Monday, June 26, 2017

genre fiction vs the clinical note

Loborsoit, Tanzania, 2012

Did you know that, prior to 1916, clinicians recorded their patients’ notes in a single common log that was kept on each hospital ward? There was no such thing as an individual patient chart until the idea took hold at Presbyterian Hospital in NYC, one hundred years ago.

“Fold the worst events of your life
into a narrative triumph.”
~Andrew Solomon~
Still, back then, there were no guidelines as to what went into the chart, how information should be recorded, or where it belonged. Not until the 1970’s, when Dr. Lawrence Weed created the problem-oriented medical record (POMR), was there any organization or consistency to the clinical note. In other words, it was hard for all the people involved in the patient’s care to follow his clinical course or to extract information from his haphazard record. It was time-consuming and error-ridden.
This kind of thing is not acceptable when it comes to practicing medicine. Nor is it tolerated in literature.
Imagine reading a mystery that reveals clues to the crime in no logical order. Imagine a romance that fails to capture the growing passion between two lovers. Readers have certain expectations that attract them to certain genres, and each genre follows its own set of conventions in order to satisfy the reader. Without this predictability and order, readers are likely to abandon the story out of confusion or disappointment.
For example, in writing mystery, plot is everything. The main character must be the detective or sleuth. The crime should be sufficiently violent (ie. murder) or cruel so as to engage the reader’s interest and curiosity. The details of the crime must be accurate and plausible (when, where, why, and how it was committed). The detective must solve the mystery using rational/scientific methods…rather than depending upon divine intervention, pure coincidence, or gratuitous drama. Justice must be served. This is what the mystery reader wants.
“Plot is a literary convention.
Story is a force of nature.”
~Teresa Nielsen Hayden~
In romance, on the other hand, a love story must be at the center of the plot. The lovers must encounter and overcome obstacles to their relationship. The ending has to be emotionally satisfying and optimistic, with a happy outcome. Romance readers expect this. They don’t want the relationship to fail.
Simply put, if you enjoy reading romance, you may not be entertained by blood thirsty creatures from the netherworld. Likewise, if you love horror, fairies and elves may not be your thing.
This is why authors in different genres observe certain “conventions” when they write…widely used and accepted techniques in literature that embody the readers’ expectations and promote satisfaction with the course and outcome of the story. Within this general framework, the details can vary with regard to time period, setting, characters, and plot.
Likewise, every patient’s story is different. No two heart attacks, no two cancers, no two injuries are ever the same…so it’s good we have a framework for recording our patients’ stories. Most of us have been trained to write our notes according to the SOAP format—Subjective, Objective, Assessment, and Plan. What patients tell us about their illness is considered “subjective” information, recorded as the HPI—the history of the present illness. We learn more about the main character in the PMH (past medical history), FH (family history), and SH (social history). Clues to the diagnosis are found in the objective realm of the physical examination and tests we order. All the elements of the story come together in our assessment. In our plan, we consider all the ways the story might end.
Because the practice of medicine embodies narrative elements, it makes sense to train health professionals in narrative skills: how to listen to the patient, how to interpret what we hear, what the patient means by it, and how to record his story. Ultimately, the goal of training in narrative medicine is to allow ourselves to be personally moved to action on behalf of the patient.
“I use the term narrative medicine to mean
medicine practiced with these narrative skills of
recognizing, absorbing, interpreting,
and being moved
by the stories of illness.”
~Rita Charon~


Tuesday, June 20, 2017

close encounters of the worst kind


This was a fairly average week for me as I moved in and around my community. I ran into three women I know who have lost children, one of them to suicide. I spotted a patient of mine in church who is losing her fight against cancer, and another one who is still waiting for her test results. I spent an evening with a friend who donated a kidney to save her brother’s life.
Because I practiced medicine in my community for over thirty years, I have a unique vantage point when it comes to knowing who is in pain. I run into patients on the street, at the post office, and in the sub shop in town. I know who just had open heart surgery, whose marriage is in trouble, and who is battling addiction. Still, I don’t think these encounters are unique to physicians.
Whether we realize it or not, we all live among people who have endured heartache and suffering that would bring Job to tears. We encounter them wherever we go. The problem is we don’t always recognize them.
“It may take a doctor
to diagnose someone’s disease,
but it takes a friend
to recognize someone’s suffering.”
You can’t always tell by looking at a person what they’re up against—that divorce is in the air, or that a coworker’s cancer came back. It’s hard to know when someone is contemplating suicide. They don’t want anyone to know so they do what they can to hide it.
Many people in pain get out of bed in the morning just like the rest of us. There is nothing strange or special about the way they dress. They get their children off to school, and spend time tending to the house or they go to their jobs. They are right there behind us in the checkout line at the grocery store, on the treadmill next to us at the gym, and in the pew in front of us at church. Or on the cushion next to us in meditation. We can’t see their broken hearts or crushed spirits so it can be hard to pick them out of the crowd. 
“The moment you change your perspective
is the moment you rewrite
the chemistry of your body.”
~Dr. Bruce Lipton~
This means a couple of things. First of all, if we don’t know their stories, we can’t help people heal. When we meet them on the street, we can comment on the weather, or commiserate over the sad state of politics in our country, or chat about the grandchildren, but we are prevented from expressing our concern for them, or sharing words of comfort and encouragement. In our offices, we ask about the onset, severity, and timing of their symptoms, but our questions dance around the underlying pain that is eating them alive. As health care providers, therapists, and caretakers, as neighbors and friends, as co-workers and acquaintances, we are helpless unless we know the true story. The whole story.
But enough about us.
Untold illness narratives have a way of hiding out in the subconscious while wreaking havoc with the body. They play tricks on people. As Rita Charon puts it, in her ground-breaking book, Narrative Medicine-Honoring the Stories of Illness, “The body and the self keep secrets from one another.” The body may experience chest pain, when the problem is despair. The patient may see a physical therapist for a back injury when the cause of his pain is anger. People may turn to opiates for relief when their pain arises out of fear.
“The healing process begins
when patients tell of symptoms
or even fears of illness—
first to themselves, then to loved ones,
and finally, to health professionals.”
~Rita Charon~
Unless we seek out and explore the anger, or despair, or fear that is at the root of their pain, nothing we say or do will relieve the cause of suffering. All the medication in the world will not solve the problem.
“The shortest distance between
truth and a human being
is a story.”
~Anthony de Mello~

Sunday, June 11, 2017

a random rant

Tanzania, 2012
Today’s post is a random rant in keeping with my conviction that the American health care system is headed in the wrong direction. This issue came to my attention after my daughter gave birth last month. She reminded me of this outrage:
Back in October, 2016, a couple in Utah learned that, after the birth of their baby, the hospital charged them $40 for immediate post-partum skin-to-skin contact, a practice widely believed to be beneficial to the newborn who has just been unceremoniously propelled into a hostile environment, and to the mother whose life has just changed forever and ever, amen. This is considered the standard of post-partum care, unless it is contraindicated for medical reasons…for example, newborn resuscitation.
Image result for kangaroo care quotes

The couple was flabbergasted at this charge. Their post went viral. It was explained to them that, nowadays, so-called “kangaroo care” is considered to be an intervention. It has its own billable code, and therefore, incurs an extra charge. It also requires supervision by an additional nurse whose salary has to be covered…for supervising a mother cradling her baby on her chest.
“I just want to lay on your chest
and listen to your heart.”
It makes one wonder. How many mothers have dropped their babies in the delivery room? Since when did an age-old, cross-cultural, intuitive and nurturing post-partum practice become an intervention?
What is the price of maternal love?
“Nowadays people know
the price of everything
and the value of nothing.”
~Oscar Wilde~



Sunday, June 4, 2017

check your assumptions at the door


The same illness can be understood in different ways by different people. Nowhere is this more troubling than in the doctor’s office. The unspoken biopsychosocial elements that distinguish the physician from the patient pose a real obstacle to effective communication.
“I know that you believe
you understand what you think I said,
But I am not sure you realize
that what you heard
is not what I meant.”
~Robert McCloskey~
The physician may see illness as a puzzle to solve, or a challenge to overcome. He understands the problem in technical terms. He can describe how the anatomy and physiology have gone haywire, recite the tests that need to be done to prove it, and rattle off the latest peer-reviewed protocols for treatment. He may be doing a bang-up job of caring for his patient, so it confuses him when his patient doesn’t respond.

On the other hand, depending on his beliefs, the patient may see his illness as a punishment, a failure on his part, or a random manifestation of universal injustice. His clinical course can be aggravated by guilt. He tells himself he should have quit smoking sooner, or watched his diet more carefully, or kept up his exercise program. But because now he has a spot on his lung, or a stent in his heart, he thinks it’s too late. Why start now, he wonders.

Illness can also be complicated by grief, as in the case of a woman who relives her mother’s losing battle with breast cancer when she discovers the lump in her own breast. She may be skeptical about her treatment options, or reluctant to begin therapy, having watched her mother suffer to no avail.

Some people cling to the belief that prayer is the answer, even when it doesn’t work for them.
Patients make certain assumptions about the nature and course of disease based on observation, experience, belief, hope, and expectation that can affect their motivation, and even their ability to heal.
“Check your assumptions.
In fact, check your assumptions at the door."
~Lois McMaster Bujold~
The physician is unlikely to take these factors into account unless he anticipates them and asks about them. The patient is unlikely to bring them up on his own out of shame, or guilt, or grief, or fear unless he is invited and encouraged to share them.

Doctor/patient communication is difficult enough without the specter of false assumptions. They are, nevertheless, a clue to the patient’s history. They are an important a piece of his narrative.

“Nobody cares how much you know
until they know how much you care.”
~Theodore Roosevelt~