Wednesday, October 7, 2015

I'm Back

It's been two years since my last substantive post on this blog ("The Right Kind of Love Between Doctors and Patients"). I'd shifted my blogging energy to Over 65, a blog about aging issues published by the Hastings Center. My co-editors and I put that blog to rest in the spring, and I'm just now getting back to Health Care Organizational Ethics, which I started eight years ago.

If I'd been smarter I would have chosen a less wonky title, especially since over the years I've written about much more than the ethics of organizations. (Not surprisingly, the posts that got the most attention are those filed under the "Doctor-Patient Sex" tab!) But organizational ethics continues to be my central focus in ethics, so I'm sticking with the original title. My aim is to post at least weekly.

As always, I'm eager to hear thoughts and comments from readers.

Friday, April 4, 2014

Why I've Been Silent for Several Months

I recently received an email from a college roommate who periodically visits this blog. Finding that I'd made no posts since November he wrote to find out if I'd been ill or, perhaps, was no longer extant in terrestrial life. He noted that at our age (college class of 1960), no news is not necessarily good news!

The reason for my silence on this site is not illness or mortality. Rather, it's that I've been editing and writing for Over 65, a blog about aging issues published by the Hastings Center. Between seeking posts from other writers, editing what comes in, and writing my own posts, Over 65 has occupied the time I've had for blogging. But with some other projects coming off my plate, I'll be posting again on healthcareorganizationalethics before too long.

If you'd like to see my own posts on Over 65, this link will get you there.


Friday, November 8, 2013

The Right Kind of Love Between Doctors and Patients

Yesterday I attended a remarkable educational session at the Brigham & Women's Hospital - "Love Stories: Deconstructing and Learning from Successful Doctor-Patient Relationships."

The stars of the session were Doris Bunte, who turned 80 this year, and Dr. Chuck Morris, her primary care physician. The large audience of medical students, residents, and staff, were transfixed by their description of their first appointment, the building of trust, and Dr. Morris's presence as a "guest of honor" at a large 80th birthday celebration.

Here's how Ms. Bunte spoke about her relationship with Chuck Morris:
I feel something inviting in you that says you are understanding me; you appreciate what I am going through. You rise to the expectations I have for a physician. You are a partner with me in my illness, helping me look at all possible angles and decisions. I feel very blessed by how closely you watch me. I appreciate your candor even about missteps between us. I value our honesty with each other when things are not working well for me. I feel a warmth. We have a mutual understanding and have never reached anger. Any illness is frightening. I must trust the doctor, especially as a patient who is alone. It is a very important partnership. 
I was happy that the panelists used the word "love" to characterize an optimal doctor-patient relationship. That's certainly true to my own experience in practice. Even before Facebook degraded the concept of "friend," I felt that "love" better connoted the attitude of deep affection, cherishing, and strong wish for the well-being of the other, that doctors should feel for their patients in the context of long term caretaking relationships.

Early in my practice I learned a lesson I've never forgotten. I inherited as a patient a man almost twice my age (I was 35, he was in his 60s) who'd suffered from a serious psychiatric ailment throughout his adult life that had impeded his capacity for work and caused suffering for himself, his wife, and his children. By the time we met his condition was quiescent. I met with him and his wife every month or two, gave what counsel I could, and tinkered with his medications. But at heart I felt guilty - I liked him and his wife, and felt I was doing nothing for them.

My wife and I wrote off for tickets to an event. (This was in the pre-internet era.) I received a letter in response:
Dear Dr. Sabin:

There were no tickets left for this event, but when I saw who was asking, I managed to find two. You've been such a wonderful doctor for my parents that I wanted to do something for you.

Gratefully yours

The incident still brings tears to my eyes. At the same time that I was feeling guilty about how little I was doing for my patient, he and his wife had conveyed to their adult child how grateful they were for my ministrations. My "technical" offerings were essentially nil, but the letter I received showed just how much the "soft" element - respecting and caring about my patient and his wife mattered to them.

In retrospect, I'd use the term "love" to characterize the bond between me and my patient, his wife, and even their adult child who I'd never met.

Over the years I've had many discussions with primary care and psychiatry residents about how we can establish clinical relationships that a) allow for the right kind of love, b) don't interfere with our capacity for objective analysis, and c) don't leave us overwhelmed when our patients do not do well. I knew these were longstanding questions in medicine. As a first year Harvard Medical student in 1960 I was in a tutorial led by Dr. William Castle, the eminent hematologist. Dr. Castle, who was 63, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:
Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel? 
Dr. Castle: I would feel terrible! 
Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)
My current understanding is that there are two key factors in learning how to establish loving relationships within which we are adequately "insulated" so that we can think objectively and withstand the bad outcomes that inevitably occur.

First, role modeling. Dr. Castle was passing on to young medical students what his respected teacher had passed on to him 40 years earlier. Dr. Castle wasn't just a brilliant hematologist. He conveyed to us that he loved his patients. We loved him and wanted to be like him. I repeat his story to students 50 years after I heard it from him.

The second factor is practice. Perhaps establishing the right kind of relationship comes naturally to some. For me it didn't. Sometimes I let my emotions interfere with the needed objectivity. Other times I was too stand-offish. With guidance from teachers, colleagues, and patients, I believe I did better over the years.

I know from observing students that it's a learnable capacity. This was brought home to me years ago when a resident who erred in the direction of being too stand-offish at the start of his training, described a final visit with a patient who was in a nursing facility, close to death from AIDS . At the end of the visit his patient was too tired to sit up any longer but no staff was available to help. The resident picked up his frail and emaciated patient, carried him to his bed, and said a fond goodbye.

That's the right kind of love between the doctor and the patient!

Saturday, October 5, 2013

Talking about Suicide

Earlier this week my friend Steve Moffic wrote a powerful post about his experience as a psychiatrist dealing with suicide. He presents a moving discussion of how difficult it was to think and talk about the suicide of a patient he treated in residency. Here's the concluding paragraph of Steve's post:
Legal fears, confidentiality concerns, shame, and stigma are formidable obstacles. But talk we must, for talking—and listening—is a key to prevention and treatment. Any clinician knows that most who survive serious suicide attempts end up being glad they did, if they receive the help they need. They wanted to relieve the terrible psychological pain, not to die. Although the suicide will relieve the pain (as in the song from Mash, “Suicide is Painless”), it can cause intense pain in loved ones. Those left behind need the same forgiveness, relief of guilt, and community support that I received from my supervisors and fellow residents. Like a rock thrown into the river, the ripples of suicide can be mighty and wide. 
In my experience, learning to talk with patients about their suicidal ruminations posed more of an emotional than intellectual challenge. When I first encountered seriously suicidal patients I was tempted to try to "talk them out of it." There were three main ways I considered doing this: persuading them that their problems were solvable; emphasizing the reasons they had for wanting to be alive; and, imagining the impact of suicide on family and friends.

Luckily, wise supervisors pointed me in another direction. The task, they told me, was to find out what made suicide seem like such an appealing alternative. Over the years I learned to probe what I called the "logic" of suicide. What made suicide seem like the right thing to do? What was the source of its magnetism?

I found this approach easy to describe but hard to do. My own temperament is somewhat rigidly optimistic. Some aspects of my growing up were difficult, and in retrospect I believe I learned to see life's glass as half full rather than half empty as a way of warding off depression. My father's brother killed himself when I was 13. I didn't know him well, but I believe that even as a youngster I sensed the pain he experienced. When my two sons were teenagers they teased me about my determined attention to the bright side of life with the term "poptimism."

When I first read The Myth of Sisyphus in high school, I was transfixed by Albert Camus' opening sentence: "There is only one really serious philosophical question, and that is suicide." I thought - "this man gets it" - and underlined page after page. But it took me years of clinical practice to truly "get it." When is a patient's wish to turn off the ventilator a "competent refusal of treatment" and when does it represent a "irrational" suicidal impulse that should be impeded? These are great questions for an ethics seminar, but when I was called upon to make real decisions in real time I learned at a vastly different level.

Thanks to Steve Moffic for so vigorously bringing the importance of talking about suicide into open discussion!

Saturday, September 21, 2013

From Faith to Atheism

What would you think was being talked about if you read the following:
"I got to come out...It used to terrify me, what people's reactions would be. But it's been so long now...I don't even care...I slept like a baby last night because I knew I wasn't going to have to live a lie any more..."
This isn't a young gay or lesbian person coming out to the family - it's Teresa MacBain, a Methodist pastor, telling NPR about "confessing " to her congregation that she has lost her faith and is now an atheist.

I interpreted the NPR interview and an article in today's New York Times in light of my Rosh Hashanah post about religion and medicine. Teresa MacBain stopped believing in God, but terribly missed the community solidarity, shared values, and supportive rituals that being part of a congregation provided. While she no longer believed in the divinity of Jesus, she had not lost faith in what she calls “the philosophy of Christ.” She averred that leaving religion did not mean she had left morality - she still adheres to the Ten Commandments, the Golden Rule and other moral teachings common to many world religions.(See this article in Religion News to learn more about how she gave up her theology but retained her moral perspective.)

Here's how MacBain described the loss of her religious community:
“For me, religion was everything, my entire world. All my friendships, connections, family,  all the places I went to deal with difficulties, to do good works, to find resources to raise kids — everything was contained within that environment. I miss that social connectivity, that network.”
Not surprisingly, like a divorced person who rapidly enters a new relationship, MacBain affiliated herself with new communities - such as the American Humanist Association and American Atheists. At a meeting she met Greg Epstein, the humanist chaplain at Harvard, who hired her to be a kind of apostle to help humanists/atheists around the country build a non-theistic form of congregational life. MacBain has left the church, but she's again in a role that is structurally much like the theistic pastoral role she occupied before the lost her faith.

Before I ended my beloved clinical practice five years ago I felt great anxiety. Even though the practice was only a portion of my work life, I felt that it was totally central to my identity. I described my fear in images like a becalmed sailboat or a car that was out of gas. In retrospect I see that it wasn't just ending my psychiatric practice that was triggering the anxiety - it was also fear of no longer being part of my equivalent of a religious congregation - the "congregation of medicine."

I chair the Harvard Pilgrim Health Care Ethics Advisory Group. Typically we have 25 - 35 participants. The group sits in a U and I sit and stand in the open segment of the U. From time to time when I'm calling the group together to start the meeting I have spontaneously and whimsically said "Dearly beloved..." I do have a feeling akin to love for the group and the process we follow. Sliding into language associated with religious practice reflects my underlying feeling that a group deliberating on the values that inform health care is first cousin to a religious congregation.

Insofar as shared religious beliefs provide the glue that unites a congregation in mutual support and a commitment to social justice I feel a kinship with it. But insofar as it claims a unique truth for its theology and condemns those who do not share its beliefs I see it as undermining the health of society.

[If you want to get a sense of Teresa MacBain's pastoral skills, put her name into YouTube and sample some of the videos of talks she's given since leaving the church.]

Wednesday, September 4, 2013

Religious Ethics and Medical Ethics

The Jewish New Year - Rosh Hashanah – starts this evening, and the New York Times featured a front page article on “Bar Mitzvahs Get a New Look to Build Faith.” The article touched a very personal nerve for me.

Both my parents and all of my grandparents were Jewish, but the family I grew up in was very non-observant. We didn’t belong to a synagogue and didn’t celebrate the Jewish holidays, other than a very perfunctory Seder at my father’s ailing mother’s home in Brooklyn. But at 11 or 12 I asked my parents to send me to Sunday School, an almost unheard of request for a child to make. As best I can recall, I wondered how the universe was created and what my purpose in life should be, and had the idea that religion might help me answer these questions.

They enrolled me in Temple Emanu-El, a large reform congregation that was founded in 1845. I quickly concluded that I’d made a mistake. In class we memorized prayers in a language I didn’t understand, studied holiday rituals, and learned about the history of the Jewish migration to the US. We didn’t touch the big questions I was interested in. When I said I wanted to quit my father asked me to stick it out for the sake of his mother, who was happy at the idea of my having some Jewish education, even if it ended in a confirmation ceremony and not a bar mitzvah.

It’s clear to me in retrospect that I was searching for a community that shared fundamental values and collaborated in actions based on those values. I didn’t find what I was looking for at Temple Emanu-el, but during the summer when I turned 16 (and in the two summers after that) I worked as a counselor at Felicia Madison, a camp that served poor children from New York City. When I got to college I was able to create a combined major in philosophy and psychology – a program that let me explore the kinds of questions I had in mind in asking to go to Sunday School. And I worked as a volunteer at a public mental hospital, which led to a career in psychiatry and medical ethics.

I believe that an anthropologist studying my affiliations would see the involvements with psychiatry and medical ethics as structurally similar to an involvement with religion. I consort with colleagues who share an outlook on the world, values, and a commitment to forms of action. There’s no theology, but it is a community of belief.

The New York Times article describes an initiative by 80 congregations to place more emphasis on values, community engagement, and social action, than on theology and ritual. The problem the congregations are trying to solve is family departure from the congregation as soon as the bar or bat mitzvah has been accomplished.

If I’m forced to define myself in terms of religion I identify myself as “a religiously-minded Jewish atheist.” In my clinical practice I found religious language natural to use – “that’s something to pray for,” “if it happens it will be a blessing,” “XYZ is your calling,” and more. When a patient with chronic schizophrenia asked me to remember him in my prayers I said I would, even though I don’t do anything a religiously observant person would call “prayer.” I felt that his request was for me to care deeply about him and his quest for well-being, and since I did, I felt it was truthful to say I would remember him in my prayers.

At the end of his life my father turned against all religions because he saw them as sources of hatred, slaughter and war. He was thinking of fundamentalist religion. In my view all “liberal religions” are comparably true and good, and all “fundamentalist religions” are comparably false and bad. As I examine the course of my adult life, it’s clear that the calling of medicine has been my version of liberal religion.

Wednesday, July 17, 2013

Learning about Aging from Patients and their Children

Last month I wrote about how 13 years after the death of Emily Lublin, a patient with whom I'd had a very warm and constructive relationship, I had contact with her daughter, Langley Danowitz. (I'm using names with Langley's permission.) Emily was more than two decades older than I. I believe she benefited from my attention as a psychiatrist, but I know that I benefited from the insights she offered about aging with spirit and energy.

When Langley and I spoke on the phone she spoke so interestingly about her experience in her 60s (and now, at 70), that I invited her to share her thoughts with others in the blogosphere. A few days ago she sent me this further posting. It's been well documented that physical activity has multiple benefits for the over 65 crowd. Langley brings the research findings down to earth with this personal story:

Fitness and How It Helped Me

To be honest, I am actually 70, as of January. This seems odd, as I feel pretty much the same as when I was 50 and 60, give or take a little stiffness when I get up. I am reminded of the Tin Woodsman’s plea for an oilcan. I hope one day to be able to just spray myself in bed and voila - all the kinks are gone. Is anyone working on this?

Aside from my oilcan hope, I know there is no miraculous fitness method. I started going to the gym late in life – I was 59 and had seen a picture of myself. (My exercise routine for years had been to read the NY Times while doing 15 minutes of leg lifts.) Once I stopped crying, I signed up with a personal trainer for a trial session. I wore my favorite exercise outfit – black ballet tights and a large tie-dyed tee-shirt. My husband photographed me as I descended to the gym in the basement of our building. The trainer was encouraging – she called me “Honey” as in “Honey, just 50 more”, “Honey, what did you eat yesterday?” and “Honey, keep going”. I hated and loved her. She got me started on the Fitness Path and I have never looked back (except when someone’s trying to pass me).

In the 10 years since I discovered fitness, I have tried a variety of exercise, from boxing to Zumba. I started with a personal trainer once a week – now I exercise EVERY DAY. Being a Party Animal, I have found happiness in the socialness of groups. Picture a class – 40 women of varying shapes and 2 guys who either are lost or got dragged in by their girlfriends. It’s like a weight loss meeting – the men are rare and ignored. Before you think I’m a martyr - I should admit that I LIKE exercise. I do it because it’s fun for me and I get to wear cute outfits. Moving my body to commands from an amazing physical specimen just warms my heart – call me strange big time. Many of my newest friends are trainers – I keep showing up for their classes and I guess they appreciate it.

I hope I am inspiring you to give exercise a chance. After all, that is why I’m writing this. If you are just starting, here are Langley’s Five Most Important Tips:

1. Be not afraid to try it.

2. Ask your doctor if you need any restrictions.

3. Join a local gym for a month.

4. Make an appointment with a personal trainer.

5. Try several different classes at your gym to see what you like.

Exercise has totally changed my life – I think clearer, I feel better and I am easier to get along with. Give it a shot and let me know how YOU like it.  All best, Langley
Here's a photo of Langley with her trainer:

In my psychiatry residency, when we overly intellectual twenty somethings asked our training director what we should read to become wise psychiatrists, he said "Listen to your patients...they will be your best teachers!" And when I was dealing with a not very communicative "elderly" man (probably 10-15 years younger than I am now) who became depressed after losing his job at a beer factory, my supervisor advised me to "have him tell you all about what it's like to work in a beer factory all your adult life..." Throughout my entire clinical career I tried to follow their precepts. In retrospect it seems clear that the domains in which I learned most about  life, human nature, and myself, have been family and clinical practice.

But there's always something new to learn. Emily "taught me" about aging before she died 13 years ago. Now her daughter Langley is continuing "conversation" I had with her mother.

What a privilege it is to be allowed to enter human lives as a health professional!