Monday, October 31, 2011

DO WE WANT NICE DOCTORS?

In an essay in today’s NY Times, (http://www.nytimes.com/2011/11/01/health/views/the-downside-of-doctors-who-feel-your-pain.html?ref=health) cardiologist Lisa Rosenbaum asks whether “nice” physicians really provide better care than those who are merely technically competent. In this context, “nice” involves interpersonal relationship skills like physical proximity, eye contact, empathy, acknowledging patient concerns, and asking about feelings. Certainly these skills will make the physician more likeable to most patients, but will it improve their care?

Dr. Rosenbaum observes, “…we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.

This discussion misses what patients yearn for—not so much likeable doctors, but doctors who can ameliorate their suffering while treating their physical disease. Niceness doesn’t treat suffering, and empathy only begins to treat it. Admittedly, both suffering and its effective treatment are objectively unmeasurable, but that’s no reason we physicians shouldn’t either learn how to do it or assign the job to someone who can do it. Instead of teaching medical students how to maintain eye contact or how close to sit, we should be showing them how to listen for elements of suffering in order to draw it out and be comprehended so it can be acted upon. But that’s an art, meaning it takes time, and this sort of profound intervention is not medically reimburseable. 

Wednesday, October 26, 2011

DON’T JUST DO SOMETHING; STAND THERE.

Please excuse the hiatus in posting. I’ve been putting my time into untwisting this blog into a book. I’ll keep you posted on progress.

The NY Times Well Blog, a reliable source of stimulating issues, ran a sparkling post October 20, http://well.blogs.nytimes.com/2011/10/20/when-doing-nothing-is-the-best-medicine/#more-62303

In that post, Dr. Danielle Ofri discusses “clinical inertia,” the medical name for doctors doing nothing instead of doing something. She notes that the term is negative, and I agree. It conjures an image of a hypothyroid physician moving slo-mo, as though wading through Vaseline, despite the indication for immediate action. I wonder what Hippocrates would think of “clinical inertia,” having advised, “When it comes to the sick, do the least.”

We docs are trained in doing, and our culture teaches patients to expect us to do, no matter what. God forbid a patient leave the doc without something in her hand—a prescription, a sheaf of test orders, a packet of sample pills, anything to indicate that a medical transaction has actually occurred. An anthropologist would call her departure baggage a “fetish,” a symbol of conferred power.

The issue’s more complex than that, though. If it’s true—and I believe it is—that the bulk of medical visits are for illnesses generated in lifestyle, then less treatment might actually be therapeutic. Emphysema begins with smoking, cirrhosis with drinking, most type two diabetes from overeating, much hypertension from hypertense lives, and so on. Simply patching those symptoms with medical technology can bring relief and is a kind service, but also enables pathogenic behavior. I’m not for firing patients who live self-torturous lifestyles, but on the other hand I need to recognize that my intervention frankly enables that behavior without diminishing it. A more effective strategy would be to attenuate my intervention while requiring more involvement by the patient. Instead of calling that “clinical inertia,” call it plain old restraint.

Monday, October 17, 2011

PREGNANT MOM DECLINES CHEMO SO BABY CAN LIVE

If you're up for a good cry, read this:
When Stacie Crimm found out that she had finally gotten pregnant at 41, she was overjoyed. So overjoyed that she knew exactly what to do when faced with the decision of whether to save her life or her unborn baby's. After she was diagnosed with neck cancer, Crimm decided to refuse chemotherapy. The heroic mom survived long enough to deliver her 2-pound, 1 ounce daughter, Dottie Mae, and hold the baby in her arms, just once.

“This baby was everything she had in this world," Crimson's brother, Ray Phillips told the news outlet.                                                             

I can’t add a thing.

Tuesday, October 11, 2011

SIMPLE QUESTION GOES LONG WAY

A friend asked me, “Do you think herbs actually do something, or not?”

Sometimes you catch a question that hotwires your mind. I got to thinking: how do we know herbs work? Well, why shouldn’t they? Some of allopathy’s most useful medicines—morphine, aspirin, some anti-cancer drugs—derive from plants. The potency of some herbs, and maybe all, is indisputable.

Since we’re asking, how do we know if pharmaceuticals work? Well, sometimes we feel a dramatic change. Most standard medical drugs are designed to be more forceful than herbs or other alternative meds, so their effects can be readily noticeable. (Did I say “more forceful?” Frankly, we often swat flies with cannons.) Anesthetics, antibiotics and analgesics in particular make an obvious sensory splash.

But with some drugs, the question can’t be answered. Adele, a member of our cancer group, wondered if her chemo was working. “I mean, how can you tell?”

“Well, how do you feel?” someone asked her.

“Are you tired?” asked another.

We yearn for a grip on this issue, some metric handhold.

“Well, when’s your next MRI?”

“Oh yeah, my MRI’s next Thursday. That ought to show whether it’s been working.”

That’s when Alec steps in. “You mean if the tumor’s smaller, then the chemo’s working?”

“Sure.”

“And if the tumor’s bigger, it’s not working?”

“Yeah, why?”

“Well, what if the tumor’s bigger, and if it hadn’t been for the chemo, you’d be dead now? Or say the tumor’s smaller, then how do you know if the chemo did that, or if it was your diet or prayer or zest for life?”

Alec can be a bit frontal, but he’s worth listening to. “You go read studies,” he continued, “and they say it works. Well, that’s reassuring, you say. That’s all well and good, but then you think about it: wait a minute, there’s no treatment that’ll work for everyone, so what if it’s me who gets the short end? And you’re back to your original question, ‘Is it working?’ All the statistics in the world don’t matter boo to individuals, anyway. Another guy in this group years ago said, ‘The only numbers I’m interested in are a hundred and zero. Either I’m here or I’m not.’”

So how do we know if this medicine we take is doing what we want it to do? Alec’s right. In most cases, especially in Cancerland, we don’t know and probably can’t know. Probably the greatest source of anxiety among people with cancer is not-knowing. While a tumor might go unfelt, uncertainty tortures around the clock.

Uncertainty is a far more potent feature of the universe than I am. Compared to forces like that, I am, like Job, dust. The realization that I can’t rearrange reality as I’d like can be really annoying. That can invite me to ask myself why uncertainty, such a pervasive, eternal, and undeniable feature of reality, bothers me. If uncertainty is inherently universal, from quarks up, then why don’t I just learn to live comfortably with it? Would dropping my discomfort be risky or dangerous or taboo or illegal, or what?

Abraham Maslow, a founder of the humanistic psychology movement, was one of the few people to study normality. When we crave mental health, what is it, exactly, that we’re after? Of the hallmark list he developed, the one that fascinates me the most is “comfort with uncertainty.”

OK, sounds good. Where do I sign up? Sorry, this is a blog, not an ashram.
Vaya con Dios.

Monday, October 10, 2011

GENUINE DISCUSSION OF HEALTHCARE REFORM

In this blog I’ve mentioned “Health, Money & Fear,” a film that waxes eloquently on the deeper nature of our healthcare crisis. I and others felt the film is so right-on that we had to share it with our community. If you have forty-seven minutes to spare, check it out online at www.ourailinghealthcare.com. If it impresses you, consider sharing it with your community. One way to do that is embedded in the opinion piece I wrote, below, for our local newspaper...

"No doubt you're aware that health care's current cost can wreck your wallet, but do you also know it eats a growing portion of the national economic pie? 

When I graduated medical school in 1967, America spent about 6 percent of its GDP on healthcare. That means one out of every $16 spent for anything went toward healthcare. Now it claims 16 percent, or one out of every $6. At this rate, we'll eventually live in makeshift shacks and shop in dumpsters, but at least we'll enjoy the most expensive health care in the universe.

As I've watched costs climb over the past several decades, I've read what those who study the subject have to say about it. One thing they agree on is that reducing costs can't be simply rearranging who pays for what. There's much more involved. Health care is astronomically expensive because we hold some painfully contradictory values about it. For example, we want all available medical technology, but we want it cheap, which is like insisting that a round-trip hike be downhill all the way. We demand end-of-life care that too often amounts to incredibly expensive prolongation of suffering. We fly into a litigious rage when doctors — that is, human beings — fail to provide us perfect security. 

Such contradictions persist mainly because we hardly ever discuss them. Imagine my surprise, then, when I came across the film “Health, Money and Fear.” It makes a case for a national single-payer strategy similar to the California proposal now navigating the legislature as SB810. It goes further, however, in examining our costly cultural issues through interviews with experts I've long respected, including former New England Journal of Medicine editor Marcia Angell, MD, and Oregon Gov. John Kitzhaber, MD. 

So I've joined with local medical colleagues who support affordable health care, plus the Nevada County chapter of Health Care for All, to show this film publicly, followed by a town hall-type discussion. A broad swath of Nevada County people, businesses and organizations are co-sponsoring the event. Admission is free and refreshments will be available."

WHEN: Tuesday, Nov. 29, 7PM
WHERE: Nevada Theater

Thursday, October 6, 2011

STEVE JOBS GOT IT RIGHT

In today’s NY Times Well Blog(http://well.blogs.nytimes.com/2011/10/06/so-doc-how-much-time-i-got/#more-61357), Dr. Danielle Ofri writes about the difficulty of informing a patient of his cancer’s lethality. She’s not the only doc who recognizes how hard this can be. 

Part of the problem is that although we adults are aware of our mortality, we deny it most of our lives. On his deathbed, William Saroyan said, “I’ve always known I was going to die, but I thought in my case they might make an exception.”

In my practice, facilitating cancer support groups, new members often ask me if they’re going to die.

I answer, “Of course.” What else can I say?

They respond, “Oh, I know that, but will I die from this?”

Here’s how the kindest oncologist I know answers that question: “I don’t know if you’ll die from this, but I do think you’ll live with it the rest of your life.”

What a positive, creative way to frame bad news! Accentuating “the rest of your life,” it simultaneously affirms finiteness and possibility. In an ideal world, frank acceptance of mortality would be a general cultural value. Whether we’ve been diagnosed or not, the sword continually hangs over our heads, poking us to do what we need to do. I can’t put it any better than now-departed Steve Jobs:

“Remembering that I’ll be dead soon is the most important tool I’ve ever encountered to help me make the big choices in life. Because almost everything—all external expectations, all pride, all fear of embarrassment or failure—these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked.”

Monday, October 3, 2011

HEALING & THE EXXON VALDEZ


"It seems as if we have confused science with restoration, knowledge with healing.”

I’ve written that sentiment here. But this iteration wasn’t from me, and it’s not about healthcare, at least healthcare for humans. It's by Marybeth Holleman, author of a highly regarded book on the 1989 Exxon Valdez oil spill, The Heart of the Sound.


Holleman feels that science, with its considerable expense, has been overused and undereffective in the still-ongoing cleanup. She writes,

The massive $400 million spill-research boom in the [Prince William] Sound brought its own unanticipated injury, through intrusive sampling methods and the swarms of scientists, tent camps, boats and planes now in the Sound much of the year.

“About $500 million (half of the entire natural resource damage settlement) has been allocated for research; some say we could have spent ten percent of this amount and learned as much. Then we could have used more of the settlement funds for habitat protection.”

Holleman insists that relentless scientific investigation amounts only to

“…proof that oil hurts animals. While it’s new information, it doesn’t do any good, isn’t restoration, unless some protective measures come from it.”

So what does this have to do with healthcare as though people matter? Maybe I’m deluded, but I see a compelling parallel in our cultural healthcare strategy, the favoring of science over healing. We don’t lean that way because we’re logic nerds, but because science’s reps—thinktanks and developers and manufacturers—knock persistently on our door and natural healing processes don’t. Thus we physicians get paid oodles for performing invasive, expensive diagnostic and treatment procedures, but zilch for just sitting and listening to patients in order to help relieve their suffering.

I’m beginning to think that the healthcare issues I interminably rant about are just one profile of the way our culture faces every challenge—as a problem to be addressed—no, “attacked”—with a high-tech physical toolkit. Certainly imagination would reveal other responses that are at least as effective, and cheaper and gentler to boot.

Saturday, October 1, 2011

WHO DOESN’T PALLIATE?

“I’ve been treating this sixty-year-old woman for emphysema. She's on some meds, plus oxygen at home. She’s smoked a couple of packs of Camels every day for the past forty years, and you know what? She won’t stop. She takes a drag from her cigaret, then one from her oxygen mask, back and forth. I’m tempted to fire her. I mean, this is ridiculous. She claws back any advantage I can give her. What do you think I should do?”

This was asked of me by a physician friend who’s aware of my interest in medical ethics. What would you do? Me, I’ve learned generally to answer every question with another question.

I said, “Well, you’ve thought of firing her. Why haven’t you?”

“I’d feel awful. She’s doing herself in, but she’s still my patient.”

“What does it mean to you—that she’s your patient?”

“I’m her doctor. I guess that means I’ll stand by her no matter what. This is really beyond what I was trained in, diagnosis and treatment. What I’m doing with her is only palliative.”

Only palliative?”

“I’m not a hospice doctor. I don’t do palliative.”

“You don’t?”