Monday, July 30, 2012

CAREGIVERS AS PATIENTS


Working with people who have cancer, I come into abundant contact with their caregivers, usually their spouses. I’ve written here about how the caregiver suffers, sometimes more than the patient does. Caregiving is all-consuming, unrelenting, exhausting, and too often under-appreciated. The physicians and others who treat patients assume that their mandate is to serve the patient, and that caregivers’ tribulations are outside medical responsibility.

Little wonder, then, that caregiving is such a hazardous occupation. Studies have found that caregivers are at risk for high blood pressure, impaired immunity, and cardiovascular disease. Spousal caregivers age 66 or older have a 63% higher mortality rate than noncaregivers the same age. It’s not as if we really need those studies; just ask a caregiver.

I’m beginning to realize that one way to get practitioners to take caregivers more seriously is to identify them as patients. Suppose a man with cancer, say, visits a doctor along with his wife. What would their care look like if the doctor recognized there were two patients to deal with?

Truly, doctors aren’t generally equipped to address caregivers’ problems, but they can be referred to appropriate professionals and support services. Where there’s a will, there’s a way, but wills and ways depend on first seeing the situation.

Wednesday, July 25, 2012

COMPASSION FATIGUE


We who are helpers need to know our resources are limited. I recently suffered my first instance of compassion fatigue (check out http://www.compassionfatigue.org). My practice is hearing the anguish of sick people and caregivers. Several of my friends got seriously ill during the past month, and others died of illness and accidents. Maybe the stars were in unfortunate alignment. Anyway, it got to be more than I could handle, and pain began to saturate the air in our home. My wife pointed out that I was exhausted, and was getting angry without provocation. 

I finally realized that I couldn’t take on any more, and told people that. I turned off the phone and gave my e-mail a couple of days rest. Now I feel refreshed, and I’m sure I dodged a stress-induced illness.

Have you experienced anything like that?

Monday, July 16, 2012

DIE IN THE STREET?


There are now 50.7 million medically uninsured people in the United States, one of every six of us. More, actually, since many who believe they’re insured learn at the most inopportune time that their policy, despite high premiums, is so thin and narrow that it’s virtually worthless.

What are the uninsured to do? Traditionally, we’ve directed emergency departments to serve them regardless of their ability to pay. We do that because the alternative is to let them die in the streets, which can create a traffic and disposal problem. 

In treating them, emergency departments, mandated to maintain expensive equipment and hypertrained staffs, turn out to be awesome money losers for hospitals. For their part, hospitals try to compensate by soaking those patients who are insured or seem solvent. (The ED that treated me for two hours a few months ago billed Medicare ten thousand dollars, and accepted eight hundred.) That is, we are all paying through the nose, via taxes and premiums, for the expensive, however desultory, care indigent patients receive.

We could look at this and say, “Wait a minute. We’re essentially paying for the care of the indigent anyway, and because they use EDs, paying through the nose. Why not cover them instead with standard care, for less?” 

That’s what a sane society would do, but we’re not there yet. As Winston Churchill said, “Leave it to the Americans to do the right thing…after they’ve tried all the wrong ones.”

Wednesday, July 11, 2012

DIETARY SUICIDE



Thanks to Michelle Obama’s interest in Americans’ epidemic obesity, we’re hearing more these days about eating disorders, even this innovative one, described in last Sunday’s supplement to the Boise, Idaho Times

DIETARY SUICIDE FAD

An ambulance sits vigilantly in the floodlit parking lot of the Burger Blitz in suburban Lincoln, Nebraska. Its two attendants quietly observe a particular patron inside the restaurant, a man who has been eating ravenously. 
 
The man suddenly stops mid-chew. A few morsels tumble from his distended craw. He shudders, turns the color of a plum. In mortal agony, he grasps for a breath beyond his reach, and finally pitches forward into the remnants of his meal, a cardboard bucket of chicken bones, ketchup, and lard.
 
“Let’s hit it,” cries the taller attendant. They leap out, pull a collapsible gurney from the ambulance, and roll it into the restaurant. 
 
The 26-year-old manager, Bobby Lee Dilworth, meets them at the table. Like the other employees, Dilworth wears a tiny checkered chef’s hat adorned with the well-known Burger Blitz emblem, a cow grinning from a meat grinder. 
 
“Evening,” says the shorter attendant, unbuckling the gurney’s straps.
 
Dilworth nods. “Third one this week,” he complains, wringing his hands. “I wish something could be done. Last night one just laid there getting stiff while other customers waited for the table. It’s not fair, you know what I mean?”
 
The attendants take this as a professional challenge. “Well, here,” says the taller one, “we'll deal with him while you clean up the table. Place'll be back to new in a minute.”
 
Skilled though they are, the attendants nonetheless cause some little commotion. Several patrons look up curiously from their boxes of Gutbusters and Chicken Tetrachloride. Perhaps they do not know what has happened, but then again, perhaps they do.
 
Perhaps they are aware of the trend that has begun to sweep the Midwest like prairie fire: suicide by gluttony.      
 
The foremost expert on this phenomenon is Dr. Karl Mandrake, Chief of the Nutrition Department at the respected Sloan-Smithson Institute in Albany, New York.
 
“This fad shouldn't surprise anyone,” Dr. Mandrake confides over lunch. “After all, we are a nation of consumers, so what could be more natural than for consumption itself to become a popular form of suicide?
 
“Most of these self-destructive acts have occurred in fast-food outlets for economic reasons,” Dr. Mandrake continues, folding his Reuben sandwich to wrestle it into his mouth. “Look at it this way: twelve or fifteen GooBurgers or Fat Dogs or whatever they’re pushing these days are still cheaper than a bottle of sleeping pills. In fact,” he grins, leaking a rivulet of mustard onto his tie, “you even have change coming.”
 
The owners of these restaurant chains seem surprisingly unbothered by the fad. Harold Colon, President of the National Faux Food Association, says, “Suicide is tragic, but we must face facts. The fact here is that to us, these people are customers, too. Let me tell you, customers are very special people—even though I’ll admit these folks sometimes make a mess. From some of the stories we’ve heard, you’d think the other customers would walk out. But they don’t. That’s what we call in our business ‘brand loyalty.’ Anyway, we feel fortunate that hardly anything disgusts our clientele.”
 
The issue is causing battle lines to be drawn.
 
On one side is the U.S. Surgeon General, who has recommended that fast-food restaurants employ full-time security guards to enforce healthy eating practices and verify that patrons carry suicide insurance.
 
On the other side is the might and wile of the fast-food industry. Explains Faux Food Association’s Colon, “In business you find a need and fill it. One chain is now trial-marketing a package that caters exclusively to suicides. They offer the meal—a meal especially rich in embalming preservatives, I might add—and the cleanup, and burial in a large styrofoam box. Their motto is, ‘We do it all for you.’”
 
In a way, one concedes, this is progress. But is it good for the country in the long run? Researcher Dr. Mandrake answers, through a mouthful of blackened redfish and creamed spinach, “That's not for me to say. I don’t get involved in politics. I’m just into health.”

Tuesday, July 10, 2012

THE HAND…OF A WOMAN


An issue that plagues healthcare is patients’ surreal expectations. We’ve internalized popular culture’s portrayal of physicians as action figures. Consider radio’s Dr. Christian, and television’s Dr. Ben Casey, Dr. Marcus Welby, Dr. Gregory House, and even Star Trek’s Dr. “Bones” McCoy. My all-time favorite is the 1950s series “Medic,” featuring Dr. Konrad Steiner, played by young Richard Boone (“A physician’s three qualities: the eye of an eagle, the heart of a lion, the hand…of a woman.” Check it out at http://xoteria.com/CH45.html.) We never see these heroes quietly sitting with a patient. No, they’re can-do go-getters who, suddenly realizing that the correct diagnosis is tetanus, run to the bedside and push the intravenous antitoxin, stat!

Curing tetanus, stat, is a good thing, of course. When we truly need it, medical technology can be miraculous. But our pop fantasy has us expecting and even demanding that docs apply technology willy-nilly. Despite abundant evidence to the contrary, we believe medical hi-tech can vanquish every enemy unto the Grim Reaper.

For example, a study of how cardiopulmonary resuscitation—CPR—is portrayed on television found that it was successful in three-quarters of the cases, and two-thirds of these patients went home. A study of ninety-nine thousand actual CPR cases found, though, that only eight percent of patients survived more than one month, and only three percent of them could lead something like a normal life. I’ll save you doing the math: of ninety-nine thousand, two hundred twenty-eight were pulled from death into a normal life. The rarity of success doesn’t mean we shouldn’t try, only that our expectations need trimming.

The flame of wishful thinking is also fanned by infomercials touting the latest “breakthroughs,” and magazine ads advising us to ask our doctor if a daily dose of PanaceaTM will fix our lives.

We’re inundated with messages suggesting that doctors can cure anything. Compared to this vaunted potency, anything patients can contribute seems negligible. Most significantly, we’ve absorbed the myth that healthcare is identical to the application of technology, which leaves subjective phenomena like suffering to flap in the wind.

Standard healthcare's failure to address the emotions of the sick is not the fault of practitioners, as few have been trained in compassion skills. It falls to us to appreciate and treat our suffering. We can do it with the help of close relatives and friends, counselors, and support programs.

Thursday, July 5, 2012

CALORIES IN, CALORIES OUT



Last month, New York mayor Michael Bloomberg, alarmed at the skyrocketing incidence of obesity and type two diabetes among the young, proposed banning soft drinks larger than sixteen ounces. (Actually, Bloomberg’s strategy isn’t much more than a public service announcement, since sodaholics can buy all the sixteen-ounce servings they like.)

Muhtar Kent, the CEO of Coca-Cola, denied that his product was responsible for the epidemic. He pointed his finger instead at Americans’ sedentary habits. “If we're genuinely interested in curbing obesity,” he said, “we need to take a hard look in the mirror and acknowledge that it's not just about calories in. It's also about calories out.”

Kent’s position is obviously self-serving, like a drug dealer who blames his customers for their habit, but still, he’s got a point. Overconsumption of carbohydrates is only part of a popular pathogenic (disease-causing) lifestyle. Too many of us fall into our La-Z-Boy and watch the game while grazing on a sack of potato chips and a two-liter bottle of carbonated sugar water.

What comes up for me is that this struggle is exclusively between the government and the soft drink industry. A vital party, the American people (or consumers, if you will), aren’t part of the conversation. This reminds me of our so-called debate on healthcare reform, the participants being the federal government and the healthcare-industrial complex. At the 2010 Congressional hearings on the Affordable Care Act, you’ll recall, not one person testified who was identified as either a patient or practicing physician.

We haven’t heard from Jill Q. Public on the soda issue. Does she know the dangers of unlimited carbs, or that her taxes subsidize high-fructose corn syrup? If the issues seem too complex such that Americans rely on the government to protect them, they’re in for deep disappointment. If you want healthier products in a market-based economy such as ours, get up from the La-Z-Boy and vote with your wallet. Sure, it might be a little more expensive, but considering that tap water’s healthier than Coke, it might be much cheaper, too.