Wednesday, December 14, 2011

A Latin Beat

Over many years of medical practice this remains my most memorable case.  It demonstrates how knowing the patient well can be pivotal and it is a brilliant reminder that life is not always governed by reason.

My patient, in his early sixties, had an elevated PSA.  He saw a urologist who performed a prostate biopsy.  It was bad news with findings suggesting an aggressive tumor.

Within two days of the procedure, he became acutely ill with fevers and chills and all the markings of a serious infection.  The prostate was doubtless the source of the infection.  Powerful antibiotics were launched but he, nevertheless, worsened with rising temperatures and then very disturbing neck pain.  Even more alarming was the sudden loss of  strength in his arms and legs.          

Consultation with neurosurgery, along with imaging of the neck, indicated that he had a subdural abscess of the cervical spine.  The neurosurgeon performed immediate and urgent surgery hoping to head off permanent damage to the spinal cord by draining the abscess.
While the surgery eliminated the infection, within two days, he was fully paralyzed despite aggressive medical and physical therapies.

After two months, with no changes,  a fortress of immobility, the neurosurgeon and physiatrist (physical medicine doctor) were absolutely sure that he would never regain any independence.  Discussions with the patient and his family regarding institutional care commenced.  As expected he was crushed.

But that is not the end of the story. Against all odds, he actually regained function of his limbs and went on to an independent and fairly active life.   Mystery and magic were thick in the air during his long and  nearly complete recovery.

Here is what happened.

Both the patient and I were, after two months,  still unable to accept his prognosis.  I kept looking for a roadmap to reverse the injury to his spinal cord, but all efforts were to no avail.

With the science of medicine exhausted, it became clear that the last hope was to deploy the art of medicine.  This put us under the jurisdiction of mystery and magic where we would attempt what one of my friends and colleagues (a poet too) calls "leaping over the science."

Knowing "Carlos" for many years, I landed on the compelling idea that music just might be the vehicle to inaugurate the leap.  It made sense.  He was, after all,  a legendary musician in the local Latin jazz scene, and a venerable mentor to many young musicians. 

 Music was a calling for him and the key narrative of his life.   Just watching him walk and hearing him talk in his graceful latin rhythms marked him as a man crazy for music. 

So, I went to his bedside and told him I believed that music could very well improve his condition.  He looked dubious initially but then managed a smile which implied he was on board.  I asked him to tell me  his favorite albums and artists and had the family bring them to the hospital.

I then discussed my plan with the nursing and physical therapy teams who signed on despite some modest rolling of the eyes.

The plan was relatively simple.  Music would be administered at set times, just like medicines, and played for at least thirty minutes per dose, four times daily.

With the tunes of Machito and Paquito D' Rivera pulsing out of his room, the general mood on the ward elevated and some of us seemed to be walking with a subtle but noticeable swing.  Carlos, on the other hand, remained immobile, sleeping through most of the musical treatments.

Just forty-eight hours into  the experiment, however,  a nurse called - he moved.  Come and see.  Arriving at the bedside I saw his right foot sticking out of the sheets with his great toe moving slowly and sensuously to a latin beat.    

The physiatrist seemed to think we had whisked the patient off to Lourdes in the dark of night and considered the toe dancing miraculous.  With just this minimal improvement, he reversed his prognosis and thought that, with intensive and sustained physical therapy, this small sign could be the harbinger of major improvement .

One year later, he walked out of  a rehab center ready to resume his old life.  Do I believe the music cured him?  Of course I do. 

Can some people leap over the science?

You bet.

PS:  Carlos declined any further prostate investigations or treatments and eight years later, he leads an independent life and his prostate tumor remains asymptomatic. 


Wednesday, November 30, 2011

The List

Most appointments with physicians are either followups or relate to new concerns and, generally, run fifteen minutes.  

At the end of a session for, say, indigestion, the patient and doctor decide on a course of action.  Thinking the visit is over, the doctor moves towards the door, at which point the patient, with some panache and the dexterity of a Las Vegas black jack dealer, draws "The List," from their pocket along with an announcement that they have more questions.   

Already running late,  with many scheduled encounters ahead,  the physician suddenly experiences  a nascent desire for a career change, perhaps  lion taming. 

"The List" varies in style and form but aficionados have apparently agreed upon a number of, until now, unwritten rules.

1- There can be no fewer than five questions on any list.
2- Pencils are the writing tool of choice and the smaller the piece of paper the better.
3- The list must not be revealed at the beginning of the appointment.
4- Issues raised on the list must have been present for no less than five years.
5- It is required that the patient's major worry is placed last on the list.

The doctor who decides to extend the appointment to address the list faces the distinct possibility of mayhem in the waiting room from patients, who correctly believe their time is as important as the physicians,  protesting loudly.

What to do?  The key is to commandeer the list as quickly as possible to make sure there are no alarming elements that need immediate attention. 

Then, the practitioner needs to discern just how concerned the patient is about any of the listings. 

The first step, in my experience,  is to tell the patient that their appointment time is up.  This is hard to say but fair given that their stated reason for coming to the office was addressed in the scheduled time.  Additionally, it is unfair to delay subsequent patients short of an emergency or pressing contingency with the current patient.

Then, most tellingly, the patient is asked if they wished to make a special appointment to focus on the list.  If they said yes, then I knew the issues needed my undivided attention.  If no, they were probably mostly curious,  wanting to economize and get as much out of the appointment as possible.

Over many years,  very few of my patients accepted the invitation to set up a special visit to address the list.

With soaring health care costs and co-pays, it is a small wonder that some individuals might try to get as much into an appointment as possible.  However, in doing so, they do themselves a disservice.  A bloated agenda, conducted by a doctor now on the run,  will invariably not lend itself to thorough and responsive care.

Mission essentially accomplished.  With the element of surprise contained and a galloping list corralled, clinical balance is restored and a sensible and reasoned approach to the list emerges. 

Indeed, this problem can be headed off by a "List" savvy doctor asking at the beginning of an appointment if there will be other questions, some possibly more immediate than the declared reason for the visit.  

So, while "The List" presents a formidable challenge for the practitioner, it can be managed with candor and understanding.  Lion taming still remains a possibility but, for the foreseeable future, the notion can be stored away in a vault for safe-keeping and possible future deployment.


Tuesday, November 15, 2011

Let's Dance

Over the years of practicing medicine, patients taught me many lessons.

On one occasion, the lesson came from a couple whom I had never seen before. They were quite elderly and each looked frail, layered in ordinariness, dressed in non-descript clothes of a  distant era.

In contrast to their appearance was the husband's courtliness, helping his wife off with her coat and then getting her comfortably seated.  Their affection for each other was palpable and they unquestionably were still very much in love.

sensed they had an interesting story to tell and was eager to discover it.

A fifteen minute appointment leaves you little time to really get to know your patients,  so  I utilized a favorite technique for connecting with patients when time is short.

Early in my practice I had discovered that even the most taciturn would open up and talk enthusiastically and appreciatively about their lives, revealing much in a very short time, when asked one of two questions: How did you and your spouse meet, or, where did you grow up and what was it like growing up there?

With this couple, there seemed most to be learned by asking how they had met.

They met in the early 1950s at the Eagle Ball Room where singles came to dance to big band music and perhaps even find romance.

He spotted her and asked her for the first dance of the evening.  After the music stopped, he asked her to marry him.  She accepted right on the spot.

Sixty-four years latter it was obviously a brilliant, if impulsive, decision.  "But how did you know that she was the one," I asked?

"Because we danced well together."  

Go figure.

So what did they teach me?  First, that the good life is not always governed by reason.  Second, that sometimes the heart is better than the head in navigating ones destiny.

Sunday, November 6, 2011

Getting To Know You

The big prize for the primary care practitioner is regarded by many as the opportunity to know their patients well in sharp contrast to the generally fleeting relationship of sub-specialists and their patients.

This was certainly true when doctors regularly made house calls where there was much to learn: Hemingway dominating the book shelves; the lawn overgrown; a chessboard with a prominent place in the living room; pictures of the kids colonizing the front hall; the scent of cigarette smoke hanging furtively in the air despite numerous efforts to quit smoking.

So while we primarily knew about our patient's blood sugars in the office, the house call allowed us to see their humanity, their singularity.  These insights went far in caring for patients as they hoped we would, with our efforts anchored to their beliefs and values.

Moreover, the attentive and open-minded physician had much to learn from patients on their home courts as they not infrequently led very interesting and informative lives.

Nowadays, knowing one's patients well is really quite challenging.  For one thing, insurance coverage availability and cost of coverage, oftentimes results in a musical chair like coming and going of patients that is disorienting to both doctor and patient.  It barely allows familiarity let alone bonding.

Then there is the  matter of the computer in the exam room, the big gorilla. 

Patients regularly report that the doctor barely looks at them but gazes fixedly instead at the computer's screen, bringing to mind the the pop hit immortalized by Frankie Valli, "Can't Keep My Eyes Off of You."

With the computer, often large, planted on the desk squarely between physician and patient, the possibility of doctor and patient seeing each other becomes somewhat theoretical,  giving each the sense of being alone in the room.

While the computer is not without its virtues in patient care and might even be thought to be indispensable, it can make it quite hard for doctor and patient to connect.

Part of the problem is that the standard fifteen minute appointment is littered with clerical tasks that the clinician is personally required to do, leaving fewer opportunities to see or even talk to the patient.

The clerical mandates vary but partially include documenting on the computer that the diagnosis list has been reviewed, the problem list reviewed, the feet inspected, if a diabetic, and the medication list updated.  

There is nothing unsavory about data entry, it is honorable work, but when done by the doctor, valuable time is lost with the patient.  So by the conclusion of office hours many practitioners feel a murderous disdain for the computer along with the sense that the day had been bleached of value by the relentless stampede of computer clicks documenting this and that.  No wonder the computer is so well casted in the role of the endlessly hungry little furnace.

It should be said that there is nothing fundamentally wrong with documenting.  Indeed there are cases where it improves care.  But it is worthwhile to remember that not all information is knowledge and therefore might very well not deserve collection.   

In the early going of the computer age, we seem to gather data incontinently so we need to become much more thoughtful about what we collect.  Moreover, when we do document, we need to ask at what price we do so.  Surely not at the expense of time interacting with patients.

Answers to the computer and insurance issues that make it harder to know our patients remain for the software designers and health care reformers to solve respectively. Physicians also need to take an active role in solving these problems.

In the meantime, it would do us well to remember the author Evelyn Waugh's response when asked by a young man what was the key to becoming a good writer.

Waugh said, "Only connect."


Saturday, October 29, 2011

On Language

Given the medical professions tradition of compassion it is indeed remarkable that some of our language regarding patients can be so adversarial and even brutal.

Looking at the words doctors use in their clinical notes makes the point.  

The patient is said to have "refused" the test, suggesting recalcitrance and an overall lack of cooperation.  Why not say instead that the patient declined the test,  a non-judgemental way of putting it, which allows the clinician, in an unloaded atmosphere,  to explore the reasons the test was declined?  

Perhaps a family member died from the very same test or procedure.  Perhaps they didn't have insurance.  Perhaps similar tests have led disastrously to false conclusions in the past.  These insights are not easily gained when words like "refused", charged with opinion and insensitivity, are deployed.

In the artillery of hostile language there is a special place for the word "denied".  Here patients are said to have denied, for example, chest pain rather than saying, non-judgementally, that they did not report any chest pain.  The typical office visit report is characteristically colonized with the word "denied".

Reading and creating such notes invariably conjures up images of the patient in an interrogation room,  replete with naked light bulb hanging from the ceiling and gray metal desks and chairs,  where trust, the coin of the realm,  runs low indeed.

The most egregious word usage is possibly saying that the patient "claimed" various things such as dizziness, headache, toe pain.  Why claimed?  Why not reported or indicated?

When medical records are reviewed and the word "claimed"is seen over and over, patients may be regarded more as liars than historians.  The results of this transformation can be calamitous as medical decisions are founded on mutual trust.

Words can not only be judgmental and insensitive but brutal too. For example, there is no convincing justification for telling someone they have heart failure.  Look someone in the eye and tell them they have heart failure or say kidney failure and you will invariably see all the air go out of their tires.  

It is not euphemistic to instead say they have cardiac or renal dysfunction.  One can even give an assessment of the degree of dysfunction, using words like significant or very significant.

Similarly, the tendency to tell patients they have dementia instead of memory loss is regrettable.  For many the word dementia is a biological hand grenade that evokes the terror of losing one's mind.   Softening the blow and holding out hope wherever possible is neither euphemistic or sugar coating.  It is humane.

So our words can tear apart or they can heal.   It remains unclear why the caring profession of medicine uses words  in ways that transforms patients into adversaries and sometimes uses words that terrorize.

The above practices suggest that for all of medicine's nobility, it has a tiny, but very significant flaw;  a concoction of arrogance and authoritarianism, rooted in a part of its history, still with enough force to make its way into modern medical care. 

It will not be easy to eradicate these practices. As physicians we are nursed on words like "claimed" and "denied",  but the job surely belongs to our medical schools where sensitivity to language and words can be taught as a way of discovering the best in our patients and ourselves, as well as a venerable tool to heal and comfort .  Encouraging literary pursuits and a fierce appreciation of language in medical training will assist future physicians to develop a vocabulary that is both caring and non-judgmental.                                        

Monday, October 10, 2011

Don't Be First On the Block

If you can help it, don't be the first one on your block to try a new drug.

This is not very easy even with widespread availability of proven and safe drugs.

Enter the drug companies, with a vast array of formidable strategies,  to make us hell bent on embracing new drugs all the same.

They also cultivate a nagging feeling in us that we are not nearly as well or functional as we should be.  It follows that their latest medications are just the thing to fix us up.

Perhaps their most successful sales pitch is advertising prescription medicines directly to the public on television.  This is not allowed in many countries,  including Australia, and it is an egregious mistake as the consequences of pill sales are vastly different and more serious than, say, refrigerators.

The ads are like smart bombs hitting their targets at will with amazing accuracy.   Despite dutiful recitations of doomsday side-effects, there is a sunny whimsicality and hopefulness which prevails, making the ads highly seductive and effective.

The companies go after the big fish: depression, erectile dysfunction and hypercholesterolemia.

A typical ad goes something like this.  A young girl goes bounding through a field of high grass, hat lifted by the wind,  much as the drug lifts her depression,  while a narrator earnestly recites a hefty list of misfortunes that could befall the user of this product, with the implied exception of the girl bounding through the tall grass.      

Listen in:  This drug can cause listlessness, constipation or diarrhea.  This ant-depressant has on occasion been associated with suicidal ideation  and insomnia.  Weight can go up or down.  Libido is commonly grounded and erectile dysfunction is certainly possible.  Skin can dry and fatigue is common.  Be sure to discuss these side effects with your physician should they be bothersome.  

Another ad teaches the viewer that folding laundry with your mate can be a major turn on, with the impending ignition of smoldering coals for those who are only ready.  Again, there is a broadcast of numerous disasters that could befall those trying to reach the promised land of hot burning coals.

Nonetheless,  patients, who used to think their sex lives were just fine,  or that they were just somewhat moody, damn the torpedoes, storming clinics and pharmacies, requesting the new product.  

These targeted drugs are, on the other hand,  members of drug categories that are important, relevant and often effective elements in our therapeutic arsenals. 

So what is the problem?

The problem is that we have developed a therapeutic culture, in which we have drugs looking for patients instead of patients looking for drugs.

Instead of normally robust sexual lives, we seek super normal sexuality.

We often mistake sadness for depression, medicalizing something that is part of the human condition and much better dealt with by fortifying our relationships.

Moreover,  it has been convincingly shown that the majority of hotly advertised medications do not offer meaningful benefit over the standards.  

For example,  anti-depressants generally work equally well.   The same is the case for blood pressure pills.  Importantly, the trumpeted drugs are alarmingly more expensive than the standards which are largely generic.  With few exceptions generic drugs should be used compulsively because of their effectiveness and lower cost.  

Drug companies might need more anti-depressants, we do not.   

Moreover, it is wise to be skeptical  about the safety of new drugs.  Many prescription drugs, over the years, despite rigorous scrutiny by the FDA, still bite us with serious side effects  when filtered through the whole of society, sometimes after only a year or so. 

It is especially unwise to switch from  tried and true drugs, which work well, for a new model, believing that a new drug is an advancement over a well seasoned one. 

When patients and I talked about the above issues I finally came to a metaphor that worked well to frame the discussion. It is a military one for taking a beach head with an amphibious assault.  In such an assault most of us would prefer not to be sent in on the first few waves.  The seventeenth, for example,  should prove to be much less gruesome.

The same can be said for new drugs,  and the taking of what amounts to a pharmacological beach head,  where it is likewise prudent to not go out on the first waves, if at all possible.    

This means that time needs to pass before we can wholeheartedly sanction a drug for regular use.  There can be compelling reasons to deploy a new drug but they are not common.

The beach head metaphor resonated quite well with most patients and few were the first on their block to try a new drug.

Sunday, October 2, 2011

The Physician Hero

While saying good-bye to my patients,  in anticipation of my retirement from my internal medicine practice, three patients told me that I had saved their lives.  How?  The stories were remarkably similar and went something like this:

You discovered my blood pressure was high and you corrected it.  You found that I had diabetes and you got it under control.  You listened carefully when I talked to you about chest pain and you promptly got me out of danger with cardiac surgery.  My father died at fifty-two; I'm seventy-four.  You saved my life.

During my early years of practice, there were occasionally similar sentiments expressed.  I had trouble accepting the praise as I thought, first of all, that a doctor should be fiercely modest.  So I labored to explain that a number of doctors and nurses had made major contributions to their well-being.  

Deep down, I felt I had just done my job, one that thousands of doctors could have done as well and maybe better.  It was business as usual.

There also was the wariness of being put up high on a pedestal knowing that could make delivering the goods difficult in the future and sometimes impossible.

It wasn't, however, business as usual for my patients.  It was magic.  All of it: the stethoscope, interpreting the labs, interpreting their story and so on.

They weren't buying fierce modesty or any explanation other than that I had saved their life.  

Finally, it became clear to me that having a life-saving,  magic wand toting doctor, who could rescue a patient from the jaws of calamity was, for them, an unassailable belief and need. No wonder they bristled and were viscerally upset when I attempted to brush off their praise and claimed ordinary powers.  

It took some years but I finally learned to accept praise for saving a life.  The key thing,  I discovered,  is to empathize, tasting the praise but never swallowing it.    

On the other hand,  there are times when praise is manipulative and needs to put a doctor on guard.  It is usually served up in a cloying manner with offers of haloes which are, in the end, dented.

So, ultimately, when the patient tells us we are their hero, let's put on our capes and be grateful for the opportunity to heal and give comfort.

And who knows,  perhaps I did, after all, save a life. 

Saturday, September 24, 2011

To Stand There or Not to Stand There

In moments of great distress patients understandably expect their caregivers to do something.  A kind of red alert follows with the common refrain of “don’t just stand there, do something” ringing out.  Action is usually necessary but there are special occasions when a refrain of “don’t just do something, stand there” works better.

An esteemed surgical colleague of mine once told me that he did his best work when he kept his hands in pockets.  He added that the average surgeon knew when to operate, but it was the gifted surgeon who knew when not to operate.

While in my internship, my resident graphically and unintentionally taught me why it is sometimes better to “stand there” than to “do something.”  It was about 3:00 AM and we decided to check on our intensive care unit patients.  We were joking with one man who had sustained a heart attack and was doing well when my resident, looking at the heart monitor, bellowed out that the man had flat lined (no pulse) and he cried out for the defibrillator paddles. 
As my resident closed in with paddles all fired up, the patient demanded an explanation. What followed was a very brief conversation that went something like this: Your heart has stopped. What are you talking about?  I have to shock you.  You better not shock me.  I’m telling you I’m fine and you better not shock me.  This fevered conversation covered about twenty seconds when the resident finally threw caution to the winds and discharged the paddles launching the patient into the air.  The monitor still showed a flat line but there was not to be a second shock as the patient pulled his intravenous lines out and (not what the doctor ordered) bolted out of bed, chasing the resident doctor down the hall.                                                                                                                                                                                               

An explanation for the flat lining became painfully clear when a nurse wiggled a wire above her head that had been disconnected from the monitor. 

In retrospect, one doesn’t have a twenty second conversation with a pulseless patient and the story, once again, signals the importance of listening to the patient.  Moreover, it amply shows why “don’t just do something, stand there” is on occasion strikingly preferable to drive-by action.

On a more quotidian level, conscientious doctors labor to eliminate unnecessary prescriptions for antibiotics in order to contain the menace of antibiotic resistance, a growing problem.  They also labor to be thoughtful about how they deploy technology, realizing that various blood and imaging tests, often spot on, can misfire and provide more smoke than light, so to speak.

Physicians who are cautious and simply stand by are sometimes lauded as thoughtful and conservative.  However, others see them as not being thorough and, in the extreme, uncaring and authoritarian.

There is altogether an important place in our medical deliberations to seize the opportunity to do nothing, at times, beyond caring for the patient and reassuring them that they will be monitored closely. To occasionally do nothing is hard wired into our medical DNA which shouts to us still: primum non nocere, above all do no harm.  This, along with the idea that doctors and patients are best advised to do nothing when they don’t know what to do, has served us well.
L. Blogspeak, M.D.

Sunday, September 18, 2011

First Outing

I am a recently retired physician who practiced internal medicine for forty-two years in the mid-west.  It is my intention, with this blog, to share lessons learned (and yes, by necessity, relearned at times) that could help patients and doctors navigate the choppy waters of medical care.
The blog is not intended to be a scholarly weighing in on new studies fraught with data and footnotes.   My hope, instead, is that it will show how patients and doctors teach each other how to read the medical tea leaves of every day problems and how they individually and collectively can deploy common sense ideas to inform complicated issues.  Moreover, attention will be focused on the special relationship of patients and doctors, a kaleidoscope of personal and medical forces that are undertood best in a climate of mutual respect and an appreciation of how much they have to learn together.
Some of the planned topics include: “Why You don’t Want To Be the First One On The Block To Try A  New Medicine;  Why It’s Often Better When The Doctor Does Nothing Than Something;  When The Doctor Needs To Be The Patient’s Hero.
Postings are planned to be weekly and I look forward to your insights and opinions.