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.