Monday, May 28, 2012

THE REAL BEDSIDE MANNER


A May 12 Toronto Star article by Lorianna De Giorgio says,

“Bad bedside manner—when a health-care practitioner fails to see the patient as human—can make or break an already complex relationship. Patients crave a deep relationship, full of empathy and trust, with their doctor or nurse. Such a relationship, however, is sometimes lacking in the medical field. Patients complain that doctors or nurses sometimes talk down to them, forgetting they have a family, feelings and concerns. What is the psychology behind a bad bedside manner? And is it a conscious or subconscious decision by the doctor?”

Ms. De Giorgio has hit on a central issue. When I hear complaints from patients, they’re almost never about healthcare’s admittedly awesome technology, but about its lowest-tech aspect, communication. Bedside manner is more than not talking down to patients, though. We’ve all but forgotten what it actually is because it’s been parked in the shadow of the MRI machine for so long. Here’s what bedside manner is: helping others to feel better with one’s presence alone.

Some people are born with this quality. For the rest of us, though, it’s a skill, meaning it improves with practice. We begin to learn it when we recognize sick people aren’t just diagnosis-labeled organisms, but suffering souls as well. We’re talking about compassion here, literally “suffering with.”

No way around it: compassion hurts. Those of us who work daily with suffering must develop some strategy for addressing our own consequent pain. Traditionally, doctors are trained implicitly to repress the pain inherent in practice. As logical as that may seem, it doesn’t work. Buried pain is always buried alive. Look up doctors’ rates of divorce, drug dependence, alcoholism, and other sorrows. Male doctors have a forty percent higher rate of suicide than the general population, and female doctors an alarming one hundred thirty percent higher.

We docs can do better. We can behave like normal people, choosing to feel the pain already resident within us, express it, and even let it affect the way we practice. Of course, doing so might slow the great wheels of medical commerce, but so what? At least we’ll find ourselves healing our patients—and ourselves—along with treating them.

Wednesday, May 23, 2012

A NECESSARY DOSE OF HUMILITY


The United States Preventive Services Task Force, having studied the potential risks and benefits of the prostate-specific antigen blood test, or “PSA,” has concluded that hazards attending the test outweigh potential benefits. The task force found that at best, one man in every thousand tested may avoid death as a result of the screening, while another man for every three thousand tested will die prematurely as a result of complications from prostate cancer treatment, and dozens more will be seriously harmed.

As you might expect, this finding hasn’t been met with universal hallelujahs. Some prostate cancer advocacy groups as well as the American Urological Association take issue with the published recommendation. In response, Dr. Michael LeFevre, the co-vice chairman of the task force and professor of family and community medicine at the University of Missouri, said, “Change is hard. It’s hard for all of us, both within and outside the medical profession, to accept that not all cancers need to be detected or treated, and that there are harms associated with screening, and not just benefits.”

The broader issue here is the nature of medicine itself. We popularly believe science to be a yes-or-no proposition. We put much stock in its pronouncements since it is, after all, an elegant method for gaining knowledge. But the answers the universe reveals respond only to the questions we ask, and what we ask is necessarily limited since as mere humans we can’t see the Whole Picture. We ask, “Does a heightened PSA level indicate cancer?”, and the response is, “It often does.” That is, it sometimes doesn’t. In addition, cancer doesn't necessarily elevate the PSA. Further testing and treatment can be tangibly harmful, possibly even more than prostate cancer itself.

Of coure, we love when medical science seems to produce a miracle. Take diethylstilbestrol, or DES, a hormone that prevented miscarriages in women between 1940 and 1971. This seemed a terrific advance until it was learned that the children of these women suffered huge rates of genital cancer. Who knew, in 1940, to ask about cancer in these women’s children?

Every few years the argument resurfaces about whether mammograms cause more breast cancer than they detect. Today the weight of evidence leans toward the more benign, yet experts nevertheless recommend ever more judicious use of mammograms.

And so it goes with a multitude of tests and treatments. I raise this issue as a reminder to take medical science with a dose of humility. That we docs are doing the best we can is both the good news and the bad news. Keep in mind the apocryphal story of the medical school dean who, addressing his graduating class, said, “I’m sorry, but about a third of what we’ve taught you is untrue…we just don’t know which third.”

Monday, May 7, 2012

DOC GAVE ME THREE YEARS


“I can’t take any more numbers” said a man in our cancer support group. “This chemo has a forty percent chance of working. Two out of three chances you’ll live five years. Five percent mortality. It drives me crazy. The only numbers I’m interested in these days are a hundred percent and zero. Either I’m here or I’m not.”

“How much time do I have, Doc?” is arguably the question oncologists hear most often. It’s understandable that we want to know, but the answer, of course, is that no can know. So the doc offers us statistics, maybe saying something like, “Well, eighty percent of people with your diagnosis survive two years.”

There are three problems with our use of statistics. One is that by definition they cannot describe characteristics of an individual, only of a group. If you’re informed that of one hundred people in your situation, twenty will be gone in two years, what does that mean to you? You might be among those twenty, you might not. In my mind, the number doesn’t illuminate much. As our group member put it, you’ll be one hundred percent here or zero here.

Another problem is that people unfamiliar with statistics misinterpret them, and almost uniformly toward the negative. You’re told, for example, that median survival time for this particular illness at this particular stage is three years. You go home and tell the family, “Doc gave me three years.” Nope. Three years was the median, meaning that half the group will die before three years and half beyond that time—in fact, some will die decades beyond that time.

A third problem is that we tend to see statistics not as descriptive, but prescriptive, actually a self-fulfilling prophecy. Believing the doc gave you three years, you can unconsciously store the figure in the back of your mind, where it continues to reiterate the message, diminishing your optimism until voila!, you die right on time.

For all these reasons, I know an increasing number of physicians who are reluctant to offer any statistics at all. Yet when knowledgeable about statistics, you can use them to your advantage. We traditionally describe survival rates with a mathematical model called a “bell curve,” which looks like this:


The curve says a small number of patients die relatively soon, a similar number survive a long time (the lower sides of the bell), and the majority fall in between. When you hear a statistic involving you, all you know for sure is that you’re somewhere in that curve. (In fact, even if you’re not sick, you, being as mortal as ever, are somewhere in that curve.) You also know that you want to be as far to the right in the curve as possible.

Bell curves are usually built from data that take just a few categories into account: type and stage of cancer, maybe age of patient, and maybe gender, for example. Within those categories are people with poor nutrition, no support, toxic habits, and who feel helpless and hopeless, along with those who take excellent care of themselves—people who eat well, manage stress skillfully, enjoy high quality relationships, and so on. But those latter practices, being difficult to quantify, aren’t often taken into account. So if you’re leading a healthy life, the bell curve that ostensibly includes you is actually inaccurate. All else equal, you’re already to the right of its median, and by continuing to adopt healthy habits, you’ll extend your life expectancy even further. So here’s my prescription for statistics: take them with a grain of salt.

Friday, May 4, 2012

CALMING THE DRUNKEN MONKEY


A recent study at the University of Rochester Medical Center (to be published in the June issue of Academic Medicine) found that training doctors in mindfulness meditation helped them to listen better and not be as judgmental.

How could it not help? When I saw patients many years ago, before my exposure to meditation, my mind was ajumble. As they related their histories to me, I cogitated about diagnosis, what tests to request, what to say to them, and how to plan management, not to mention worrying about my own performance. Patients might not have suspected they were addressing a man whose mind was a six-ring circus. Attending entirely to my own agenda, I was with them in body only.

These contacts didn’t exemplify a healing relationship. Sure, plenty got done in terms of physical diagnosis and treatment—and commerce, by the way—but little health or comfort were added to the world.

I had no idea that I could have been fully, calmly receptive to this other person. I knew neither how tumultuous my mind was nor that silence was even possible. All my experience and training suggested that my mental extravaganza was normal.

Most medical visits these days are for disorders that stem either from normal aging or pathogenic behaviors like overeating, poor stress management, and sedentary style. We docs can offer these patients some symptomatic relief, but—contrary to the expectations they’ve absorbed from pop culture—we’ll be unable to cure almost any of them. We can help them substantially, though, by guiding them in living with their conditions and in altering habits. This requires authentic relationship, meaning enacting heart-to-heart contact, learning deeply who they are, and earning their trust. This is impossible when your mind is, as the Hindus put it, a “drunken monkey,” but quite achievable when you listen skillfully.

Mindfulness meditation is an effective practice, but not the only one available. Almost everyone can find a meditative form with which they’re comfortable. As a matter of fact, just about any activity can be meditative, including yoga, tai chi, running, and even just plain sitting still. The trick is to do it mindfully—that is, with full attention. If you’re interested, I have two suggestions. First, Google “mindful,” and you’ll be taken to dozens of useful websites. Second, please keep in mind that Buddha got enlightened without paying a single dollar.