Thursday, March 29, 2012

Rx HAPPINESS

Maybe I should blame it on aging, but the world looks ever more simple to me. These days, the most potent medicine looks like living well, period.

What exactly does that mean? Lying around the pool with a mint julep in one hand and Cuban cigar in the other? Maybe for some, but most of us really need to think about what our personal “good life” is.

We'd probably include friendships in our definition. A substantial mass of research indicates that the benefit of intimacy with others exceeds that of most drugs and surgeries. One study of seven thousand men and women, for example, found that people unconnected to others were three times as likely to die over the course of nine years as those who had strong social ties. That study inventoried lifestyles, too. As you might guess, those with fewest ties and unhealthiest styles suffered the shortest life spans, and those who lived healthfully and had strong social ties lived the longest. But wrap your mind around this: those with close social ties and unhealthy lifestyles actually lived longer than those with sparse social ties but more health-promoting habits. 

In another study, researchers taped the conversations of nearly six hundred men, of whom a third had heart disease. They found that those who used first-person pronouns—I, me, mine—most often were most likely to have heart disease and most likely over the next few years to suffer heart attacks. In another study of over two thousand heart attack survivors, social connectedness had a greater influence on survival than the heart drug being tested.


This makes me recall another study, of women with breast cancer. All else equal, their survival duration was directly proportional to the number of their “confidants.” Those with no intimate friends survived the shortest time; those with six—the maximum number the study tracked—survived the longest.


I don’t want to minimize the value of friendships, but I doubt that’s all we’re discussing here. It’s more about having a good time such that we want to remain here longer. While this seems a simple enough goal, too many of us feel we don’t deserve a good time, as that would be hedonistic, self-absorbed, or in some way existentially elitist. If that’s you, are you willing to reconsider?

Monday, March 19, 2012

WHY DON’T FRENCH KIDS BOUNCE OFF THE WALLS?

Five percent of American school-aged children have been diagnosed with ADHD and are taking pharmaceutical medications. In France the percentage is one one-hundredth of that figure.  

Where we assume our afflicted kids must be suffering a “chemical imbalance” in their brain—a condition that’s never been proven, by the way—the French attribute it to psycho-social and situational causes. Thus our kids get drugged and les enfants get individual and family counseling.

Yeah, I know there are thousands of parents who’ll testify that before getting Ritalin or Adderall, their children were unmanageable, and were perfectly reasonable afterward. These drugs do, after all, have their effect. But could their behavior have been effectively altered without drugs? Better yet, what sort of family situations would militate against ADHD in the first place?

The French raise their children differently than we do. They don’t mind saying “no.” For example, they can’t snack whenever they want. Meals are at specific times, and the French regard eating as a family event. The French still hold the high scholastic expectations that we began losing in the 1970s. Their stricter limits, psychologists tell us, help kids feel safe and secure.

We’re more lenient and actually less in touch with our kids. American dads and moms both work far longer hours than their French counterparts, and after work are too tired for much kid time. And American parents and kids alike spend more time with electronic gadgets than in personal contact.

Maybe in some cases ADHD is a biological problem, but I suspect the bulk of it results from lifestyle. Some kids may truly be helped with these drugs, but a pediatrician described an approach to me that doesn’t just bandaid symptoms. He said, “I teach the parents how to meditate.”

Friday, March 16, 2012

SOCIAL CANCER AT WORK AGAIN

An article in this week’s New Scientist (http://www.newscientist.com/article/dn21580-many-authors-of-psychiatry-bible-have-industry-ties.html) is headlined “Many Authors of Psychiatry Bible Have Industry Ties.” You may remember that I scooped this very story a month ago on this blog; see http://healthcareasthoughpeoplematter.blogspot.com/2012/02/do-we-have-pill-for-you.html.

Here’s the gist: the American Psychiatric Association committee charged with revising the profession’s manual, the Diagnostic and Statistical Manual of Mental Disorders, has recommended changes that will summate in greater use of psychiatric drugs.

I’ve witnessed this tendency for decades. Into the 1960s, psychotherapy—that is, conversations between people and their therapists—was psychiatry’s main tool, but it’s been gradually displaced by drugs. Certainly drugs have been of some benefit, particularly the phenothiazines for schizophrenia, but more and more, drugs have become psychiatry’s almost exclusive tool. Pharmacology has so widely evicted psychotherapy from training that—to use this blog’s terminology—people matter little there now.

The New Scientist article points out that the DSM-revision committee is populated largely by people with ties to the pharmaceutical industry. Well, that’s to be expected these days, I suppose, and I suspect they’ll deny that their ties influence their revision decisions. But maybe the public’s not all that stupid. As the old Yiddish saying goes, “You can’t pee on my back and call it rain.”

I think a lot about the field in which I work, cancer—what it is, what it means, how it affects people. I suggest we have a social cancer here, malignant greed metastasizing into organs like economics, education, politics, and healthcare. We need a treatment for it. Maybe government regulation or criminal prosecution would be a kind of chemo, but I think we can get at it more elegantly through increased personal responsibility. We can no longer believe that government or professional agencies are looking out for us. We need to do it ourselves. 

Tuesday, March 13, 2012

AS GOOD AS OXYGEN

A friend sent me to a marvelous site today, a stream of inspirational mindshakers. The Tao that can be spoken isn’t the Tao, but art comes close. You can find it at http://academictriathlon.wikispaces.com/file/detail/ThinkingWAYOutsideTheBox.pps.

I’m sure not going to follow that act, so that’s it for today’s blog entry. 

Friday, March 9, 2012

TOO MUCH INFO OR NOT ENOUGH?

An article in today’s NY Times Well Blog (http://well.blogs.nytimes.com/2012/03/08/what-doctors-and-patients-dont-want-to-talk-about/#more-72573) relates a recent article in the New England Journal of Medicine by Dr. Robert Truog, who teaches medical ethics at Harvard Medical School and practices intensive care medicine at Children’s Hospital Boston. Dr. Truog writes that while the doctor-patient relationship has become less vertical, less patriarchal, it’s still not fully transparent.

That is, certain subjects are seldom discussed, particularly the omnipresent question of care versus cost. This is one facet of a permanently central issue, what we call “informed consent.” Are we fully cognizant of everything that goes into a medical recommendation? Patients assume that care decisions are made on the basis of medical science, yet an influence at least as dominant is economics: in truth, we’re always rationing. We’ve always rationed and always will. No one but maybe Warren Buffet or Carlos Slim will ever get all the care they want—and it probably isn’t even in their best interest to get that anyway.

Fully informed consent is often abbreviated by incomplete conversations between docs and patients. Says Dr. Truog, “I think a relationship has developed where we as physicians don’t tell patients everything and patients don’t really want to know everything…it’s not like you just do an information dump and that’s all; being transparent and open with your patient goes beyond the rote skills of making eye contact, sitting down instead of standing at the bedside and asking certain questions. It comes down to the words we use and the way choices are framed. The way we present or hide our own values is critical and should receive attention.

“For example, we videotaped experienced practitioners for a project on how to counsel women when they learn a fetus has a congenital defect. What came up was that these physicians often made the assumption that more information, like getting an amniocentesis and really figuring out what the abnormalities are, is always better. In fact, one of the quotes from a wonderful physician was: ‘Information is always good.’ But some patients and families really don’t want more information. They feel that if they have the information, they put themselves in the position of playing God. Not having the information spares them from having to make a choice.”

Exactly. Dr. Truog has expressed the crucial deficiency: we docs assume “communication” means conveying information to the patient. We forget it’s a two-way process. In my experience, speaking is maybe a fifth of communication; the bulk of it is listening, which requires time and skill. Instead of avalanching patients with data and then leaving them to make a choice, why not get to know them first—hear their perspectives, values, and needs, and only then offer information?

Thursday, March 1, 2012

THE PATIENT TRIBE

I’ve mentioned here a few times that to understand how physicians think, it’s helpful to consider them a tribe, a group with a unique and exclusive perspective, language, and objectives. 

Patients are a tribe, too. 

Since each group honestly senses a different world, miscommunication, as exemplified by the following vignettes, is a deeper problem than we normally recognize.

Dr. N: “Ms. V asked me how serious it was. I told her to just let me worry about it.”                               Ms. V: “Fine if Dr. N wants to worry about it. Maybe he can turn it off, but I can’t.”

R.: “I told Dr. F I hurt, but all he recommended was an over-the-counter pill which didn’t touch the pain.”                   Dr. F: “R. just told me he hurt. If he’d told me his pain level was nine out of ten, I would’ve prescribed something stronger.”

Dr. B: “It was time to talk with Mr. L about hospice care, but I didn’t want to scare him.”                     Mr. L: “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.”

J.: “If only Dr. R had admitted he’d made a mistake, I’d have forgiven him. It’s his stonewalling that made me sue him.”                   Dr. R: “My lawyer told me not to talk about it.”

B.: “Dr. Y called me into his office to talk about test results. After he said the C word, I didn’t hear a thing. I’m sure my eyes glazed over. But he kept talking and talking…”                                   Dr. Y: “I sometimes wonder why I spend so much time educating patients. Half the time they’re not listening.”

D.: “Dr. O’s nurse informed me of my cancer with a message on my answering machine. On Friday afternoon, too. Didn’t make for a great weekend.”                       Dr. O: “I don’t like patients to stew over unknowns. I’d rather they get information right away.”

Dr. G: “Mr. H’s son told me to do everything for his dad, pull out all the stops. I thought if I told them that’d be futile, it’d destroy their hope. After he died, they seemed to look at me like I failed them.”                            Mr. H’s son: “Sure we wanted everthing done, but Dr. G never told us he thought that’d only stretch out dad’s suffering.”

N., a physician: “My surgeon, Dr. E, told me the night before my surgery that there was a five percent chance I’d die on the table. He could have told me there was a ninety-five percent chance things would go well. I hadn’t ever considered how two sentences could say the same thing but elicit such different reactions.”           Dr. E: “Semantics.”

Dr. N: “I like to think I’m concerned about my patients’ emotions, so I ask them if they feel stressed. If they say yes, I send them to a psychiatrist. If they say no, I leave them be. Ms. V told me she could handle it.”                 Ms. V: “I told Dr. N I thought I’d be able to handle it okay. I learned soon enough, though, that that was wishful thinking.”

Dr. F: “H. told me she wanted to try alternative treatments before she’d go to standard oncology. I told her that was playing with her life, and I stand by that. Most of the people I’ve seen go alternative are dead.”                                H.: “I wanted to try alternatives first because control is important to me. I wanted to be in the driver’s seat. When Dr. F told me many of his patients who’d done alternative treatments are dead, I said so are many of his chemo patients.”

Hospice nurse L: “I advised the family that when his hearbeat stops, do not call 911, call Hospice. Emergency techs are obligated to do CPR, and at best that would only prolong his suffering. When I asked them if they understood, they nodded. So I said, ‘Just so we’re clear about it, what will you do when his heartbeat stops?’ They said, in unison, ‘Call 911.’”


In each of these scenes, participants would have benefited from more extensive conversations. We have our work cut out for us. Docs and patients inhabit different realities, but since even men and women actually come together occasionally, so can they.