On Touching

Touching has always been a way to express our love and humanity.  Its ability to heal has been recognized since physicians made house calls in caves.  

Royalty has used it to great advantage too, knighting with touches of the hand and sword.  Moreover, the "royal touch" of British and French monarchs, which was believed to cure a glandular form of tuberculosis, enhanced their position as purveyors of divine power for many centuries.

There is still plenty of touching in the 21st century but the practice is somewhat on hard times.  I am reminded of one of my patients, a grade school teacher, who was terminated after hugging a child who had fallen and scrapped her knee on the playground.  My patient was ultimately pushed out of the school district by parents and administrators who couldn't see the difference between compassion (which it was) and perversion.

The workplace is now largely free (you can thank Anita Hill) of unwanted gropings and touchings.

But at a price.

Fear of  sexual harassment is so widespread at work  that  tearful and overwhelmed individuals must oftentimes soldier on without the immense benefit of a pat on the shoulder or a discreet hug from a colleague.

In medicine, touch remains  one of physicians most powerful tools.  

I remember a woman on a rehabilitation unit who had unmanageable pain.  She was in great distress and the staff and I were at wits end.  Finally  I recalled an article suggesting that severe pain could be relieved by hair brushing.  After getting myself and the nursing staff to buy into the idea that this kind of touching could relieve severe pain, I ordered hair brushing for ten minutes every six hours, scheduling the brushing just like a pain pill.  The results were astonishingly good.

Doctors have many different ways of comforting patients utilizing touch.  In my case,  I placed my free hand on their right shoulder while examining various organ systems.  My belief is that this practice created a connection between us that was strong, resilient and therapeutic.

The smart physician can sometimes diagnose and treat patients effectively without ever touching or examining them.

The wise physician knows that the addition of a perfunctory physical exam (say aah) in such cases can result in speedier and more durable cures.

Placebos remain one of doctors most powerful tools and touch is arguably its quintessence.

Asking For Help

Primary care physicians often refer their patients to specialists, say a cardiologist,  for what is simply known as a consultation.  If the doctor or patient is unsatisfied with the consultation, a second consultant might be  brought in for what is called a second opinion.  On rare occasions,  an internist might refer a patient to another internist for advice and consultation.

While the primary doctor usually orchestrates the referral, patients sometimes do it themselves.

A second opinion might be invoked when someone has been advised to have a major operation.  Or, it might be invoked in an unusually complicated case where the primary physician and his/her consultants are out of ideas.

The selection of the doctor to give a second opinion can be fraught with biases.

Consider the following.  If the patient makes the choice, it is often influenced by family and friends who can be easily moved by the celebrity of a consultant, or their personal experience with him/her,  rather than objective performance measurements such as post operative complication rates.  

When the primary doctor picks the consultant, it is often someone in their own group.  This introduces a financial bias where keeping the fees in house might trump inviting a consultant from another organization, who might be more qualified to weigh in on the case.   

If the ordering doctor picks a colleague from their own group, there are at least two more important concerns. The doctor giving the second opinion might be reluctant to disagree with care rendered by someone who is in their personal, clinical and financial orbits.  Additionally,  there is the matter of herd mentality (common in groups and hospitals) where physicians, with social and clinical ties, tend to manage certain problems uniformly, making it less likely that alternative approaches will be considered.

Surprisingly, internists almost never ask internal medicine colleagues for formal consultation.  This is unfortunate since another internist, with a panoramic view of medicine, might be of much greater service in mysterious or complicated cases than a squadron of sub-specialists who tend to look at cases through a single lens. 

My years in medicine have shown me that a consultation or second opinion, centered in knowledge and a wide ranging experience, is often, in tough cases, more valuable than endless testing, which tends to get more and more  incoherent as time goes on. 

Sound judgement is vastly superior to rampant testing, which once unleashed,  tends to generate more smoke than light.

In good hands the second opinion (a third opinion is almost never a good idea) is often clarifying and reassuring for both patients and doctors.  Bias should be kept to a minimum and doctors and patients should work together in picking a consultant.

On Cleavage

It is almost inevitable that a physician will experience, over a long career, sexual arousal while seeing a patient.

In the vast majority of cases the feelings are rare, brief, without any violation of decency standards.

Many of us learned in our training that we might experience occasional erotic sensations  in the course of our clinical work.  We were assured that it was not abnormal to do so, though we were told we must never  act out any of those feelings.   To Wit, fleeting feelings were normal, prolonged feelings were a call for going on red alert.

Episodes of arousal are  usually biological, without emotional baggage, but they could indicate, presenting as a flirtation or seduction, a significant personality or psychological disorder.  

When the experience is anything more than ephemeral it becomes crucial to determine whether it is the doctor or patient launching Cupid's arrow.   In either case problems may go way beyond the exam room, permeating important relationships.  Psychiatric consultation can be of great benefit in sorting things out.

About twenty years into my practice I felt confident that sexual arousal in the exam room was not one of my problems.

But that changed one day when a new patient with a cough was brought into my office.  

Not only was she curvaceous but she had a full bosom with an an arresting cleavage.  Inchoate feelings of arousal started almost immediately and I found myself in a battle to not look at her chest, hoping my eyes would lock instead on to her eyes,  suggesting sincerity and caring rather than the embarrassing and over heated feelings I was struggling against.

Alas, my defenses crumbled when I examined her.

It was my habit to tell  patients what I was doing as I examined them: now I'm going to look at your throat, now I'm going to listen to your lungs.  Disaster struck when I came to listen to this patient's heart when I heard myself say, quite clearly and audibly - and now I'm going to listen to your breasts.

She gave no signal that she heard me though I felt certain she had.  Since she said nothing I decided not to open a can of worms and,  feeling exposed  and mortified, said nothing.

For the next twenty-two years, when coming to a  heart exam 
I would faithfully say, "and now I'm going to listen to your (pause, pause, pause, get it right) heart.

What did I learn?

I learned that  I was human and not always as in command of my feelings as I had imagined.  Moreover, I learned that patients can be generous in forgiving our frailties.  

Whatever feelings of attraction  I had for the patient were extinguished by the experience and our doctor patient relationship took an ordinary trajectory.

Retry

Dear Reader -

I sent out my last post, Televised Snake Oil, on 6/13/13.  I've since learned that some of you never received the post or had to go through some tricky gymnastics to view it.

It's not clear to me why this happened.

I will resend hoping the problem somehow auto corrects.

Blogspeak

Televised Snake Oil

I was looking up the meaning of a word on my desktop the other day when a small box containing an advertisement drifted, uninvited, onto the screen.

The advertisement was for an inhaled steroid used to treat asthma and chronic obstructive pulmonary disease.  The drug is often effective, but it is in no way a first line treatment as there are multiple strategies, with significantly lower cost and fewer side effects,  which may work as well or better.

It is only in recent years that drug firms have taken their products directly to the public on television and the internet.  Previously, the main sales strategy was to have drug representatives meet directly with physicians to trumpet their products.

Doctors were flattered, cajoled and bought to gain their endorsements.  For example, lavish lunches were provided for the doctors and their staffs in exchange for ten minutes of the doctor's time.  Clinicians and staff came to regard these lunches as an enshrined benefit.  

While  wolfing down sandwiches (stuffed with arugula), golf balls,  pens, refrigerator magnets, pads and all manner of tchotchkes were put out for the taking. While any self-respecting  robber would never steal a tchotchke, doctors couldn't get enough of them.

Physicians, who additionally agreed to give talks favoring use of a company's new drug, were oftentimes regaled with all expense trips for two to exotic places.  Generous stipends such as a financial aid package for millionaires were not uncommon.

Altogether, the relationship between many drug companies and a sizable  minority of doctors was whoreish.  The pharmaceutical industry has lots of money to buy favors and many doctors are on the take.  Even physicians who never put themselves up for sale were too willing to accept drug companies as the first and last word on treatment issues.   In doing so, doctors left the fox (the pharmaceutical industry) guarding the hen house.

Happily, many medical organizations have now set limits on gifts which doctors can take from a drug company.  The free lunch is disappearing and many clinics do not allow drug reps on their premises.  Moreover,  free drug samples, a major hook for commanding physician time, is now regarded as off limits.

Despite these reforms, the relatively new phenomenon of marketing medications directly to the public via TV or the internet is even more sinister and egregious than the previous system of marketing centered around drug reps and a culture of payoffs to doctors. 

Television has proven to be a remarkably effective tool in influencing and seducing buyers.  This is not much of a concern for, say, tooth paste commercials,  but it becomes a big concern when viewers are left to interpret medication commercials which at bottom are high on promises and low on scientific rigor. 

The physician is conspicuously left out of the equation until calls start pouring in from patients who want to go on an advertised medication.  Many of these patients (consumers) were doing just fine until they came face to face with the idea that they could have, say, low testosterone.  No wonder they felt tired and could no longer press 300 pounds.  Both men and women were alert to the suggestion that correcting low T with an under arm application of a testosterone gel might well promote a feeling of sexual vibrancy. 

While some  people might benefit from T.V. promoted drugs, the vast majority either do not need them or are already doing well on standard treatments.  Moreover, since someone has to pay for air time,  publicly advertised drugs are usually much more costly.

The point remains that the devil you know is better than the one you don't know.

It's the doctors job to evaluate new treatments, including benefits and side effects.  Their  opinions should result from scholarly sources such as the best medical and pharmacological journals. 

Responsible journalism, promoting rational discourse, also has an important role to play in engaging and informing the public on medical issues.

Direct advertising is biased and misleading, it raises prescription costs, and is without a net benefit to society.

Canada, the UK and Australia ban direct advertising and we should do the same.  In doing so we would go far to insure  that when treatments are ordered, it is the doctor, not the drug company, that is guarding the hen house.

On Doctors And Data Entry

Managers are typically keen to know how hard the bees are working in the beehive.

When the bee is, say, a factory worker it's fairly easy to measure work output and quality: count the number of glass objects placed on a conveyor belt in an eight hour period and note the amount of breakage, if any.  Workers can be easily compared using this metric.

When the bee is a family practice physician or internist measuring work output and quality of work becomes problematic because the work elements that count defy straightforward analysis.

Undaunted by the complexity of this task managers sometimes plow ahead with a simple measurement, believing, it seems, that if something can be measured, it should be measured, regardless of how limited the return.

For example, I recently learned about a very good clinic that came up with the very bad idea of reviewing physician performance based on their skill and versatility at data entry.  

In this case, a computer review of physician records evaluated how often doctors documented that they, among other things, recommended colonoscopies and mammograms to their patients.  The information had to be entered in a specific place in the electronic record or it was assumed that the doctor did not make the recommendation, even if the information was entered elsewhere.

Getting to the designated documentation spot involved navigating the electronic record with a variable number of clicks depending on where the doctor was in the patient record.   The time necessary to click and enter the information likely ranged from a few to thirty seconds.

When the study period was over the computer analyzed all the data and the physicians were assigned grades (a report card).  Those who scored low were encouraged to shape up.

Using the computer, with its pixilated wisdom, to answer the above questions is actually a good idea.  The documentation of screening tests is important.  And placing the information in a standard place makes lots of sense.

But considering that the average fifteen minute appointment is chock a block with patient concerns, doctors have precious little time for data entry.

It's of great interest that two of the very best clinicians in this study got the lowest grades.

Why?

It appears that given the choice of talking with their patients or entering data, they chose the former. What really counts - empathy, availability, ethics, intelligence, thoughtfulness - cannot be measured in the usual sense and certainly not by a doctor's talent for data entry.

In the end, the measure of a doctor is not subject to formulas but by reputation, the child of character.

The Annual Exam

Patients often emerge from an annual exam wishing that they had stayed home, especially after the doctor freights them with enough new findings and diagnoses to shatter the most bullet proof sense of good health.

A typical list of problems and recommendations might look something like this:

You have freckles galore, almost always innocent, but you never know, so on to the dermatologist you go.

You mentioned heart burn, probably due to simple esophageal reflux, but you never know, so off you go to the cardiologist, it could be angina. 

You have a deviated nasal septum. 

You have bilateral heel spurs.

You have a creaking of the neck (arthritis?).

No wonder many fear the annual exam more than root canal. 

Still, the idea of finding problems before they hatch, seems both important and logical.  If this were indeed true, then  maintaining good health would doubtless trump the negatives of going through the exam.

However, the Cochrane Group, the epicenter of evidence based medicine, has studied the annual exam issue extensively and concluded, in an October 2012 study, that large groups who have them regularly fare no better than those who do not.

There have of course been individuals who have benefited greatly from a screening exam.  Finding a melanoma on the back in its earliest stages or unequivocal elevation of blood pressure in an asymptomatic individual come to mind.   

It's just that if you compare large groups of individuals who take annual exams with those who do not, their health outcomes are very much the same. This applies also to illness related to cancer and cardiovascular disease, leading causes of morbidity and mortality. 

But if some people benefit from the screening exam, then, why not have one?

Traditionally, lots of information is collected during the exam (do you have gas, do you have trouble swallowing?) that takes up lots of time to gather with surprisingly little benefit. 

Since most of these patients will do no better than the unexamined, it is likely that many of the diagnoses made will actually be a form of over-diagnosis.

Over-diagnosis oftentimes leads to unnecessary tests and, even worse, unnecessary treatments.  Side effects in this scenario are especially intolerable as we ask the patient to buy risk with little prospect of benefit.

Finally, there is the matter of squandering health care dollars at a time when savings are badly needed.

So what can physicians implement to replace the current annual exam?

Let's replace the annual exam, with its painting by the numbers motif, by one that allows the patient to engage the doctor, in an unhurried way, about their concerns (it is common that the concerns of doctor and patient differ widely during exams).

So while the physician is hell bent on asking questions about every organ and body system (rarely decisive or illuminating), the patient is keen on discussing their longstanding backache or worries about memory loss.  Perhaps our exams could begin like this: "Hi Joe, what would you like to discuss today?"

In whatever form this new style exam takes it is necessary that there be ample time to discuss prevention strategies and immunizations.  

Given the research of the Cochrane group fewer people will get routine screening exams. When, how often and if to take these exams will be guided by further research on health outcomes.  For now decisions should be made on an individual basis.

What appears clear, however, is that we are putting too many patients through routine exams with little to show for it.  This is counterintuitive but supported by good research.

Whether one gets routine exams or not the following are major factors in achieving and sustaining good health:

Always notify a doctor when experiencing new signs or symptoms.  It's especially necessary when the changes are outside ones experience or when they represent an acceleration of a known problem.

Make and keep friends.

Search for intimacy.

Choose your parents and blood line wisely.

And most importantly, do all things in moderation.

OK most things.