the time it takes...the trouble it saves

 

 

 Training in the practice of narrative medicine focuses on motivating and enabling health care providers to uncover the real story behind the patient’s illness…not just his symptoms, but his attitudes toward health and healing, how his illness affects his life and the lives of people around him, and his fears and hopes for the future.

 

“It can be argued that the largest

yet most neglected health care resource

worldwide is the patient.”

~Dr. Warner Slack~

 

Let’s say a woman presents with a complaint of palpitations…the sensation that her heart has been beating rapidly and/or irregularly, off and on, for a couple of weeks. It scares her because her father died suddenly following a heart attack at the age of 54. She limits her caffeine intake, exercises regularly, and is otherwise healthy. When you see her in the office, her cardiac exam is normal…her pulse is 80 and regular. Her blood pressure is normal. So, you schedule her for a stress test and a cardiac event recorder. The only thing that shows up is an occasional episode of sinus tachycardia. You have now run up several thousand dollars in bills and you still have no diagnosis.

 

Had you taken time to ask about recent stresses in her life, she might have told you about the cigarette burn she recently found on her twelve-year old’s shirt sleeve. And how poorly he’s doing in school. And how worried she is about him because if he’s smoking already, what’s next? And how hard it is as a single mother because she has to work two jobs and she can’t keep her eye on him the way she should.

 

“We know that stress is perhaps

the most underrated of all  

our heart disease risk factors.”

~Michael Miller~

 

It’s no wonder her heart is acting up. But her cardiac condition is not the problem. Stress is. And stress can be a whole lot harder to treat than a cardiac arrhythmia. You could run every test known to mankind in an effort to convince your patient that her heart is fine…but until you identify and address the real issue, she will continue to have symptoms. Her problems will only get worse.

 

Narrative medicine encourages us to take time to elicit the patient’s whole story, and to consider the context of his illness. To touch the sensitive spot. To probe the wound. Not only to make an accurate diagnosis but to explore the patient’s fears, expectations, and beliefs about his condition…anything that might delay healing.

 

Or promote it.

 

“The good physician treats the disease;

the great physician treats the patient

who has the disease.”

~William Osler~

 

jan

 

 

 

 

 

 

 

 

 

 

 





i smell smoke

 

 

 

 

Another random rant:

 

It’s no wonder we have been hearing more and more about the problem of “burn out” among health care professionals as we witness the premature exodus of capable, dedicated physicians and nurses from a system that defies excellence in patient care by virtue of its unspoken battle cry: Bigger. Faster. Greedier.

Burn out is defined as:

 

“…a state of physical, emotional, or mental

exhaustion accompanied by

doubts about one’s competence

and the value of one’s work.”

~https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642~

 

But it doesn’t have as much to do with fatigue as it does with frustration. The problem isn’t about keeping up with technology or advances in diagnostic and treatment modalities. We can do that. The problem is that we are forced to compromise thoroughness in favor of efficiency. Connection in exchange for productivity. Compassion in lieu of profit.

Dedication, fulfillment, and integrity are no longer part of the equation.

When I gave up after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant I was quitting. I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over the decision for years.

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue or forgetfulness or ill-health.

No. What finally got to me was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit…which translates into seeing more patients faster regardless of the complexity of the presenting problem. I worried I would miss something, and I feared for my patients because of it. It scared me. I had to leave.

 

“The very concept,

I would say ministerial function of being a physician,

is to be attentive, is to be present,

is to listen to that story,

is to locate the symptoms on the person

of that patient,

not on some screen,

not on some lab result,

but on them."
~Rosmarie Voegth~

 

It's no wonder we worry about competence given the constraints imposed on our ability to deliver excellent care to our patients. It's no surprise we question the value of our work when we measure it in terms of quality and compassion while the system is busy tallying the receipts. 

Physicians are encouraged to manage their stress…when they are helpless against it. To get outdoors more. To meditate. To eat better and to get more sleep…when, some days, we don’t have time to eat at all. When we can’t break away long enough to poop on the pot. When we don’t have the strength to blink at the end of the day…not because the work has gotten any harder, but because the hoops we have to jump through have multiplied…and somebody in a fancy office is holding them higher.

 

“America’s healthcare system is neither

healthy, caring, nor a system.”

~Walter Kronkite~

 

 Looking back on thirty years of practice in the American medical system, I can only say, "It weren't broke." But it sure needs fixin' now.

For more on professional burnout, check out  https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/

jan





 



this week's challenge

 

 

 

I just registered for the third annual conference on narrative medicine to be held at Kripalu Center for Yoga and Health in July. The title of this conference is "Narrative Medicine--A Cutting-Edge Approach to Healthcare."

*

Narrative Medicine A Cutting-Edge Approach to Healthcare

·                     July 8–13, 2018

·                     Sunday–Friday: 5 nights

·                     Presenter: Natalie Goldberg

·                     Presenter: Nancy Slonim Aronie

·                     moderator: Lisa Weinert

·                     and more…

For caregivers, doctors, nurses, yoga teachers, writers, and anyone interested in personal narrative as a healing path to recovery.

*

Now, I don’t know about you, but when I think of cutting edge approaches to health care I think of things like new and more effective antibiotics, high tech scans and digital something-or-others, and robotic microsurgical techniques. But storytelling?? Not so much.

Advances in medicine, whether having to do with the development of new drugs, tests, or methodologies, have to pass rigorous tests of their efficacy and safety before they are introduced into mainstream practice. This requires large scale randomized, double-blind, placebo-controlled studies…which are notoriously difficult to design. Once you have demonstrated the safety and efficacy of, let’s say, a new drug, you still have to consider its cost effectiveness, applicability and acceptance rate. It’s surprising anything makes it through the process. But storytelling??

 

“I love storytelling.

It’s endlessly healing.”

~Ben Vereen~

 

For the sake of this discussion, let’s assume that the techniques taught in narrative medicine programs represent an advance in the practice of clinical medicine…that this method improves patient satisfaction, shortens hospital stays, decreases the number of readmissions, and in the long run, saves time and money. The numbers that prove these claims may be hard to get at. How can we measure the effect of patient satisfaction on healing? How would we code and bill for the time it takes to listen to the patient’s real (aka “whole”) story? Won’t it wreak havoc on our schedules to engage with our patients on their terms?

 

There is one way to find out:

 

Try it.

 

See if it works for you. Other people have. Other healthcare providers have reported not only improved patient satisfaction, but an improved sense of personal and professional fulfillment, a greater sense of dedication to and connection with their patients, better insight into the cause and clinical course of the patient’s illness and recovery. More accurate diagnosis. Fewer unnecessary tests. More effective interventions. All of which add up to better health care.

 

“Each time I told my story,

I lost a bit,

the smallest drop of pain.”

~Alice Sebold~

 

This is my challenge: look over your patient schedule for the week. Find a day when you have a little built in leeway. Pick a patient who is coming in for the first time. Or for a new problem. Ask this question:

 

“What do you think I should know

about your situation?”

 

Then just listen. Try not to interrupt, or redirect, or clarify what the patient says. There will be time for that later. He will tell you everything you need to know…what has happened, how it affects him, how he feels about it, and what he thinks about it. Bam!

 

This is the technique employed by Rita Charon, director of the Program in Narrative Medicine at Columbia University and chief contributor to the landmark text, The Principles and Practice of Narrative Medicine.

 

If the concept behind narrative medicine interests you, you might consider ordering a copy. Or…attending this year’s conference!

jan

 

 

 

 

 



#neveragain

 

 

If you practiced medicine back in the 1970s, you witnessed a dramatic change in the practice of pediatric primary care. By then, advances in medicine had reduced the incidence and toll of many deadly childhood diseases, including infectious diseases (through vaccination, antibiotics and improved hygiene/sanitation), pediatric cancer, asthma, and heart disease. Instead, the emphasis turned toward disease prevention, behavioral pediatrics, and safety. We saw major public health initiatives emphasizing automobile safety (the use of seatbelts and approved car seats for children), prevention of accidental poisoning with the use of child-resistant packaging and safety caps, SIDS prevention, and the use of smoke detectors…all calculated to reduce the incidence of the number one cause of death in childhood: unintentional injuries.

“The safety of the people

shall be the highest law.”

~Marcus Tullius Cicero~





But then, of course, there were still the guns. Headlining the February 2, 2018 issue of Newsweek magazine is this:

“Kids and Guns:

Shooting now the 3^rd leading cause of death for US children.”

 

Which brings me to this true story:

A boy was accompanied to my office by his mother for his well-child exam. I took his past medical history, family history, and social history before examining him. I asked about school, what sports he played, whether or not he wore his seat belt, whether or not there were smoke detectors in the house…routine questions, among others, that covered preventive/safety issues in the home.

Then I asked whether or not there was a gun in the house. Did he know where it was kept and if it was locked and/or loaded? Well, to my surprise, his mother became irate at these questions. It was as if I were accusing her of a crime. Prying into something that was none of my business. As if I was trying to shame her for having a gun in the house. In fact, she was so offended, she wrote a letter to my office manager and left the practice.

Not long afterward, there was a deadly accidental shooting in our community. A young boy died.

 

~from Townhall

February 20, 2018

Beth Baumann~

 

This story serves to illustrate the explosive (no pun intended) nature of the gun control debate. No other safety issue has generated such a heated response. This is a concern that all health care providers must confront. It is a huge personal, political, and public health problem. It belongs to all of us.

#NEVERAGAIN

jan

we've come a long way

 

 

Yesterday—February 3—was National Women Physicians Day. Who knew there was such a thing? This is proof we’ve come a long way since I decided medicine would be my path in life…since the days when women in medicine were regarded with suspicion, disdain, and even mockery.

 

“If society will not admit

of woman’s free development,

then society must be remodeled.”

~Elizabeth Blackwell~

My journey into the practice of medicine started with my hospitalization for rheumatic fever when I was just three years old. Even at that young age, the experience shaped my sense of self. I never lost my appreciation for the suffering illness creates in a person’s life. I learned to harness the power to heal, and to revere the people who made it possible.

When I was in high school, I volunteered at one of the largest and poorest hospitals in Buffalo, NY. I majored in medical technology in college. I applied to medical school when there was still a 10% quota on women who were admitted—just ten in of a class of one hundred. Today, more women than men go on to study medicine.

“Every woman who heals herself

helps heal all the women

who came before her, and all those

who will come after."

~Dr. Christine Northrup~

I hope that more than just the numbers have changed.

I hope that young women who pursue the study of medicine are openly welcomed into the medical community, mentored, and encouraged to stay with it. I hope they are able to maintain high standards of medical ethics, selflessness, and dedication to patient care. That their male colleagues do not confront them with the disdain, disparagement, and arrogance that sometimes greeted us. That their female colleagues—nurses, therapists, aides, and support staff—feel connected with them in the art and science of patient care.

“The trained nurse has become

one of the great blessings of humanity,

taking a place beside

the physician and the priest.”

~Sir William Osler~

I hope they feel supported by their spouses, children, and friends. That exhaustion doesn’t do them in. That they practice balance in their lives. I wish them enough time and energy to embrace their creative nature, to enjoy their leisure, and to seek spiritual sustenance.

Because...

“Wherever the art of medicine is loved,

There is also a love of humanity.”

~Hippocrates~

jan

 

 

 

 

 



revisit. revise. recover.

 

 

 “I write because

I don’t know what I think

until I read what I say.

~Flannery O’Connor~

This observation by author Flannery O’Connor rings true to anyone who harbors a vague feeling of anxiety for no identifiable reason.

“Worrying is like

walking around with an umbrella

waiting for it to rain.”

~Wiz Khalifa~

Even though they are living in a comfortable rut—let’s say, they are financially secure, their health is good, their family is intact—they can’t deny the knot in their gut or the dull ache in their chest that suggests something is wrong. Or, maybe they wake up every day with a sense of dread, exhaustion, sadness, or withdrawal that screams “depression”, even though, as people tend to remind them, they have nothing to be depressed about. After all, they have a steady job and a nice home, their children are doing well, and their bills are paid. They should be happy.

Still, the feeling is always there…uncertainty, fear, emptiness, hopelessness. They just don’t know why.

“These mountains you

are carrying,

you were only supposed to climb.”

~Najwa Zebian~

This is where storytelling comes in. Writing enables us to seek out and sort through memories, and to locate them in time and space. It encourages us to name the gremlins that stalk us, to label our fears, acknowledge our wounds, and reimagine our lives. We are no longer the victims of some obscure fear or unacknowledged sorrow. We can claim it and conquer it.

“The act of putting pen to paper

encourages pause for thought.

This, in turn, makes us think

more deeply about life…”

~Norbet Platt~

Physicians do this for every illness—from diabetes to heart disease to cancer. We ask about symptoms. We search for causes and encourage our patients to do what they can to avoid or eliminate them. We name the disease and suggest a course of treatment. If we have done our work well, we alter the course of the illness. We take control of it. We change the patient’s narrative.

This is storytelling at its finest. It is also the goal in clinical practice and in narrative medicine. When we write about illness, we revisit the initial injury. Perhaps it was a childhood rape, or a tragic accident, or the loss of a friend or family member we couldn’t face. By naming it, we confront it. The road to recovery leads us to a new perspective or understanding of it. Then, when we read what we’ve written, we finally know what we think.

Storytelling is the very process by which we revisit, revise, and recover.

Revisit. Revise. Recover.

jan

 

 





perception vs reality

 

The medical history can difficult to obtain for many reasons. A patient’s description of his illness can be affected by his perception of it, his experience with it, and what he imagines about it. By his expectations. By fear or denial. Or he may simply lack the language to express it.

“Perception is reality.”

~Lee Atwater~

For example, if I had to tell you what has been going on in my left foot for the past six weeks, I would be hard pressed to describe it. You would be left scratching your heads. It all started with localized pain during weight-bearing (but no tenderness to touch). It started to swell, and then, after four weeks, I noticed bruising. I don’t recall any injury. It’s hard to know what triggers the pain because it seems worse at night for some unknown reason. I have no idea why it is getting worse despite the fact that I have been faithfully resting my foot like I know I should. It frustrates me because I can’t exercise. It worries me, too. What if I need surgery? What if I can’t take care of myself?

Even though I’m a physician, and I know all about strains and sprains, overuse injuries and stress fractures, tendonitis and arthritis…I can’t really describe the discomfort. And because I don’t remember injuring my foot, I can’t make sense of it. This is weird.

Imagine how difficult it must be for patients to describe their symptoms or to make sense of their illnesses when they have neither knowledge, experience, nor language for what is happening to them.

“Write hard and clear

about what hurts.”

~Ernest Hemingway~

Most people are not used to thinking about their symptoms in the kind of descriptive terms physicians depend upon to narrow the diagnostic possibilities. For example, they might not realize that the difference between a headache that is generalized, dull and steady rather than unilateral and throbbing may distinguish a tension headache from a migraine. They may not be able to distinguish between the kind of pain caused by heartburn and myocardial ischemia. They might not use those terms to describe it at all. The patient is more likely to view his symptoms in terms of lost wages, his inability to provide for his family, or his own impending decline rather than the onset, character, and duration of his symptoms.

“Every sickness has an alien quality,

a feeling of invasion and loss of control

that is evident in the language

we use about it.”

~Siri Hustvedt~

Severity is especially tricky to assess. It depends to some extent on the patient’s innate tolerance for pain. Is he a stoic or a whiner? His perception of pain depends upon how his symptoms affect his mood, his ability to carry on, and his fears which are largely based on what he has heard, what he imagines, or what he has witnessed in others.

Take it from me, under the best of circumstances, the medical history can sometimes remain a mystery.

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

jan