Do You Care About ‘Cancer Survivors’?
While I do enjoy a good conversation and find using words in print as one of my most satisfying hobbies, I generally distain academic arguments about the meaning of words. Perhaps this is left over from being an English major and sitting in dread while classmates spent hours debating the poetic meanings of every noun, verb and adjective in a 500 page book. They would talk about their personal experiences and they would talk about historical context and they would talk about words Greek or Latin roots.
“Perhaps the wagon was just ‘red’,” I would say.
They would counter, “But what does ‘red’ mean in the context of the author’s sexual orientation?”
I value the importance of words, but I do not think they are perfect. To me words are a means to an end. In my opinion, a story does not really need to be told, it needs to be experienced. Words cannot truly give you the story. You have to have the experience. Words, even the right words, are inaccurate and merely labels.
For this reason my gut wrenched when I started reading this article about ‘cancer survivors’ from Slate that was forwarded to me. “Not another gagging discussion about the meaning of words,” I thought. “Regardless of what we call them cancer survivors are still themselves. A label does not change them or what they experience. It does not change what they feel they have or have not survived. It does not change their face, their smile or grimace.”
Then I remembered my belief that communication is central to healthcare. That a good physician must use the best words possible to a patient. Meaning is crucial in what a physician says to a patient. Every word that is said in the physician-patient setting must be constantly raked over the metaphorical coals of every possible context. If a change in a word or phrase can be made to help patients fully understand their choices then it should be made. Even if the modification does not address every imperfection of the label it will keep the conversation fresh.
Weekend at Bernie’s
This is real life.
http://www.reuters.com/article/idUSTRE63545020100406
“The 91-year-old deceased man was pushed in a wheelchair through Liverpool’s John Lennon airport wearing sunglasses before check-in staff became suspicious and he was prevented from boarding the plane”
I wonder if Weekend at Bernie’s is on Netflix instant watch?
Computer the Mysterious Intruder
A little note from TheHealthCareBlog about using computers in the exam room. I’ve thought a lot about how to balance technology and efficiency with connection and communication in the doctor-patient interaction. Here is a tip that may or may not be helpful.
“Danny Sands, MD, had great insights on what happens when a computer is introduced into the examining room. He said, “Interacting with a patient alone is a two-way conversation. However, when there is a computer in the room, it is part of the conversation. It both processes and provides information, and, because of that, it must be positioned in such a way that it can be a part of the conversation without being an imposition, just like if there was another person in the room. Ideally, with a laptop or desktop computer, the computer would be at the apex of an equilateral triangle with the human participants at other vertices. With a tablet computer, the computer should be held by the user as they sit side-by-side. In either case, the screen should be easily visible to both (but it should be possible to temporarily shield it from the patient when necessary). Too often, as in the situation you describe, the computer is a mysterious intruder in the room, and the goal of the clinician is to interact with the patient only as a means to the end of entering the appropriate information into the computer program. This can be blamed on poor room layout, bad user habits, and badly-created user interfaces. Some would also blame the bizarre reimbursement system that rewards quality documentation above quality care.”
I think this is just one of those things you have to practice and always be mindful off.
Parkinson’s Patients never forget how to ride a bicycle
This video shows that the worst ideas might be good ones.
I’m not sure if anyone can see this video from the New England Journal of Medicine, but it blew me away.
Growing up I never thought of the human body as fascinating. Even as I became more interested in medicine the biology and science didn’t draw me in as much as the personal connections involved, but as I’ve started reading the science has grabbed my attention.
I knew a woman with Parkinson’s. I vividly remember that occasionally she would have a terrible time walking. Her company could help her by giving her cues saying, “right foot first.”
Then she would be able to walk a few steps. I remember how distressed she was over this as her body deteriorated around her mind.
In the video we see a 58 year old man with Parkinson’s in the Netherlands attempt to walk and fail. Then he gets on a bicycle and goes for a ride.
My mouth dropped when I saw this. How could this be possible? What is it that prohibits walking in a hallway and allows riding a bicycle through a busy parking lot?
It reminds me a little of re-teaching stroke victims how to talk with music therapy. Some stroke victims are physically able to speak, but can’t through some mental barrier. They can however, sing. Speech therapists can then have them sing familiar songs to re-teach them how to talk.
The gentleman in the video still has his trouble with “freezing gait”, however the the authors do note that cycling is at the very least an alternative form of exercise.
Understanding Health Care Reform
let the vaccine wars begin!
Ok, so the vaccine wars have been going on for a couple of years with some parents of autistic children blaming the preservatives in vaccines for their children’s difficulties and the CDC stating that there was no link. Now the CDC is scolding residents of the state of Georgia for not being vaccinated against pig flu in this article from ABC news http://abcnews.go.com/Health/SwineFluNews/georgia-h1n1-cases-spike-low-vaccination-rates-blamed/story?id=10238235.
I wonder if we’ll see a lot more stories like this citing lack of vaccinations as the cause of various outbreaks… I guess we probably will even if the CDC isn’t fighting back with the media.
If you happen to be reading this I’d like to hear your thoughts on vaccines and if you have any first hand stories on how you feel vaccines have affected your life.
Following the Trends of Primary Care Private Practice
What does it tell you when people are abandoning what you are trying to achieve? Do you re-adjust your goals or do you ignore trends and follow the path you feel is best.
My current goal is to become a country doctor. I’d like to run or at least be a part of a small private practice in a small community. It is hard for me at this point to articulate what draws me to that goal. It just feels like the right thing for me to do.
This article from the NYT would like me to take pause and reflect on the advantages and disadvantages of private practice and face some of the realities forced on primary care physicians these days.
Apparently more young doctors are joining hospitals rather than venturing forth in the private practice. This is even leading to many private practices to being sold to larger entities because existing practices are having a hard time attracting physicians.
This retreat from long hours and Medicaid reimbursement paper cuts into the hospital citadel of stable pay is potentially creating a further rift between the face of medicine (the doctors) and their patients. Does this make a difference though? Medical care will still be provided to patients at all hours, but perhaps at the cost of a longer drive? The patient won’t know the face that the will see that day necessarily, but is that a bad thing? Perhaps. Trust is extremely important and often people don’t fully trust that a large entity has their best interest in mind. That goes both ways, though. You can trust that more doctors in a community, more minds are better than one. A hospital will have members of different specialties available.
For right now, a private practice is still what appeals to me. I’m enticed by the intimacy with the people in the area and the status that comes with caring for a community. Is it easier as a private practitioner or in a hospital setting to drive community health projects? It depends I guess.
Another point is that doctors in a hospital can worry less about paper work and paying the bills and managing employees and can put a greater focus in to medicine and the people they are treating.
Perhaps that is a fair trade-off?
Perhaps this trend will allow me to better fit in the niche that I’ve envisioned for myself?
The War Front Between Eastern and Western Medicine is at the Individual
I know nearly nothing about Eastern Medicine or Western Medicine, but I have heard a few comments that reflect a difference exists. Is Eastern healing more of an art? Is Western Healing more of a science? Is Eastern Healing more causal and exact and is Western Healing just a series guesses? I think that these are interesting questions to explore, as is the question is Eastern Medicine and Western Medicine basically the same. Are they simply expressions of compassion?
A few weeks ago, I had a discussion with a patient, lets call her Hae. She was on my list to schedule a routine follow-up appointment in the Specialty Clinic. I called through a Korean interpreter and greeted the patient. She sounded glad to talk to someone. As anyone who works in health care or any social service can tell you: an illness manifests itself in different ways and you can hear it. An illness can make a person rude and impatient. In speaking with them you hear pain sharpening their words. An illness can make a person feel a sense of entitlement. You can hear them relentlessly try to take back what pain has taken from them. Some patients just sound confused.
When Hae spoke she sounded hopeless. I offered her an appointment and she balked at the timing. She said that she already had an appointment with another doctor (her primary care doctor) and she did not wish to return to our clinic. I thanked her for her time and was about to hang up when she said, “But I don’t like this doctor. He never does anything for me.”
“OK,” I said. ” Would you like to come in here for an appointment?”
“Yes, but when was at your hospital last time you didn’t do anything for me. You only talked.”
This is a common complaint in the Specialty Clinic, especially as people travel from across the state. They say, “I’m not going to drive 200 miles and pay $150 in gas and another $100 for a hotel and another $10 for parking at your clinic for your doctors to just talk to me.” The criticism is valid, in my opinion. A lot of what the physicians do in the Specialty Clinic is simply “eyeball” patient or see how healthy they look and make some basic recommendations. This is not trivial, however. A patient can live with a chronic illness for a long time and feel perfectly healthy, then for seemingly no reason at all they fall out of their shell and get really sick really fast. It is important to see them often to catch them before they shatter.
Hae continued, “If I make an appointment in your clinic will you do something to treat me?”
I stammered something non-committal like, “The doctors will do what they can…”
“But, I need treatment. No one helps me. I go my doctor and he sends me to your clinic. I go to your clinic and they say that nothing is wrong and send me to my doctor and now you are asking me to come to your clinic again, but you are not offering to help me. I am in so much pain all the time. I need treatment.”
I had access to Mae’s medical record and I began reading it so I could understand what the hospital’s interpretation of her problems were. Mae went on to tell me about her symptoms and her pain. Her medical records said that she had no diagnosis. This is very uncommon for me to see. Usually, by the time we see a patient they have already been diagnosed. Mae simply had pain. She had been sent to us because she had an MRI that showed tiny indeterminate nodules that likely had nothing to do with her pain.
I told her, “I can’t promise that the doctors here will be able to offer you treatment.” I was getting into tricky territory because I’m not medically trained and I cannot get into any thing specific.
She started to sob, “Do you mean there is no cure for me?”
I worried that we were having trouble with the language barrier. I tried to choose my words carefully and while I trusted the competence of the interpreter thoroughly I had no idea what was actually said to her.
“No, I am not saying that there is no cure for you. If the doctors see you and believe that there is a treatment that would be good for you they will recommend it.”
She replied, “I don’t understand why doctors here can’t do anything.”
“Well, the doctors can’t treat you until they know what the exact problem is.”
She stated her symptoms again.
“But the doctors don’t know what is causing your pain. They have to know what is causing your pain before they can treat you.
She started to get angry. “I don’t understand why doctors here in the U.S. cannot do anything. In Korea I would have seen someone and they would have treated me right away. Why can’t they do that here?”
“Because in order to treat you the doctors here have to know what your diagnosis, what the cause of your problems are. Unfortunately, we just have to wait a while and do another MRI.”
She began to break down again. “I feel like nobody cares about me. I feel like nobody cares about my pain. I feel like nobody cares if I live or die.”
I tried to assure her that I was speaking to her and that I cared about her. I went on to say, “the doctors cannot give you a treatment until they know what your diagnosis is. Sometimes in Western Medicine if the doctors don’t know what to do they have to wait a little while and do another test and then maybe they will have enough information to make a diagnosis. Then once they have a diagnosis they will recommend a treatment for you… if there is one available.” I was kicking myself for being so honest and transparent, but I couldn’t lie to her just so she would see us.
We went back and forth like that for over 50 minutes with the interpreter caught in between. Many times Hae would decline the appointment and as I thanked her for her time she would get worked up again stating that she wanted to be seen, but she wanted to also be treated. I would tell her that we would be happy to see her, but I couldn’t guarantee anything other than talk. Our conversation was like the Cyclic Universe theory where the big bang is repeated for all of eternity.
I made one last push, pacing up and down the staff only hallway, “I am very sorry that you are in pain and that it seems like no one is helping you. I understand that Western Medicine does have flaws, but I assure you that the doctors here do care if you live or die and I do care if you live or die. If you choose to be seen here I assure you that the doctors will do everything in their power to help you. However, they might not have a treatment for you.”
At that point she said that she understood and that she appreciated the information. She said that she did not wish to be seen in our clinic. I asked her to please follow-up with her primary care doctor and I thanked her for her time. She agreed and said goodbye.
Was it a wasted hour of my time and my employer’s pay? Was it a waste of Hae’s time? Did I upset her or calm her? Did she follow-up with her pcp and is there any treatment that will help her?
I hope her body can heal her. I hope that I helped shrink the rift between her and her primary care doctors and western doctors in general. I hope that she gave me a greater insight to one of the many barriers in the doctor patient relationship… Or in this case, the patient-scheduler relationship.
Carnel Medicine In Haiti
CNN Article on a volunteer physician’s experience in Haiti
Most people I know have been very emotionally affected by the disaster in Haiti and feel compelled to help. At the same time we feel useless. Often when you help some one or some thing you receive an immediate reward. If someone tells you they are hungry you can immediately help them. You buy a sandwich satisfy their need for food. They will likely smile and give you thanks. You know you have helped that person. You can see it and you can feel it. It is a complete and tangible transaction. You can see what you have changed and it can drive you to continue to good things in the world. Unfortunately, where Haiti is concerned most of us do not have the skills or the resources to help in this concrete “I’ve made a difference” sort of way.
For us who lack these skills and resources the only outlet for our desire to help is through money. We all know money is important and any aid effort needs capital to mobilize, but unless you have a gymnasium named after you it is hard to really see that your contribution made a difference.
According to articles that I’ve read there are enough bodies in Haiti right now and they need money more than anything. Even with this knowledge only donating funds doesn’t seem like enough to me. I feel I have to get dirty. In my heart it is the only honest way to help. It is to easy to give money.
I think this is what gives me the desire to be a doctor. I want to be able to help at all costs and most fundamental way that I can see to help is by healing or at the very least by comforting. In Haiti those who are there volunteering are getting dirty. They are stripped down.
The article linked to above talks about having to face the gritty and unashamed reality of the situation with one’s brute humanity. There is no CT contrast dye in Haiti. No modern equipment at hand. The physicians are forced to lay down their technology and use their hands. They are forced to create their own surgical areas. They are not being provided for and must create everything they need.
I admire these people covered in blood and intimate with the women, children and men they treat. I admire how they fight against pain and fear with touch and knowledge. I admire how they face their humility.
Perhaps I’ll be able to join them someday on the front of primary care?
link for future rural pcps
one of the gov’t programs you’re always reading about. exchange years of service for tuition payment or loans.
http://nhsc.hrsa.gov/
