Friday, May 27, 2011


Earlier this week, while conversing with a group of hospice volunteers, a question germane to hospices arose: why are families so often referred too late?

Here and elsewhere, hospices complain that their patients come to them within a week or two of dying, so that just when services begin to get coordinated, death intervenes. That's a pointless loss, considering what hospices have to offer in the way of personal and family counseling, symptom control, and respite. In continuing medical education sessions, we docs are repeatedly encouraged, cajoled, and begged to refer people earlier. Yet this tardiness persists, and one has to wonder why.

Around here, you're eligible for hospice care when your physician certifies that you'll likely die within six months. (Of course, some patients outlive the six-month prediction, and "graduate" from hospice.) Third parties, including Medicare, pay for hospice services only when that's the exclusive intervention. In other words, you can't receive treatment that's hopefully curative while you're in hospice. The decision to enter hospice, then, means letting go of every thought of recovering.

Hardly anyone looks forward to that eventuality. Doctors' reluctance to recommend hospice can derive from the notion that doing so might connote medical failure. Patients and their families don't want to hear the H word, either, as it can dash hope and fracture protective denial. All parties, then, may understandably conspire to avoid hospice until the Reaper is pounding on the door.

It doesn't have to be that way.

Hospices are founded on the principle of palliation, sometimes called "comfort care." The message is, "We've done what we can to cure you; now we'll do our best to make you comfortable." That's a humane thing to do, of course, but one wonders why we need to choose between cure and comfort. Why don't we apply palliation even when lives aren't threatened? Are not hospice services like counseling and expert pain control useful for virtually every patient and affected family?

For that reason I look forward to the day when there are no more hospices, and all care is palliative.

Tuesday, May 17, 2011


Anyone who thinks Americans don't care about environmental poisons have another think coming. Check out this news article in today's Indianapolis Register:

The Orrin Hatch Nuclear Power Plant lies on a rocky, arid plain ten miles from Turgid Gulch, Wyoming. It was built atop an abandoned toxic landfill which was formerly the property of Greener Than Green Corporation, manufacturer of ecologically sensitive automatic weapons.        
There are no structures within sight of this nuclear facility except for a solitary single-family home exactly one thousand yards away, hugging the far corner of the landfill.
The home is that of Evan Ricketts, his wife Maryjane, and their four children. Ricketts, a thin, balding, wrinkled, fretful, peeling, twitching man who had been the landfill's caretaker, worries about his sparse neighborhood.
“I’ve started to think this might not be a healthy place to live,” he says. “The air’s thick and pink, like cotton candy. You can’t take a breath but for coughing up this yellow stuff with rusty flecks in it. We get bad smells in the house, like to gag a maggot. Gas bubbles rattle the floorboards, and you can feel the foundation grind around at night. We used to be able to drink the water even though we had trouble keeping it down, but then it got too sticky to flow through the pipes. Now we haul in water from Turgid Gulch.”
One wonders why they haven’t moved away.
Maryjane Ricketts chuckles ruefully at the question, coughs into an oily rag, and answers, “We put the house up for sale, but no one would come look at it, not even realtors after the last one’s car sunk through the driveway. When the air's a little clearer you can still see part of the bumper. So we’re stuck, I guess.”
As if the toxic soup upon which their home floats weren’t enough, the Ricketts were affected last year by what the Nuclear Regulatory Commission called a “minor malfunction” at the Hatch nuclear plant. Technicians later admitted that a few of them were “horsing around,” as they put it, and accidentally released several million gallons of radioactive water deep into the landfill. This loss of coolant caused an entire wall of the plant to melt away. Although this was the wall that faced the Ricketts' home, the NRC determined that radioactive contamination was limited to a radius of exactly nine hundred yards, a hundred short of the Ricketts’. Following natural underground contours, the wall's molten concrete cooked the Ricketts’ septic tank in seconds and vaporized their toilet.
“Hoo-eee, that was a close call,” concedes Evan Ricketts, “but to tell you the truth, we've all felt a little puny since then. Can’t quite put my finger on it. Little things, like my bleeding gums and these lumps in my neck. The wife, she miscarries every month or so. The school nurse tells us the kids are about half the size they ought to be, but I can’t tell because I can’t see so good anymore.”
The Ricketts’ problems baffled their family physician, who finally called in the Wyoming Health Department. Its studies concluded that no pollution standards were exceeded and no laws had been broken.        
Despite increasing attention to their situation, things did not go well for the Ricketts. “Got laid off,” mutters Evan Ricketts, “and I can’t get work now ‘cause I’m too well known. They call me ‘Hot Rocks Ricketts,’ and when I go for job interviews they make me just slip my papers in under the door. Can’t get on the welfare because we own our own home. We don’t know what we’re gonna do.”
Documents relating to the Ricketts’ dilemma meandered through the nation’s capital until they reached the legendarily incorruptible Government Accountability Office. A full-scale GAO investigation turned up vast amounts of information that had been suppressed, and its final report led to indictments of the current operators of the power plant, the CEO of Greener Than Green, the Director of the Wyoming State Health Department, and the Ricketts’ personal physician.
All were charged with income tax evasion.
As for the Ricketts, their friends and neighbors haven’t let them down. This past month, a thousand local residents staged a help-a-thon, “Hands Across Turgid Gulch,” in which they raised enough money to buy the Ricketts a new trash compactor.
Thanks, Indianapolis Register. News like that renews my faith in humanity.

Monday, May 16, 2011


Most of us agree with the truism that healthcare is a science and an art. But during the past few decades the art has gotten lost behind the MRI machine. "Use it or lose it," we say in this business. Less utilized, healthcare's art atrophied. Now we seniors remember it, but too many younger docs aren't aware healthcare was ever anything but science.

Science is about the objective, measurable world. It's about logic and precision, which we're awfully good at. Our remarkable scientific hardware lets us perform wonders undreamed of a century ago. Lacking the softer edges art conferred, though, it's drifted from human experience toward more manipulable technology. Check out the reports of robot "doctors" and online psychiatric algorithms, for example. I joke about medical care dispensed from vending machines, but we're not far from it today.

When we in the healthcare professions comprehend our work as essentially science, we gradually abdicate our interpersonal art, the skill of communication. We begin to lose our senses of compassion, forgiveness, joy, skepticism, perspective, and humor.

Patients daily tell me about their healthcare experiences. Most are praiseful and grateful, especially for the medical science that's been applied to them. When they express dissatisfaction, their complaints are uniformly about personal contact. Patient A says his doctor faces his laptop instead of him. Patient B says the staff lost his records. Patient C complains that a nurse was condescending. Patient D says his doctor devastated his hope.

We can replace organs, but it sometimes takes two weeks to fax a test report. We can obliterate germs that once wiped out half a continent, but fail to hear our patient telling us we're not adequately treating her pain. Our hi-tech is great, our low-tech often wanting.

Our science outperforms our art simply because we place more focus on it, and here's why: it makes money.

When I was in training, we handed penny balloons to post-op patients with instructions to blow them up a couple of times a day. The back-pressure kept their lungs inflated, and so warded off pneumonia. No balloons these days, though. Instead, patients are given complex, expensive gadgets that do the same thing at a hundred bucks a pop. We're not just talking about these breathing doohickeys here, but thingamabobs and doodads throughout the medical office and hospital. If you wonder about the source of healthcare's skyrocketing costs, here's a good place to look. We overuse medical technology, and mainly for these reasons:
  • It gets marketed heavily.
  • Having heard about it in many forms of infomercial, patients demand the "latest."
  • It's expensive, so needs to be used in order to amortize its costs.

Compare that with, say, communication. This low-tech intervention doesn't get hawked because no one has yet been able to patent language and so corner the market on it (though I'm sure a number of corporations are looking into it). Since communication isn't commercialized, consumers don't hear about it; no wonder they assume healthcare and technology are identical. Finally, communication is free, so what could it possibly be worth?

Still, some practitioners here and there are intent on preserving healthcare's diminishing humanity. You can tell who they are. They sit still when they're with you, look you in the eye, touch you, ask you questions about you as well as your illness, and listen to you carefully without interrupting. Robots can't do that.

Monday, May 9, 2011


There's a thoughtful essay in the NY Times Well Blog today by Theresa Brown, RN, on doctors disparaging nurses in front of patients (

One might think of this abusive practice as anachronistic, a vile remnant of the 1950s, but it's still very much alive.

A reader who commented on Ms. Brown's piece (#2, MKM) noted that as a former hospital clerical worker, he/she had probably received more abuse from nurses than from doctors. That's the way the chain works: abuse rolls downhill. Almost without exception, child abusers had been abused themselves as children.

I doubt docs will stop abusing anyone until their own abuse stops. From my own training in the 1960s, I recall that freshman medical students suffered a status somewhere below mollusks. Sophomores and juniors were noticed, but mainly as nuisances, like rodents. Seniors found that the summit they’d attained was at the same time dirt on the shoes of interns, who in turn were nameless drudges to resident physicians. And so on up to the pyramid’s apex, the Chair of the Department, who glowed with success while fretting about the associate professors clawing at his or her ankles. From what I hear, medical training is a little more humane now, but the atmosphere remains unquestionably vertical.

Still, re-education is possible. My guess is that the docs who disparage nurses in front of patients (along with other abuses) do it unthinkingly, almost as a matter of course. They have no idea they're damaging people, and if they did, they might behave differently. A nurse or other colleague can take them aside, as a nurse once did with me, and advise, "Doctor, if you keep going where you're going, you're going to get where you're headed."

Thursday, May 5, 2011


Maggie, a woman in our cancer support group, told a touching story yesterday.

She has breast cancer of a type similar to what a friend had. The friend died after a particularly unpleasant course about twenty years ago, leaving a young daughter, Amy.

Maggie had been reluctant to see Amy, fearing she'd reignite Amy's memories and her fears of going the way her mother had. But they did meet recently, and after they'd spend some time together, Amy said, "You're going through this differently than my mother did. It seems to have made you stronger and more dignified. Watching you, I'm no longer frightened of breast cancer."

I've heard that there's more than one of us on the planet so we can be examples for one another.