Friday, December 28, 2012

PLEASE HELP ME OUT HERE


I was talking with a friend who teaches communication in a medical school. She’s getting on (aren’t we all?), so her dean asked her to think about who will replace her when she retires.

She hasn’t been able to identify anyone. She told me, “It seems like younger people just aren’t interested in this field.”

I concur. Four to six times annually I miss the cancer support meetings I normally facilitate because of vacation or illness. In past years competent substitutes like colleagues or their interns were always available to fill in. This year I really had to scramble. There are no more interns, and most of my colleagues were overbooked, tired, and, I realized, past middle age.

The younger psychologists I know who work in hospitals are fully absorbed in issues of diagnosis and medication. They seem to have little or no expertise or even interest in normal communication. It’s as though only a single generation--we 1960s hippies--was touched by the significance of deep contact. What’s to become of this craft?

Maybe I’m missing something. It could be that the emotional aspects of illness are being addressed by some other department. Maybe standard medical practitioners like docs and nurses are finally becoming as compassionate as we’d like. Or maybe social workers finally have adequate time to sit with patients and their families. I just don’t see much of that yet.

So help me out here. What do you see? When I and my ilk shuffle off this mortal coil, what will the experience of sick people be like?

Friday, December 21, 2012

CREATIVE PROCRASTINATION

A few days ago a friend told me, "I've heard the world might end on Friday. That's when I'm scheduled for a colonoscopy. Maybe I should postpone it till next week."

Thursday, December 20, 2012

VIRTUAL HEALTHCARE


Thanks and a tip of the hat to Christine Newsom, MD for sending me an editorial, “Virtual Grief,” from the November 28 JAMA.

Written by Dr. David Wu of the University of Washington’s Palliative Medicine Fellowship Program, the essay describes a significant blemish on the beautiful face of electronic medical records, EMRs. Dr. Wu reports finding an entry, inserted by a social worker, on the record of a patient he’d seen stating simply that the man had been shot and killed.

Dr. Wu hadn’t seen the patient as often as the electronic messages about him—lab and x-ray reports and so on. The man had slowly become virtual: unpresent in the flesh, he was represented by a computer avatar, like a character in a video game. In fact, Dr. Wu realized that as he spent more time with his patients’ EMRs than with them, they’d all gone virtual.

I haven’t been in medical practice many years now, so I’m unaccustomed to electronic record-keeping. When I recently examined a deceased patient’s chart, the nursing notes surprised me. Evidently nurses save time these days by checking a particular box to automatically write a note. If, for example, you want to enter, “Patient asks for more pain medicine than orders specify,” you can do so with a single keystroke, and then another part of the program adds the recommended course of action, “Physician to be notified.” Page after page exhibited only these un-nuanced notes, cleansed of the glorious human contact that must have occurred. 

In saving nurse time, computerized shorthand improves efficiency, which is, I guess, what healthcare’s about these days. A future archeologist reading this chart will surmise that our hospitals weren’t places that cared for people, but factories smoothly efficient in fixing disordered units, and especially in keeping records.

Dr. Wu writes, “Under this system, I’m not as good a doctor as I once was. What I mean is that I’ve come to prize what the system prizes: efficiency over human contact, computerized data over stories, virtual reality over authentic life.” Feeling compelled to inject some degree of humanity into the EMR of his patient, Dr. Wu wrote that it had been an honor to be the man’s doctor.

I hope his heartfelt comment doesn’t get incorporated into the next generation of this EMR software.

Wednesday, December 19, 2012

OBESITY AND DEMOCRACY


The Robert Wood Johnson Foundation says Americans are becoming alarmingly fat. According to a recent Foundation report, “If obesity rates continue on their current trajectories, by 2030 thirteen states could have adult obesity rates above sixty percent, and all fifty states could have rates above forty-four percent.”

Depending on who’s holding forth, obesification results from lack of exercise, passive indoor entertainment, child safety issues, processed foods, and more meals eaten out. Arguments aplenty concern sugar, fats, high-fructose corn syrup, and a slew of additives. The item seldom discussed yet actually at the bottom of our most difficult issues, is: us.

It’s as though our lifestyle, whatever it may be, was handed to us by some authority that forces us to flop onto the couch for another boob-tube dose, gobble junk foods, ignore grocery labels—in sum, abdicate control of our lives. 

That is, we’ve become a passive people. We accept the label “consumer” not only in commerce, but across the board. Healthcare has come to be a transaction between a “consumer” and a “provider.” While a huge majority of us, if asked, think our endless wars--currently against terrorists, cancer, and drugs--are unproductive at best, somehow they continue anyway. While lunatics are gunning down people by the score, we respond by simply ducking.

If we’re going to get back into shape—in our bodies and in our nation—we’ll need to seriously review the life choices we make from moment to moment. There can be no democracy without active, informed participation. What will it take for us to wake up?

Saturday, December 15, 2012

NEWTOWN


I lit a candle yesterday for the dead, wounded and horribly grieving people of Newtown, Connecticut.

I lit it for our Congressional representatives, too, those who sigh that their hearts go out, but lack the spine to keep guns from those who shouldn’t have them.

I lit it for the millions of frightened souls who believe their guns will protect them, while they’ll actually make them and their loved ones less safe.

I lit a candle for the majority of gun owners, who are sober and sane…until they’re not.

I lit a candle for our national mental health. Yes, our mental health: there’s something very wrong with us when we respond to mass random violence mainly by hoping it won’t occur in our town.

Finally, I lit a candle for a country that can’t seem to generate the courage to end this intolerable madness. Maybe we need to remind ourselves that America was once known as “the home of the brave.”

Thursday, December 13, 2012

BODY AND MIND UNDER ONE ROOF


Our local newspaper published a story this week about the Sierra Family Medical Clinic, located in the wilds of San Juan Ridge, fifteen miles outside already-rural Nevada City. The clinic, which has provided cutting-edge care for a quarter-century under the direction of its founder, Dr. Peter Van Houten, recently added an in-house psychotherapist to its services.

Certain lifestyles predictably lead to illness. Examples are poor self-image, addictions, unskilled stress management, and acceptance of toxic relationships. When I practiced standard medicine, I was vexed to find I frequently operated a high-tech turnstile, patching folks up only to return them to the same miseries that corroded them in the first place.

Counselling can interrupt that cycle. Dr. Van Houten reported that when his clinic referred patients to outside therapists, forty percent of them kept their return appointments, but if they saw the clinic’s own therapist that very day, eighty percent returned. Since hardly anyone makes significant lifestyle changes after only a single exposure, this is a major advance.

One wonders why this should be such a revelation. Don’t we all feel that the body and the mind are connected in some way? If so, why shouldn’t a psychotherapist be a natural component of a medical clinic? The way we practice now, we may as well hang a sign over our doorway reading, “We treat only your body; for the way you feel, think, believe, and thus lead your life, shop elsewhere.” Thanks, Dr. Van Houten, for showing the way.

Tuesday, December 11, 2012

HOW ARE YOU DOING? NO, REALLY.


When I asked my sainted old mother how she was, she answered, “I don’t know. I don’t see the doctor till Tuesday.”

Well, that was that generation. Virtually worshipping science, they tended to abdicate their truth to those experts. We’ve come a long way since then. Or have we?

“How are you doing?” When you think about it, that question we routinely ask one another isn’t just surface fluff. “How” is an inextricable feature of every life. We are verbs requiring adverbs. We conduct our unique style of relationships, social processes, eating habits, stress management, exercise pattern, and so on. “How” is a whole lot, actually, yet how do we answer the question? Fine. Not too bad. Can’t complain. For all our complexity, we offer ludicrously anemic responses.

My mother had a point, though. The temple of medical science produces some important answers. Exploration of our physical parts—tests of body fluids, radiological images, biopsies—can reveal much…about “what,” but not “how.”

Most of the folks I know who received sour diagnoses suddenly shifted their attention to their life's adverbs, reconsidering their attitudes and the ways they’d chosen to be in the world.

A couple of decades ago, we bought a home that while certainly livable lacked interior window trim. After seven years, we put it up for sale. We figured it would sell more easily if we finally installed the trim. As I measured, cut, and nailed over several days, I thought, “Blimey, we could’ve been living with trim these past seven years.”

This is my modest way of suggesting that we might have a better time if we examined and enhanced our lives now, before we’re diagnosed. To me, the term “preventive medicine,” which once meant getting PSAs, mammograms, lipid panels, and colonoscopies, has come to mean instead steering toward our best life, beginning now. Then, whatever comes from seeing the doctor next Tuesday, it won’t be the entire story. 

Monday, December 10, 2012

WHAT’S BEHIND CHEMO BRAIN


A small study presented recently at the San Antonio Breast Cancer Symposium (http://www.newswise.com/articles/cognitive-problems-may-be-present-before-chemotherapy-in-women-with-breast-cancer)
suggests that “chemo brain”—the fuzzy thinking that sometimes accompanies chemotherapy treatment—might not necessarily be due to chemo, as fuzziness occurs prior to treatment.

“Chemo brain” was noted—though to a lesser extent—in women with breast cancer who awaited radiation therapy, but not in a control group of women who didn’t have cancer.

So what’s at work here? Maybe breast cancer itself meddles with your mind. More likely, though, as lead researcher Bernadine Cimprich, Ph.D., R.N., surmised, confusion results from the “mental demand and stress of a breast cancer diagnosis.” She wisely added, “Women should not avoid accepting recommendations for lifesaving chemotherapy for fear of ‘chemo brain.’” Dr. Cimprich recommended existing interventions to combat stress after a breast cancer diagnosis, including mindfulness training, psychological support, cognitive behavior therapy, and exercise.

I’m continually surprised that her advice isn’t a recognized component of all cancer treatment. If you’ve been handed any serious diagnosis, you’re all too aware of how this news, by itself, alters your mentality. In our tiny, rural cancer center, our social worker visits every newly diagnosed person to inform them about the many psychosocial interventions available, intended to complement their oncological treatment.