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.

Sunday, September 26, 2010

THE MARCH OF THE ROBOT DOCTORS

I came across it again, so maybe it’s not the 15-minute fad I thought it was: robot doctors.

A stainless-steel machine wheels up to your bedside, a human face displayed on its monitor screen. The face is that of a real physician who’s three floors or maybe a thousand miles away. Sensors that pop from the gadget take your pulse, blood pressure, temperature. At her end, the human doc reads an electronic rendition of your history and test results, and says to you, through the monitor, “Not to worry. We think we know what’s going on now, and you’ll be fine. Here’s a medication to calm your nerves.” A handlike process offers you a little blue pill.

Yup, looks like this might be the future. Think about it. Why pay five docs two hundred K each when you can get the same done with one doc and five twenty-K robots? Do the math. Business is business, after all, and make no mistake: healthcare is business on steroids. So get used to it, Patient #2375-D-00714.

Friday, September 17, 2010

MONOTASKING


When we talk about serious illness, the conversation inevitably turns toward something called “quality of life.” Nice phrase, but what exactly does it mean?

Recall Robert Pirsig’s 1974 book, Zen and the Art of Motorcycle Maintenance. Subtitled “An Inquiry Into Values,” the book explored this Q word. What, after all, defines the “quality” experiences that together constitute “quality of life?” As he roamed the United States on his Suzuki, Pirsig developed the notion that quality is bound inextricably to attention. The more completely we focus on anything we do—anything: changing a tire, knitting, writing—the more we learn who we are and how to proceed. But don’t take my word for it. Ask spiritual practitioners around the world.

If quality is proportionate to attention, we’re in trouble, since the past decade or two we’ve sped in the opposite direction, “multitasking.” We believe multitasking must be a good thing since folks everywhere declare pride in their ability to do it. It’s even become a requisite for employment. Studies show, though, that very few people do it well. 

You can ride one horse better than two, and this isn’t just idle philosophizing.

A friend got an x-ray to monitor a small tumor that’s been idling in her lung. During the procedure she heard her two technicians in a heated personal conflict. The x-ray suggested that her tumor was slightly larger than two months before. Now she wonders if that’s so or if the technicians, distracted by their argument, misprogrammed the apparatus. Her oncologist agrees with her, and has scheduled another study next month.

Another friend was being treated by her chiropractor, who was handed his cell phone by an assistant. While the chiropractor manipulated my friend’s spine, he bargained for a used car. My friend, enraged, wanted to say something about this but if she angered him, she imagined, he might injure her.

Still another friend complained, “I saw my doctor, but didn’t really. I mean, while he asked me questions he constantly had his back to me, typing on his laptop.”

I hope we agree that these were less than optimal healing atmospheres. My regular rant here is that healing—the diminishment of suffering—is hastened by intimate human contact. I'm beginning to fear, though, that contact may be an endangered species.

Ironically, contact was at one time the only medicine available. The earliest European hospital--and the model for many others--was the Hotel Dieu in Paris, founded in the seventh century. The staff of this “Hostel of God” consisted for a thousand years not of employees but of nuns dedicated to healing. MRIs, antibiotics, aspirin, and even reliable knowledge being unknown, patients received the remedies of their time along with more effective treatment: adequate food and shelter, quiet, dignity, stained-glass imagery, and the care of sisters trained in attention.

If you’ve ever experienced an instance when you didn’t get a healthcare practitioner’s full attention, how did you feel? If you concluded that’s just the way things are, please reconsider. We practitioners multitask only because that’s what we were trained to do. Believe me, it minimizes our own quality of life, but we literally don’t know better...unless you tell us. Ask your chiropractor or nurse or doctor, “Have you heard about monotasking?”

Tuesday, September 14, 2010

GUIDANCE THROUGH CANCERLAND

I meet someone at a party. He asks what line of work I'm in. 

I say, "I facilitate cancer support groups."

He takes a step backward. "Wow," he says, "that must be heavy. Really depressing. I mean, all those dying people crying on each other's shoulders."

His is a common and even understandable assumption, but in thirty-some years of facilitating cancer support groups, I've never seen that sort of unalloyed bummer. Sure, people cry sometimes, and some die. But that's real life, isn't it? And there's plenty of love and laughter, and that's real life, too. 

Because the picture of support groups as total gloom is so common, a few of us psychosocial types got together at our cancer center and decided to make an educational video. The center funded two terrific videographers, Jan Fishler and Richard Bannister. Members of several support groups (patients, caregivers, kids) volunteered to be in it. We shot two hours one June afternoon, and Richard and Jan pared it down to something under seven minutes. The video is deliberately un-copyrighted; feel free to pirate it.

Saturday, September 11, 2010

SUPPORT, THERAPY AND FRIENDSHIP


In speaking with people who are forming cancer support groups, I’ve regularly encountered one particular issue: who’s qualified to facilitate?

Doesn’t what occurs in a support group, after all, constitute psychotherapy? Is the facilitator someone who’s able to handle whatever arises? What if a participant comes unstrung? Can a facilitator also be a friend of participants, or is that what’s called in therapy circles a “dual relationship,” something to be avoided?

Such questions fascinate me, addressing, as they do, the interface between therapy, support and friendship.

If you’ve been sick, you’ve probably noticed that those close to you react variously to your situation. Some drift up to you with tented eyebrows, crooning, “How aaaaaaaaaaaare you?” Right away, you feel worse. They go on to say, “My cousin’s uncle had that, and he lasted three months.” Or, “Hang in there. I just know you’re gonna be okay.” To say the least, they’re not helpful.

A number of others simply drift away. Either your illness frightens them or they want to help but don’t know what to say. 

A few, though, are tangibly healing. By their language and demeanor, it’s obvious they’re there with you. You feel better afterward for having been with them.

Now, they are friends in the fullest sense. A friend is someone who stays by you no matter what; who accepts what you’re going through without trying to fix you; who listens to you at the core level; who tells you not what they think you want to hear, but their truth.

This high-quality friendship is identical to what we call “support.” Some of us have never in our lives experienced this degree of intimacy and honesty. When we finally encounter it, say in an effective support group, it’s like having been blind and now suddenly granted the gift of sight. We demand more of it, and in fact begin to question why we’d choose to associate with anyone who’s less than supportive.

Psychotherapy’s a little different. We engage a therapist to challenge us, push us, delve into parts of ourselves we haven’t sufficiently explored. That’s a deeper agreement than support groups maintain. We’re not in a group to turn ourselves inside out, however useful that process can be, but only to find navigational aid for a currently difficult challenge.

I’ve been facilitating support groups for over thirty years, doing it before there was even a name for it, yet I have no training in it. I’m a family practitioner, not a psychiatrist. I approach it simply as friendship, and work constantly on my own friendship skills. To “practice,” after all—whether to practice medicine or to practice piano—isn’t simply to do it repeatedly, but to improve. (In his eighties, Pablo Casals was asked why he still practiced cello three hours daily. “I’m beginning to make progress,” he replied.)
From persisting in this work, I find most of my friends these days are staggeringly thorough human beings. Some even happen to be therapists.

Wednesday, September 8, 2010

TRIBAL LANGUAGE


My September 4 posting, “Tribes,” gathered mixed reviews. While the Seattle Post-Intelligencer called it “…absolutely brilliant…” the New York Times described it as “…the debris of a demented mind…” As my mother told me, you can’t please everyone.

What I was trying to lead into was the notion that patients and doctors occupy the same real estate but separate perceptual dimensions. Seeing slightly different versions of reality, they behave accordingly. Whether we’re a patient or a doctor, recognizing the quality and depth of difference is crucial to effective communication.

I regularly attend our local hospital’s “tumor board.” This weekly meeting, mandated for hospital accreditation, is a valuable forum in which oncologists receive input from nurses, technicians, social workers and other physicians in order to fine-tune patient care. When my wife asked me what exactly goes on in these meetings, I was tempted to invite to her to one, but then I realized that for all she’d understand medicalese, she might as well attend the Bulgarian parliament.  

“Patient is a fifty-year-old male with a high-grade, stage IV liposarcoma with mediastinal mets. CT scans showed one enlarged paratracheal node. Biopsy revealed extensive pleomorphism.”

That’s easily comprehensible to the medically trained, but others would need several pages of translation. And that’s fair, since shorthand, or jargon, is necessary in most professions. A carpenter might say, “Run a series of two-by-sixes down this mudsill on sixteen-inch centers.” 

Jargon is especially suitable to physical reality, the primary field of medical training. You don’t just have cancer, you have a stage IV liposarcoma with mediastinal mets. Just as the Inuit are said to have two dozen words for various types of snow, physicians use a language that finely parses medical complexities.

We docs get little training, though, in the non-physical aspects of illness, such as subjective sensation, emotions and meaning, so our language in that department isn’t as rich. I’ve often heard docs call patients “emotional” without elaborating further, so I’m left wondering whether they’re sad, depressed, anxious, angry, hysterical, or desperate. A basic difference between the doctor tribe and the patient tribe, then, is that the physician vocabulary is rich for the physical world but poor for inner nuance, and the opposite is usually true for patients. 

When the patient complains, “I’m in pain,” expect to the doc to prescribe a mild painkiller, the drug with the least expense and side effects—and probably least potency. That’s not a bad decision, after all, but it’s based on a dearth of incoming information, since there’s pain and there’s pain. Unless the doc has experienced her own variety of pain levels and knows to ask, the pain of others looks generic to her. (A suggestion has arisen more than once in our cancer support groups: “No one should be allowed to treat a disease they haven’t had themselves.”) 

Patients can overcome this disconnection by expanding their own language, expressing their pain in more detail, offering the doc a deeper peek into their suffering. “It doesn’t just hurt, Doc. It takes me over. It feels like I’m being electrocuted. If it lasts even for a few hours, I can feel my personality change.” Whoa. How about a little codeine, then?

Language doesn’t just describe reality; it also prescribes it, instructs us in what to see. An oncologist I know is asked several times a day, “Will I die from this cancer?” He could truthfully answer, “Well, yes, probably.” But knowing how patients will likely react to that, he says instead, just as truthfully, “I don’t know. But I do think you’ll live with it the rest of your life.” 

Here's another example of prescriptive language. When medicines seem not to work, docs can feel useless and frustrated. Some head that off by explaining, “The patient failed the treatment.” Of course, it would be more accurate to say the reverse, but here docs are using language to treat themselves.

There’s far more to write about patients’ and physicians’ different worlds, but that’s all I can do today. I have tomatoes to pick.

Saturday, September 4, 2010

TRIBES


Let's say I’m a member of a tribe, the Sharks. We Sharks enjoy a shared history, language, and rituals—in other words, an entire world outlook and its consequent modus operandi. Another tribe, the Jets, with its own world outlook, lives next door. 

Sharks and Jets inevitably contact one another. Imagine I’m picking blackberries one morning. I never look forward to this, since the thorns stick and slash me. Nearby, a Jet is also picking. Her hands dart quickly, deeply into the the tangle of thorns and emerge without scratches. Watching her closely, I notice she doesn’t just thrust into the bush, but snakes her arm through it as though she sees a spatial channel I can’t perceive.

Indeed, that’s exactly the case. I’ve been taught since infancy to see things, like the moon and trees and blackberry branches. She’s been taught to see things, too, but taught also to see the space that defines them, so when it comes to blackberries, she’s as familiar with no-thorn as I am with thorn.

Turning, she notices me and says, “Jeet?” That’s a standard Jet dialect greeting. A contraction of “Did you eat?”, it expresses Jets’ preoccupation with food. I answer, “How you doing?” I realize she’s staring at my shoes. I’m proud of my shoes, comfort being of paramount value to us Sharks. Jets, though, think shoes are for wimps. Barefootedness is sacred to them, even though they complain constantly of stubbed toes and twisted ankles. 

This Jet seems to want to ask me something about my shoes, but then thinks the better of it and departs. I want to know about her picking technique, but I’m not sure how to ask.

Two tribes, two ways seeing, and consequently two ways of navigating the world. How can they better understand one another? 

Now imagine there are two other tribes…called the Patients and the Doctors…

Friday, September 3, 2010

ATTITUDE



My favorite yoga teacher once commented, “Attitude isn’t just an important thing. It’s the only thing.”

The Sept. 2 NY Times “Well Blog” offers a great example (http://www.nytimes.com/2010/09/02/health/views/02chen.html?pagewanted=1&_r=1 ) with an interview with Dr. Ruth Berggren, an infectious-disease specialist who worked at Charity Hospital, New Orleans, when Hurricane Katrina hit.

After the levees broke, the place was hell on earth. As electricity failed and supplies dwindled, the attenuated medical staff had to improvise care constantly. When their resources and hope began to fade, they buoyed themselves with this principle: We may not be able to control what is happening to us, but we can control how we treat each other.

They articulated that attitude aloud over and over, promising that they wouldn’t leave until every one of their patients was safe. Their attitude was tested when they witnessed helicopters evacuate insured patients at Tulane University’s hospital, but no helicopters appeared at Charity, a public hospital where few patients have medical insurance.

Dr. Berggren and her team were finally rescued six days later, but only after all their patients had been evacuated first. Not a single patient died.