Monday, January 31, 2011

OVERLOOKED IN THE ABORTION ISSUE



The contentious maelstrom around abortions routinely neglects an important aspect, the well-being of those who are pregnant.

I was trained at Los Angeles County Hospital in the mid-1960s. In those days, if you decided to terminate your pregnancy and were well-off, your family flew you to Japan or Sweden. If you were poor, you sought  a local abortionist. 

Abortion being thoroughly illegal then, there were no professional standards. Abortionists didn't need a degree, experience, or, for that matter, scruples. They did their work with whatever came to hand--kitchen implements, harsh chemicals, even turkey quills. More often than not, their patients/victims developed bleeding, perforation, and infection. When I was on my Ob-Gyn rotation, we daily saw an average of eight to ten women with these complications. Many were as young as twelve, often hurriedly dropped off at the ER by frightened boyfriends or parties unknown. On the average, one died every day.

Imagine that: your daughter, who still keeps dolls in her bedroom, getting secretly pregnant, mutilated by a backstreet criminal, and shamefully dying alone. If abortion once again is declared illegal we'll return to those days. As always, the wealthy will find little difficulty terminating pregnancies and the less affluent will risk death while their impregnaters suffer no risk at all. 

To say to these young women, "You should have thought of that before…" strikes me not only as inhumanly callous, but actually supportive of the taking of a human life.

Friday, January 28, 2011

THE END-OF-LIFE CONVERSATION


An article in this week's Journal of Clinical Oncology (http://jco.ascopubs.org/content/early/2011/01/24/JCO.2010.33.1744.abstract?sid=8027a539-e187-47f9-a22c-c44361ac2edf) recommends that people with advanced cancer should be told what end-of-life care choices are available earlier in the course of their disease. Unfortunately, these options are often presented only days before death. Hospices nationwide complain that patients are regularly referred to them too late for much benefit.

This delay is no favor to patients or their families, as it sustains suffering rather than authentic life. In addition, it generates huge and unnecessary costs. It's estimated that between one-third and one-half of a person's lifetime healthcare costs occur in one's final two weeks.

What's our problem, anyway? Why do we find it so difficult to talk about death? 

Well, it's scary, isn't it? One Halloween evening when my kids were little, I took them trick-or-treating. I thought it'd be a kick to walk through a cemetery that connects two neighborhoods. They threw a fit. Wouldn't do it, no way. At their young ages, they'd already been indoctrinated into the notion that death equals abject fear. 

That notion seems to be one of our national pastimes: when last year's healthcare reform bill contained a passage offering physicians remuneration for end-of-life conversations with patients, fear addicts all over the country interpreted it as "death panels," pulling the plug on grandma.

We aren't bound to think that way. In fact, our culture's atypical in its deep fear of death. I was in Mexico for the Day of the Dead last year. Their version of Halloween contrasts with ours. The day before, families visit the graves of their relatives and scrub the stones clean. On the day, a mass is held in the cemetery and then everyone parties. They picnic on the graves, sharing food and tequila with the deceased. Mexican cemeteries are places of loving remembrance, not fear.

All fear is based in unknowns, of which the most fundamental is death. But that doesn't have to be. The unknown can generate curiosity as easily as it does fear. How much do we abbreviate our lives in order to "play it safe?" In her classic On Death And Dying, Dr. Elisabeth Kubler-Ross concluded that once we lose our fear of death, we begin to live fully.

It's not so hard to achieve that recognition, really, especially since it's a given, a sure thing. We will die, period. That's not morbid, only a simple certainty. Further, everyone else will die, too. The realization that we will lose everyone we love ought to help reframe how we'll interact with them in this moment. Now and then I toy with the idea of strolling down our little town's main street dispensing Certificates of Mortality to the tourists.

This reluctance to face our impermanence is part of why we don't have end-of-life discussions with our doctors. Another part is what's in doctors' minds. They can harbor the feeling that their patient's death signifies medical failure. Considering how central the issue is in medical practice, I'm surprised how seldom it appears in training. It occupied zero space in my medical school, and in the hundreds of continuing medical education sessions I've attended since, I can't remember more than three or four that even touched on it.

Those of us, whether patients or healthcare practitioners, who find this subject important will find a way to bring it up within the intimacy of the examining room. If we don't, no one else will.

Monday, January 24, 2011

IS IT TRULY MEDICAL INSURANCE?


My friend Margaret recently asked me what I thought about her dropping her medical insurance. She described it as a "catastrophic" policy, meaning low premiums and a high--$8,000--deductible. Her "low" premiums amount to $10,000 annually. Think about that: she pays the first $18,000, then, plus twenty percent of the remainder. Her notion is to drop the policy for two years, till she's eligible for Medicare.

When she characterized her policy as outright extortion, I had to agree. After all, insurance companies aren't in the business of health. They're in the business of making money, period. They employ armies of sharpies who find ways to squeeze every cent from their customers. That's the reality of it. Their only regret, when we die, is the loss of our premium.

Margaret's at an age when serious illnesses begin to kick in. Some are life-threatening and the rest are chronic, meaning incurable. If she drops her insurance, she's betting she won't contract one of these--or be in a serious accident--the next couple of years. I had to tell her I thought it was a risky bet.

A goodly chunk of home foreclosures these days is due to healthcare bills. A friend recently told me that after she brought her seven-year-old son to the emergency room for a splinter, she received a bill for over $3,000. Another friend hospitalized overnight for a broken leg was charged $10,000, essentially for the room. You've heard these stories, too. The system is scandalously, crazily unjust, and until we fix it, it's too easy to get wiped out. So when you go to pay your medical insurance premium, stop believing it's about health. Think of it as home insurance.

ADVANCE DIRECTIVES

My friends Dorothy and Stan recently asked me to help them with their "durable power of attorney for healthcare." That's the legal form we all should have--or at least some variant of it--that names an agent who can make decisions in our behalf if we cannot.

We tend to think of "cannot" as a condition in which we're too sick in old age to comprehend our choices, but that's not often the case. Life, you've probably noticed, can change rapidly. We're doing our same-old-same-old and suddenly we wake up in intensive care having had a stroke or auto accident. If we're unable to assert treatment (or no-treatment) preferences at that point, the hospital will follow its own default procedures unless our authorized agent appears and dictates what he or she feels is our preference.

These forms are available in several styles, sometimes from office supply stores that handle business boilerplate sheets. More thorough versions like "Five Wishes," which also specify items like organ donation, are usually available through hospices. Most don't need to be notarized, and are free to nominal in cost.

One thing to note. When you need your advance directives document, it often can't be found, having been filed away with old invoices or totally misplaced. So make a half-dozen copies. Give one to your specified agent. Have one placed in your file in your doctor's office. If you're hospitalized, be sure one's added to your chart. Get creative. Post a scanned copy on Facebook.    

Wednesday, January 19, 2011

A DOCTOR'S NOTE FOR MY ABSENCE


I haven't posted anything here in a week, the longest hiatus on this blog. Fact is, I've been sick.

I know, I'm a doctor. I'm not supposed to get sick. But of course I do. I cave in, just like anyone else. Up till today my brain has been a sack of virus, unable to conjure a sentence. But since today I seem able to connect a verb with a noun here and there, I suppose I'm on my way back.

This isn't a real blog entry, though, only a place holder. The viruses that have moved out have left only empty space. On the one hand, poor me, no Fascinating Thoughts. On the other: wow! Emptiness. I can't wait to see what grows here.

Tuesday, January 11, 2011

SHOOTINGS: A PUBLIC HEALTH PROBLEM


Massacres don't look so unbelievable these days, do they? We hardly hear anymore, "I never imagined it would happen here." It's finally undeniable that it does happen here and there, so let's just accept that and move on, okay? The shooter was another crazy guy who exploded unpredictably, right? I mean, when your number's up, it's up. What are you gonna do?

Indeed. A visiting anthropologist would call us a fatalistic people. "They barely inhabit their lives," she'd say. "Instead they observe them as if they were the audience. Their voracity for entertainment has surpassed their ability to respond, so responsibility has atrophied. And hey, get this: they once called themselves the free and the brave."

We don't have to live with these murders.

Here's a fact that may surprise you: almost all Americans believe certain people shouldn't have access to firearms. Like three-year-olds, for example. Or convicted felons, or terrorists. Or people who are mentally ill. The late Charlton Heston, former president of the National Rifle Association, stated in an NRA website video, “…we all agree that guns don’t belong in the hands of people who are mentally incompetent, so gun-buy background checks ought to include mental record checks…”

But hold on here: who creates these mental records? Who defines sanity? Will men in white coats come for me if I disagree with the mayor? That is, I'm not about to hand a shotgun to a mentally ill person, but on the other hand, I don't want to rely on some "expert's" word about who's mentally ill, or for that matter who's sane in an insane situation or who's just being their own eccentric selves.

One has to sympathize with those who claim psychiatry isn't scientific, for while there's plenty of skill and wisdom, there truly is little science. For example, psychiatrists determine what is and isn't normal by a show of hands. At their profession's 1975 conference, they voted to move homosexuality from the disorder list to the normal column. In the same way, the American Psychiatric Association's Diagnostic Statistical Manual committee recently voted Narcissistic Personality off the roster, no doubt because it's been mainstreamed. These revisions and others will be revealed in the DSM Fifth Edition, to be published in 2013.

Given psychiatry's subjectivity and the spotiness of gun law enforcement, there's no shortage of cracks through which the mentally ill can fall. Outrage following the Tucson tragedy is sure to expand the responsibility for addressing the issue from law enforcement into public health. This is sensible, two heads being better than one. 

Me, I have no answers to offer, only questions hopefully to stimulate creative discussion. If we fail to disarm psychotics, it is our own mental health that needs to be questioned.

Friday, January 7, 2011

SUPPORT AND PSYCHOTHERAPY

Facilitating cancer support groups for patients and caregivers for some thirty-five years now, I wonder about the difference between "support" and "psychotherapy" groups. Yesterday a friend handed me a list of differences that she received in graduate school. (I never saw such a list before, since I wasn't trained in this work.) I'd guessed some of the differences, but others are illuminating. I'll summarize:

        

If you've never been in a support or therapy group, it's easy to regard  them as equivalent, which is neither here nor there except that "psychotherapy" still conjures stigma. No one can be elected President who's admitted they've been in therapy, the common assumption being that therapy is treatment for insanity. That's a garish misconception, of course, but whatcha gonna do?

Some years ago I facilitated a support group for doctors. You've probably read here before that docs generally aren't doing well emotionally. Many are depressed, even desperate. There's nothing wrong with them: like people who have cancer, they're responding normally to a terrible situation.

Our group was a support group, not a therapy group. Yet its members were vociferous, adamant, and even obsessive about the confidentiality of their membership. Though I explained differences between support and therapy, they weren't dissuaded: it's evidently taboo for a physician to seek help.

As I've pondered that since, it's occurred to me that support is identical to friendship. Review the features of support, above, and tell me if you don't agree. So maybe we misnamed our physician support group. Maybe we should have called it the Doctors' Friendship Circle. What do you think?