a conversation that matters

True story:

Just yesterday a friend and former patient of mine stopped me after church to tell me how much better she was feeling since my husband—the consummate family physician—had seen her at home the previous Sunday. It's true. He made a weekend house call even though he wasn’t on-call that day.

She’d been suffering from incapacitating neck pain and headaches for a couple of weeks, but hadn’t called my husband about it because she was in palliative care for an oppositional defiant malignancy that nothing could stop. She didn’t call him about the pain because her oncologist and hospice nurse had already called in prescriptions for narcotics that hadn’t touched it. She understood the concept of palliative care to mean that nothing more could be done for her so she assumed the pain was part of the process.  

Nevertheless, even though her specialists were not treating the cancer anymore, the goal of my friend's medical care was to keep her as comfortable and functional as possible, for as long as possible. I reminded her that incapacitating pain is not considered by most patients to be comfortable. When a patient who is otherwise still independent becomes housebound because of it, she is not really functioning. She deserved to be treated for the pain.

Her husband was the one who finally called my husband who then took time out of his weekend off to listen to her story and examine her. Based on what he found, it was apparent that her problem was muscular. It had nothing to do with the malignancy. After one day on a muscle relaxant and low dose steroids, the pain subsided. She slept through the night for the first time in weeks. And to her relief, the pain has not recurred, which explains why she was able to get to church this weekend. Why her appetite came back. Why she was smiling despite her generally poor prognosis.

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Rita Charon, in her ground-breaking book, “Narrative Medicine—Honoring the Stories of Illness,” presents an unconventional approach to gathering information from the patient. She simply invites the patient to “tell me what you think I should know about your situation.” Then she listens. She doesn’t scribble down notes or tap away at her keyboard while the patient is speaking. She listens.

Had my friend’s oncologist or nurse used this approach, I think she would have told them, “I’m having severe pain in my neck. I can’t move it when the pain comes on. Then I get a severe headache. It’s so bad I can’t leave the house. I can’t eat. But they said nothing more could be done for me so I didn’t want to bother you about it." 

That miscue resulted in weeks of unnecessary suffering for a woman who had already suffered enough.

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“Be brave enough

to start a conversation that matters.”
~Author Dau Voire~

jan

primum non nocere

I learned something new today. This is a good sign because some people like to joke about my incipient dementia. At least, I hope they’re joking.

I was toying with the topic for today’s post when the phrase “primum non nocere”—first do no harm—came to mind. I learned that the Hippocratic Oath is not its source. It actually comes from Hippocrates’ writings in “Epidemics”: “The physician must…do no harm.” These words are the bedrock of medical ethics and practice. Hippocrates is regarded as “the father of medicine” for good reason.

In fact, many of the traditions that influence the way we practice medicine today were passed down to us by men. Not because women were excluded from the practice of the healing arts in ancient Greece. On the contrary, women were highly respected as physicians and healers. Even Plato held them in esteem. Though they were few in number, patients sought them out. They were regarded as the “wise women” of the community. Their “soft hands” were considered to be “healing hands.”

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But as the science of medicine advanced, the feminine ethic lost credibility. Its wisdom and power to heal were dishonored in favor of dispassionate technical expertise—testing, procedures, and proofs. Today speed and efficiency reign, and reimbursement issues drive the system. Over time, tradition has suffered. As a result, patient care has suffered, and even physicians have suffered.

One of the time-honored traditions that survives today expressly prohibits the physician from entering into a personal relationship of any kind with his patients. This, of course, is an impossibility. It disavows the emotional intimacy that is the inevitable fruit of shared suffering. It contradicts the compassionate physician’s experience and denies him a powerful tool.

Today, the physician is taught that it is unprofessional to share personal experience, insight, beliefs or values with the patient. This rule of non-engagement is hammered into our heads during training when we’re still easily moved to empathy, at a time when connectedness with other human beings is still something to be desired and defended.

Sadly, this means that patients may know more about their hairdresser or mechanic than they know about their doctor—the person they trust with their health and their children’s health. With their lives. Most patients know nothing about him but what they can gather from the plaques and certificates displayed on the walls in his office—what schools he attended, when he graduated, what honors he earned…which speaks to his intelligence but what about his inspiration, his motivation, and his conduct?

This can be troubling for patients. They have little choice when it comes to selecting a physician and, except for the credentials hanging in his office, they may know nothing at all about him. They worry about it, and they should. Is he competent? Is he caring? What motivated him to undertake years of grueling study and training? What sustains him? How does he manage it all?

This precedent distances us from our patients at times in their lives when what they may need from us more than anything else—more than another prescription or another test or another procedure—is our presence with them, our strength, compassion and support especially at times of serious illness and suffering. At times when fear and grief cut deep. At times when they may need to understand that nothing more can be done for them…or for someone they love—a friend, a spouse, or a child. When our patients need us the most—that is, when there is no hope for them—we are trained to turn their care over to the nurses, or the family, or their pastor.

We leave the bedside the way we approached it—as strangers, not storytellers.

 

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“Some patients, though conscious that their condition is perilous,

recover their health simply through their contentment

with the goodness of the physician.”

www.thewellnessseeker.com

~Hippocrates (460-400 BC)~

jan