Grand Rounds at Health Business blog.

Grand Rounds is up at the Health Business Blog. Have a look. I'm pleased my post on doctor etiquette was included.

Etiquette-Based Medicine

This has nothing to do with couples and illness, but I was so surprised when I read this article, I had to blog about it.

One of the most prestigious medical journals in the world, the New England Journal of Medicine, just published an article on Etiquette-Based Medicine, by Michael W. Kahn.M.D.

Now you'd think this article would be about some cutting edge approach to medical care, along the lines of narrative medicine (a practice at the College of Physicians and Surgeons at Columbia University) or about some of the terrific scientific and social innovations that come from the The Cleveland Clinic, which is ranked among the four leading hospitals in America (US News & World Report, 2007).

But this NEJM article is really about etiquette. The article opens with the question:
"Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?" The author goes on to say, "A doctor who has trouble feeling compassion for or even recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated."

First of all, a doctor who is unable to feel compassion and can't see suffering when it's under his/her nose is, imho, not practicing excellent medicine and should probably be re-trained or re-positioned into a role that has less to do with direct patient care.

Second of all, do we really need to bring Miss Manners into the consulting room? Isn't that a bit insulting to doctors. Do they really need to be reminded to say hello and introduce themselves to the patient? Apparently so, according to the author. The basic manners include:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

"I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience," writes the author.

I find this terribly sad. I am not my medical condition. And for my doctor to learn about my condition he/she has to go through me. If my doctor can't recognize suffering or have empathy (not sympathy), he/she is only getting a portion of the data, that which can be conveyed in simple answers to questions asked. The story I have to tell about my pain condition, for example, is bigger than answers to, "When did it start?" "How would you rate it on a 1-10 scale?"

I welcome doctors who are scientifically brilliant. I want to hear what they have to say about their area of expertise. And if they have good manners and can "smile if appropriate," I would even have a cup of tea with them. But I would never equate that with a "satisfying experience."

I don't need or want my doctor to weep with me. I don't want him/her to look deeply in my eyes, hold my hand and say, "I feel for your pain." But I do want my doctor to be able to make a genuine human connection with me - one that makes it possible for him/her to ask deeper questions and for me to give deeper answers. And who knows, that connection, that relationship may actually play a serious part in the healing process.

Saying Goodbye to a Good Dog

Ambrose Bierce in his Devil's Dictionary defines "DOG" this way:
"DOG, n. A kind of additional or subsidiary Deity designed to catch the overflow and surplus of the world's worship."


My sweet dog Mina died a year ago today, and I am ready to say goodbye. She came into my life when I was very sick with an uncontrollable pain condition. She was as important a part of my recovery as was my husband and my doctors. She gave me shelter in her heart -- that is what I felt every day of our time together. And, in the ways of a universe with a sense of irony, she died at age twelve from an enlarged heart. Her breeder had told us about her many gifts and promised that she would only disappoint us once. Mina kept that promise.

Here is the eulogy I shared with her many friends after she died:

As many of you know, Mina has been slowly declining over the past year. She has had a heart condition since she was young and has compensated masterfully for it over the years. Two days ago she went into serious respiratory distress, and last night we brought her into the emergency ward of Angell Memorial Animal Hospital. Despite their tireless efforts, she continued to deteriorate. She lay on her side, breathing rapidly, and was largely unresponsive. I called her name once, and she lifted her head. Our eyes met, and we said good-bye to each other. At 5:30 am on May 1st, just as the sun was rising, we brought her out of the hospital into the cool morning air and laid her down on her blanket under a tree. I held her as Richard knelt by her side. She was one month past her twelfth birthday when she died.

We have been blessed to have had her in our life for seven years. Every moment with her was an invitation to live with joy and equanimity. Her high-held, swishing tail was a signal to relish the day. Her determined sniffing as she hunted down the exact right spot to dig in to excavate some long buried chicken bone was a reminder to pay close attention to the concealed miracles that surround us. Her delight at reuniting with her beloved friends, all of you, called on us to deepen our own commitment to community. Her forbearance of our impatience when we needed to get going and she was still sniffing, was a gentle lesson in magnanimity. And her capacity for empathy while respecting boundaries is a power I will continue to strive to emulate.

One of her vets once said that some dogs are dogs; and others are people. Mina was people. I know that she left her paw mark on each of you. I also know that you share in our deep sadness in her passing. Mina always remembered her friends, no matter how much time passed since the last visit. Know that she loved you, and that your love made her life richer, as it does ours. May her imprint remain in all our hearts, and may all of us take what she gave us and express it in our lives.

Please join me in taking a moment to honor Mina and the animals in your life who give you love and shelter.

Grand Rounds at Doc Gurley

A fierce Grand Rounds is up Doc Gurley's. Check it out.

Pain as Art

I stumbled upon an article in the Health section of today's New York Times that described a unique, online art exhibit.

Mark Collen, 47, is a former insurance salesman who suffers from chronic back pain. San Francisco college student James Gregory, 21, suffers from chronic pain as the result of a car accident. The two created the Pain Exhibit, an online gallery of art from pain sufferers.


The categories pain art falls into include Torture, Imprisonment, Loss of Faith, Fear, Hope, Love, Transformation, and Acceptance. That about covers the spectrum. Each image is comes along with an artist statement that describes his or her pain condition and the personal meaning of the image.

As you might expect, many of the images are hard to look at and evoke in the viewer a shiver of mortality and fear. It is too horrible and too intimate to get this close to another's pain, even if you're suffering with your own.

Eye of the Storm portrays the both the agony and the terrible loneliness of a migraine sufferer. Do You See What I Feel? shows that for many, pain doesn't show on the outside. So sufferers may appear normal, and be treated as normal, while experiencing a steady pounding of pain internally. Trapped in Hell is very hard to look at. It captures the desperation of a sufferer who can't bear the pain one more second, yet can never escape from his own body.

There are people who are forced to endure terrible conditions -- torture, from within and from the outside, inflicted by biology, by government, by neighbor. Those of us who have found some pathways out of this hell, and those of us who are lucky enough to have never visited there yet must bear witness.

That's the least we can do.

Grand Rounds at Dr. Val

Have a look at this week's Grand Rounds hosted by Dr. Val. btw - her blog is terrific, great medical info on a range of topics.

Couples and OCD (Obsessive Compulsive Disorder)

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors such as handwashing, counting, checking, or cleaning are often performed with the hope of preventing the thoughts and reducing the terrible anxiety that accompanies them. In spite of the disorder, many people with OCD function at high levels.

Adrian Monk, the TV detective played by Tony Shalhoub comes to mind as an OCD sufferer plagued by the urgent need to engage in certain rituals to ward off germs or dirt, to keep objects perfectly ordered, to count steps, and to check things repeatedly.

Typically, the treatment for a person with OCD is cognitive-behavioral therapy and medication.

However, two clinical psychologists at the University of North Carolina at Chapel Hill will, for the first time, use cognitive-behavioral therapy (CBT) to treat couples in which one partner has OCD.

According to an article on PsychCentral:

"Jonathan Abramowitz, Ph.D., associate professor and associate chair of the psychology department in UNC’s College of Arts and Sciences, who is also director of UNC’s Anxiety Disorders Clinic, and Donald Baucom, Ph.D., professor of psychology and director of UNC’s Couples Therapy Clinic, will provide treatment for about 20 couples as part of a new study funded by the Obsessive Compulsive Foundation."

“First we will find out about the OCD symptoms and how the couple has been managing with these problems,” Abramowitz said. “Then we will help the couple learn to work together to address the OCD patient’s obsessions and rituals and assume a healthier relationship in which their interactions do not make OCD worse.”

“The hope is that when both partners learn the CBT techniques, the partner without the disorder can be more helpful in encouraging the OCD mate to work through fears realistically,” Abramowitz said. “This would be good for the OCD sufferers and their spouses.”

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Musings

How can it be that the couple is being seen as the nexus of treatment for OCD "for the first time?"

Couples are intertwined, for better or for worse. We carry our conjoined lives with us wherever we go. One goes to the supermarket and remembers that the household is out of the other's favorite brand of yogurt. We call each other up when one is going to have to stay late at work. Our memories of joys celebrated and injuries inflicted are everlasting. And when one is sick, both lives are dislocated.

When one partner is ill, with OCD, PTSD, GERD, or any other acronym, the other partner is intimately involved. The well partner knows all about the other's diet and bathroom habits, how far she can walk, when well intentioned company begins to tire her out. And the ill partner can read her sweetie's face from across the room and see signs of hope or weariness. One person may do internet research on the ailment, while the other deals with insurance labyrinths. They may go to specialist appointments together and dissect what they heard and understood afterwards.

Whether they talk openly or not about the illness, the illness changes two lives, not one. And the two partners combined have exponentially greater potential for having impact on the experience of illness, also for better for for worse.

After so many years, I can tell what's on Richard's mind by tiny changes in his breathing pattern. He can hear in the first diphthong of the first work I utter when he phones me if I've had a good or a bad day. We carry each other. We defeat each other. We save each other. We grow each other up. Over and over again.

How can this be the first time that the unit of treatment is the couple? I am not suggesting that the patient should abdicate control to the partner. The person in whose body the illness resides gets dibs on making treatment and personal choices. But why would care providers not use the interconnectedness of the couple as a channel for healing?