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.

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?

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.

…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.

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.

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.”

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.

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?