Friday, July 29, 2011

GREAT HARDWARE, TERRIBLE SOFTWARE

A friend recently took a bad bicycle spill. Along with assorted other injuries, she broke her jaw and hand. A helicopter flew her to a major trauma center, where she was promptly triaged and her jaw laceration stitched. She learned that her injuries were relatively minor compared with people who were brought in with missing limbs and lacerated livers. Naturally, those in more serious condition were attended to before she was. During the next fourteen hours she lay on a gurney, requesting repeatedly that she be seen, but no one even came to put ice on her broken hand.

The contrast between the light and dark sides of American healthcare is ever more visible. Our medical technology, our hardware, especially in regard to treatment of trauma and infectious disease, can be truly wondrous. Where we are scandalously lacking is in our low-tech software, our ability to communicate.

However we're encouraged to pretend otherwise, healthcare isn't simply another commercial transaction. Deep personal issues, often questions of life and death, are involved, so it's an EMOTIONAL process. This makes communication absolutely central to the medical encounter.

We commonly think of optimal communication as clear speech, but those of us who labor in these fields know than nine-tenths of communication is sensory reception--listening, observing, sniffing, empathizing. Thus one of the most important people in the private medical office is the receptionist: he or she sets the emotional tone of the visit.

Every WalMart store features a greeter. "Hi, how are you? Welcome!" Smart medical operations like the Mayo Clinic do likewise, and even assign employees or volunteers to accompany patients throughout their visit. They don't just advertise that they "care." They demonstrate it. If my friend's trauma center wasn't simply a repair factory but actually a caring place, she would not have had to endure fourteen hours of a fractured hand without even a little ice on it.

More about this soon, as her trauma center visit exemplifies much about what's right and wrong in our healthcare system.

Wednesday, July 20, 2011

MORE ON CHRONIC PAIN

struck a nerve, so to speak. There are now over a hundred comments on it, and several here on this blog, consistently stressing two points, drugs and subjectivity. My thanks go out to all commenters.

Drugs--especially opiates, or narcotics--are, in the short run, a miracle and a blessing. When I was an ER doc, one of my most satisfying experiences was to inject a bolus of morphine into the vein of someone writhing on the table from a kidney stone. I'd say, "Count to ten." By seven, they'd sigh and smile.

Take opiates for awhile, though, and problems can appear, and not necessarily addiction. Sometimes we'd keep hospitalized patients on opiates for a couple of weeks, sending them home with a diminishing dose. I never saw a single one become addicted, though I recognize some people with a craving personality do get hooked. A more common problem is side effects, including agonizing constipation, lethargy, and even disorientation. Considering that we develop tolerance to opiates, chronic users will require progressively higher doses and suffer proportionate side effects. In addition, the feds do indeed maintain a regressive attitude toward opiates, reflected in the fearful reluctance of many docs to prescribe them at all. (I've mentioned elsewhere in this blog the usefulness of that phrase that knocks around in cancer support circles, "No one should be allowed to treat a disease they haven't had themselves.")

The other theme in all these comments is subjectivity. Some policies limit opiate prescriptions to cancer patients, since, evidently, they're not faking. Cancer is objectively real, and everyone knows it can hurt. For those patients who don't have verifiable pathology, though, who knows whether their pain is "real" or not? So it is that many people are slog through their lives today treating their severe pain with Tylenol.

This brings to mind the previous blog entry, about prospective medical students being screened for communication skills (http://well.blogs.nytimes.com/2011/07/10/screening-for-a-better-medical-student/). A proficient communicator--that is, someone who listens fully and speaks truly--is therapeutic, period. When people know their suffering narratives have been heard, they feel better. Beyond that, being heard begins to help them live with their symptoms rather than devote their lives to avoiding them. Of course, this level of practical compassion isn't achieved through med school application interviews. It needs to be a perennial element of medical training.

Wednesday, July 13, 2011

MENTAL ILLNESS AND GUNS

There's wide agreement that firearms in the hands of mentally ill people--for example, Tucson's Jared Loughner--constitutes a public health threat. Even the late Charlton Heston, when president of the NRA, stated in a video on that organization's website, “…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…” Yet strangely, laws intended to protect patient privacy also protect their arms ownership.

A man in our town is mentally ill and known to be armed. I suspect he exemplifies similar situations around the country. When he's properly medicated he presents no problem, but when he goes off his meds his behavior become so erratic and threatening that his neighbors call the police. The police arrive to find the man composed. The frustrated neighbors tell them he's a mental patient who was acting crazily till twenty minutes ago, and give them his psychiatrist's name. The police call the psychiatrist to ask if the man is indeed his patient. The psychiatrist, obeying the Health Insurance Portability and Accountability Act, ("HIPAA," pronounced HIP-a), says he's not permitted to tell them whether the man is his patient. The police are left, then, with neighbors complaining about a man who's acting, at least for the moment, eminently sane.

Can there be no solution? In 2002, the state of California enacted a law, AB 1424, which recognized that people who are seriously mentally ill can occasionally appear sane. The law stated that mental health professionals qualified to involuntarily hospitalize can no longer rely exclusively on their momentary meeting with a patient. They must consider a longer and wider history, including information provided by a patient’s family and others.

Yet even here there remains a disconnect, as police officers aren't qualified to diagnose mental disorders. They could legally arrest this man in order to bring him to a mental health professional, but they haven't done so, possibly because of liability should the man be found normal. Taking into account, then, the possibility of an error in one direction or the other, our society's current ethical ambience seems to favor protecting the man's gun ownership over protecting public safety.
 

Are you aware of similar situations in your locale? What's your take on this?

Monday, July 11, 2011

SELECTING MEDICAL STUDENTS FOR COMMUNICATION SKILLS

Excuse me, please. I haven't blogged as often as usual the past couple of weeks because it's finally summer here. Need I explain further?

I'm moved to write today, though, because of a fascinating development in medical school admissions strategy, outlined in an article in today's NY Times Well Blog, http://www.nytimes.com/2011/07/11/health/policy/11docs.html?pagewanted=1.

Of course, medical schools continually tweak their admissions procedures. When I applied, which was shortly after Lincoln's assassination, there had been a push for more "rounded" students. My science grades were mediocre but I shined in languages. The standard interview question was, "Why do you want to be a doctor?" I was able to respond correctly ("To help people") trilingually, so I was in. My class consisted mainly of science nerds, but a few poets and artists, too--all of whom became psychiatrists, by the way--and a couple of really entertaining weirdos. The class following ours featured a concentration of political activists; when they organized the hospital staff and led them out on strike, the admissions committee scrapped its progressive policy and returned to admitting science nerds, period.

Now some leading schools, including Stanford and UCLA, are beginning to screen for communication skills. Applicants are given multiple interviews which include discussion of ethical problems involving payment, alternative remedies, circumcision, and so on. The schools wish to address two increasingly visible problems in medical practice: doctors' generally suboptimal communication skills and the growing need for partnership between physicians and other practitioners.

This new admissions strategy looks progressive but one wonders how it will survive in generally unfriendly soil. It will need to compete within the extant atmosphere of medical training and practice, where human contact is still considered an endeavor somehow less useful than hard-nosed science. It'd be nice if this strategy were the beginning of intense communication training all through the medical curriculum.

At any rate, this admissions strategy won't reveal its usefulness until the students move into practice. Considering the length of professional training, we might not see an effect for a decade. But I'm hopeful.