps the wheels of commerce spinning but doesn’t elevate the general health.

Here’s one of my favorite quotations, by John Knowles, M.D.,late President of the Rockefeller Foundation and Medical Director of Massachusetts General Hospital:

"The people have been led to believe that national health insurance, more doctors, and greater use of high-cost hospital-based technologies will improve their health. Unfortunately, none of them will. The next major advances in the health of the American people will come from the assumption of individual responsibility for one's own health and a necessary change in the life style of a majority of Americans."

He said that some thirty years ago. Are things better now? One can hope…

By the way, I’m going away for a couple of weeks, so if you’re a regular reader of this blog be sure to tune in again in mid-November.

Friday, October 22, 2010

LEARNING FROM ILLNESS


When our kids were little, we noticed that they had a growth spurt following illnesses. They dramatically matured in some way. Suddenly they read better or were more friendly. Realizing now that that curious phenomenon happens in adulthood, too, I’ve shifted my perspective about sickness: it really does have a silver lining…if you look for it.

I routinely ask people with cancer what they’ve learned from the experience. I don’t do that at first meeting, of course, since such a conversation requires trust. As you might expect, everyone offers a different answer. For many, cancer delivers revelations that change their lives, and for some…well, one woman responded, “Here’s what I learned: don’t get cancer.”

Sometimes we’re able to squeeze a significant personal event for its inherent wisdom. Sometimes we miss it altogether, and that’s too bad, since sickness is so expensive, it’s a shame not to cut our losses by at least learning something from it. In addition, if a life-threatening illness doesn’t push our face into the existential mirror, then what will we extract from less compelling events?

I haven’t had cancer, but I have had my share of raps from two-by-fours. Thirty-five years ago, suffering from viral meningitis, lying on my back in a rigid arc, I was surprised to find myself thinking, “Hm. What am I supposed to get from this?” I did learn a little something from it, and, later, this: if it takes two-by-fours to awaken my curiosity about how the world works, why don’t I get sensitive enough to respond to one-by-twos—or feathers, for that matter? In fact, why don’t I learn from virtually every experience?

Thursday, October 21, 2010

VALUES


Commenter DreamsAmelia (see her Oct. 20 note) writes with passion and eloquence that demand a blog of her own. At least she’s cranked me up.

She writes about the proposed devastation of Winkler Botanical Preserve in Alexandria, VA. The idea is to build a traffic-easing exit ramp from Highway 395, and the Preserve is in the way. The sorry lack of foresight, history and imagination that can destroy a park for short-term commuter relief is epidemic. Where I live, in the rural Sierra foothills, huge mining companies perennially vie to rape our land for its gold, ruining our air and water in the process.

When you look deeply into healthcare’s current engine, you see that its flywheel is similar: business considerations outweigh human values. In the span of my life I’ve watched healthcare devolve from  service to commerce, but so gradually that its practitioners barely noticed. The obsession with diagnosis as be-all and end-all is a perfect match with profit as be-all and end-all in the business arena. The kids (I call them that because I’m of an age to be their grandfather) who are now entering medical training either have no idea that medicine was practiced more slowly, softly and inexpensively in living memory, or they do know that and believe today’s impersonal, industrial style actually represents progress.

How to reverse the engine? I believe that every one of us yearns to be loved and comforted, enjoy contact with others, and maximize our life quality--in other words, realize values beyond financial. I see it in online social networking, where people want desperately to believe their “friends” are real friends. I see it in supermarkets, where a shopper slows the checkout line to smalltalk with a clerk. I see it in patients’ demands for more humane healthcare. I want to help ignite those yearnings, help change Americans from passive “consumers” into active, potent, healthy citizens.

Wednesday, October 20, 2010

…AND DOCTORS CAN ALSO BE NOCEBOS

A reader commented yesterday, “But the problem is, my doctor is NOT much of a placebo for me...this is hard to explain to my mother, for whom doctors ARE placebos…”

There is that difference between generations, isn’t there? Our parents, believing doctors commuted from Mount Olympus, put themselves into medical hands with nary a question or qualm. If my parents’ doctor had offered to sew their elbows together, they would’ve eagerly assented. I remember one doctor treating my teenage face with radiation, and another doing oral surgery on my sister for what I recognized later was no problem at all.

Now, thank goodness, we’re more sophisticated, more likely to demand evidence that the doc’s a genuine healer and not a nocebo. When I wrote about doctors as placebos I forgot to mention its opposite. A nocebo is something that’s chemically inert but makes you feel worse. Just as docs can be placebos, they can be nocebos, too.

I’m not sure which your own doctor is to you, but his professional atmosphere is evidently a turn-off. You wrote, “…in that dreadful office with the blaring fluorescent lights in a high rise building I don't connect with anyway.”

Whatever a doc’s values, they’re inevitably expressed in the office ambiance. When I arrived for a medical appointment several years ago, the receptionist sourly questioned me as though I’d come to burgle the place. Like you, I was irritated by the harsh fluorescents, and even more by the nurses’ clinical detachment and the half-hour wait in the examining room. I left that doctor and found another who operated his office as though people mattered.

Legislation can dictate who pays for healthcare, but it can’t command its humanity to bloom. That can come about only by patients voting; every appointment, every transaction, is a vote for or against a style of practice.

Tuesday, October 19, 2010

DIAGNOSIS VS. RELIEF

In the October 18 posting, I mentioned the tendency within current healthcare to favor diagnosis over subjective goals like relief and comfort.

No sooner did I write that than I heard from a good friend who’s been suffering abdominal pains for several months. She saw the least invasive and least expensive practitioners first—a chiropractor, acupuncturist, and body worker. Their treatments, which were intended to simultaneously diagnose and treat her symptoms (e.g., “See what avoiding gluten for a couple of weeks does to your pain level”), proved unsuccessful.

Finally, anxious that the problem might be a surgical condition like cancer, she saw a physician’s assistant and the PA’s physician supervisor. My friend left with a sheaf of test orders.

A day later, still hurting, she said, “Wow! I just realized that they only ordered tests. They didn’t offer me anything to relieve my symptoms.” True, she never requested pain meds, but I find it remarkable that the doc and PA suggested none anyway.

I know these practitioners, and respect them for their kindness and thoroughness. Yet they, too, inhabit a subculture in which diagnosis flashes in neon colors while relief molders in the shadows.

I doubt my friend will take it upon herself to educate them, as she’s preoccupied with her symptoms. In any case, this imbalance between diagnosis and relief pervades the system. That’s just one little reason why “healthcare reform” can’t simply consist of who pays for what. We need to rebuild healthcare from the foundation up.

Monday, October 18, 2010

NEWS FLASH: DOCTORS ARE PLACEBOS!

We think of a “placebo” as an inert substance that acts therapeutically because the patient believes it will. Up to forty percent of post-treatment improvement, as a matter of fact, is due to placebo effect.

Placebos aren’t just pills. Doctors are also placebos.

Imagine that you, sick and vulnerable, have come to your doctor. Knowing this person is intelligent, well-trained, dedicated and experienced, you put yourself in his or her hands and expect salutary results. Even though the doctor hasn’t yet done a thing, you feel a little better already: placebo.

Unfortunately, my medical classmates and I were absent the day they taught Placebo 101. Had we been there, we’d know better how to use placebo power skillfully. Indigenous shamans, on the other hand, receive intense placebo training. They have time for it because they’re not required to take microbiology and biochemistry. Like much else in life, it’s a tradeoff: they wind up lacking scientific background, and we lack healing magic.

Of course, nothing prevents us docs from learning how to play our placebo role effectively. For example, we could decide to see our examining room as a sacred space. That means getting quiet and centered before we enter it, and then, once inside, treating its intimacy and potential power with serious respect. It means converting its atmosphere from mundane to transcendent, from despair to hope, with ritual.

The traditional medical ritual is the physical exam, with its four major components, observation, auscultation, palpation, and percussion. The amount of diagnostic information this can reveal is staggering. All this staring and listening, feeling and tapping can also be mystifying to the patient; in the benign disorientation the ritual engenders, it begins to create a wider reality, one richer in possibility.

Despite its medical and spiritual value, though, the physical exam is dying. As often as not, the doc relies more on a quick history and abundant testing to reach the grail of diagnosis. Just as today’s psychiatrists are taught psychopharmacology but very little psychotherapy, too many young docs learn to practice without the sublime contact skills that both reveal and comfort.

A century ago, Dr. Edward Livingston Trudeau opened America’s first tuberculosis sanitarium. The disease was considered medically incurable then, but Dr. Trudeau achieved great success simply by offering his patients rest, fresh air, good food, and abundant attention. His motto, preserved on a plaque near the shore of Lake Saranac, New York, was,

“Cure sometimes,
Relieve often,
Comfort always.”

In those days, diagnosis wasn’t everything. Relief and comfort were and remain our most profound goals. One of today’s proponents of reviving the physical exam is physician-author Dr. Abraham Verghese. In a recent NY Times interview, he said that performing the exam tells the patient, “‘I will never leave you. I will not let you die in pain or alone.’ There’s not a test you can offer that does that.”

Monday, October 11, 2010

HEAL THYSELF


According to a recent article in the NY Times (http://www.nytimes.com/2010/10/07/health/views/07chen.html?pagewanted=1&_r=1), physicians have higher rates of suicide than the general population. Male doctors suffer a rate forty percent higher, and female doctors an alarming one hundred thirty percent higher. Since freshman medical students exhibit mental health profiles similar to their peers, it must be something within medical training and practice that damages physicians. The fact that practitioners themselves are in such poor emotional shape is a profound indictment of our healthcare system.

There’s no shortage of causative theories for these suicide rates. Do they result from the isolation medical students endure, or perhaps the intense competition in which they’re immersed? Numerous studies are now addressing these features. Strangely, though, no one has asked me.

I suspect the key lies in gender differences. You’ve probably noticed that women generally express emotions more easily than men do. Being female, they don’t need to exemplify male strength and cool, so they can allow themselves to be vulnerable, and to be cooperative with one another.

Physicianship has historically been male turf. My medical school class (1967) comprised sixty-four men and four women. Now, I understand, the majority of medical students are women, but it’s been a hard climb.

I remember one of my few female professors, a dignified, illustrious medical scholar, who began a lecture with a dirty joke. We laughed politely, as it wasn’t funny. Obviously not used to this humor, she’d picked something like what we giggled at in third grade. As she told it, she was red-faced embarrassed. Thinking about it years later, I realized she’d attempted to put us at ease by enacting a ritual that said, “You can listen to me; I’m one of the boys.”

I wasn’t conscious enough in those days to have pursued the subject, but now I wonder how my female classmates accommodated and responded to the  subtle but endemic sexual harassment and condescension directed toward them. I witnessed one strategy in my senior year, when a female gynecology resident stood up in rounds and asked why she wasn’t permitted to perform a culdoscopy on every patient. (A culdoscopy is an invasive procedure that involves inserting a high-tech periscope through the upper vaginal wall into the abdominal cavity.) Today such a suggestion would be considered close to criminal, but then the chief of gynecology was merely curious. He asked her why she wanted to do that. She replied, “This is a teaching hospital, isn’t it?” She was one of the boys, alright, in spades.

What does it mean for any of us, male or female, to act the mythologic male? Who knows, after all, what a “real” man is like aside from the cultural images we absorb? In Berkeley, decades ago, a psychotherapist named Chris Elms (thanks, Chris!) posted flyers all over town for his men’s groups. The bore a photo of young boys at the beach around the turn of the century, posing for the camera in their woolen swimsuits. Every one of them was flexing his biceps. Elms’ caption read, “Tired of holding that pose?”

Here’s the pose: strong; invulnerable, in fact, imperturbable; confident; able to handle any situation without help. Indeed, this model runs deep and wide. It describes almost every hero, from films to comic books. Medically, it’s Doctor Christian to Doctor House, and every fictitious physician between. It’s the implicit character model of medical training and practice.

I could list hundreds of facets of medical training that exemplify this myth, but that would be a book, and I’m only writing a blog entry here. In sum, though, a bright and altruistic freshman medical student is taught, slowly and thoroughly, to ignore suffering. Don’t believe for a moment that doctors, who for a living wade in suffering every hour of their career, don’t hurt as a result.

But obviously, you can’t practice medicine if you’re continually crying. Act like a man, for God's sake. Practically, though, you need to do something with the suffering you’ve absorbed, and there are only two routes available: express it or repress it. Repression, like denial, is an effective defense but must eventually fail. A member of a cancer support group put it perfectly when she said, “Buried suffering is always buried alive.”

All healthcare practitioners, not just physicians, need a self-care tool that’s currently in short supply, the ability to express their own suffering and still practice. This isn’t an easy challenge, since it requires deep self-reflection and usually intimidating adjustments. When the old masters like Sir William Osler wrote about the sacredness of the medical profession, they weren’t just addressing the magic that ought to occur inside the examining room. They included the deep, almost mystical, preparations doctors must make in themselves.

Wednesday, October 6, 2010

DOCTORS WITHOUT BORDERS


Associates and I are currently designing a conference in which we’ll convene doctors and patients in order to explore their cultural differences.

I’ve written here that I consider the two groups “tribes,” with all that connotes: distinct perspectives, languages, and behaviors. We hope that by educating each tribe about the other’s culture we’ll be promoting effective communication.

How do the worlds of patients and doctors differ? Why bother about this, anyway? Consider these interactions:

  • Marie says, “I asked Dr. N how serious my illness was. All he said was, “Let me worry about that.”

  • Dr. A says, “She’s such a frustrating patient. When she told me about her pain she played it down, and now she says I didn’t give her strong enough pain meds.”

  • Says Dr. B, “It was time to talk with Mr. T about hospice care, but I didn’t want to scare him.” Her patient, Mr. T, says, “I wanted to ask Dr. B about hospice care, but I didn’t want her to think she’d failed, so I didn’t mention it.”

  • Will leaves his exam angry that the doctor took his history with his back to him, typing on his laptop.

  • Josephine says, “If only Dr. C had simply admitted he’d made a mistake, I’d have forgiven him. It’s his stonewalling that made me sue him.”

  • Bennett says, “My doctor called me into his office to talk about some test results. After she used the C word, I didn’t hear anything…”

Those examples barely scratch the surface. You could probably conjure dozens of others. People aren’t being mean or dismissive; they’re behaving reasonably within their exclusive perspective.

Please help me out here. How would you educate each tribe about the other?

Tuesday, September 28, 2010

ON BEING SURE

I heard a pediatrician tell a revealing story. It began when parents brought their eight-year-old son to the ER after he was bumped on the head and then temporarily confused. The doc examined the boy, concluded it was a soft-tissue injury unlikely to have residuals, and suggested the parents take him home and observe him for the next twenty-four hours.

"Uh uh," said the parents. "Let’s be sure with an MRI."

Well, why not? No one was using the MRI machine at the time, even though it needs almost constant use in order to be amortized, and what the hell, insurance would pay for it anyway. So the kid got the MRI.

The pediatrician ended the story by pointing out that the MRI result, "normal," didn’t leave anyone sure, only surer. Well, why can’t we have surer than surer? At this moment some technological breakthrough is on its way to every ER which will make the MRI look coarse, but will cost six times more. The question must arise: how much certainty do we need?

One reason American healthcare is so expensive is the premium we place on certainty. As a society, we don’t tolerate ambiguity well. Think about a time you endured, when just knowing what was happening, even though it might be awful, was better than not knowing. Uncertainty leaves a wide wake of fear. Recent history shows it can even cause wars.

But who would possibly oppose a quest for certainty? The surer we are, the less room there is for self-doubt. That’s part of our heritage, after all. “Be sure you’re right,” said Davy Crockett (or maybe it was just Fess Parker), “and then go ahead.”

The trouble is, though, that the universe itself is factually shaky. People have won Nobel Prizes for proving that certainty is a chimera, an illusory ideal. As soon as you’re sure where that electron is, it’s not there. Still, we strive for certainty, and we believe we can come close, but how close is permanently anyone’s guess.

As a sometimes carpenter, I can tell you that the art of progressing from a home’s foundation to its finish lies in reducing gaps, from foot-plus framing spaces down to cabinetry’s barely perceptible wedges. Medicine is no different. A sixteenth century doctor might have concluded after examining you that you had an infection. That at least put it in the ballpark. A late Victorian doctor might have narrowed it further, to “botulism infection.” Today’s doctor will read you, if you insist, the genome of the botulism bacterium.

We’re daily reducing gaps in medical knowledge, but at exponentially rising cost. A doctor who feels your abdomen and charges ninety dollars can estimate your spleen size within a centimeter or two, while a thousand-dollar CAT scan measures it a hundred times more accurately. To paraphrase anthropologist Gregory Bateson, is this a difference that makes a difference?

Failing certainty doesn’t mean we’re doomed to operate from ignorance. We make educated guesses about the world and navigate accordingly. I suspect the reason we’re on the planet more than a few weeks is to perfect our guesses, continually approach permanently elusive Truth. The good news and the bad news are identical: we’re doing the best we can.