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.