Forest Bathing

For years I've enjoyed taking long walks in the woods. But it's only from reading a recent New York Times article that I learned I've been following the Japanese practice of shinrin yoku - "forest bathing."

There's nothing new about walking in the woods. Our ancestors spent their lives in forests. I assume many forest-dwelling genes are buried in our DNA. But as our species has become progressively more urbanized we spend most of our time indoors. A 2001 EPA survey reported that we Americans spend 87% of our waking time indoors, and another 6% in an enclosed vehicle!

In 1982 the Japanese Ministry of Agriculture, Forestry and Fisheries coined the term translated as "forest bathing" to describe the effort to imbibe what it saw as the healing power of nature by going into green areas with a mindful attitude. Since then, in the U.S., an "Association of Nature Forest Therapy" has trained and certified multiple cohorts of forest guides. A Google search shows that forest bathing is catching on as a commercial "back to nature" trend.

As an adolescent, Walden and Henry Beston's The Outermost House were among my favorite books. It seemed obvious that there was something very "natural" about being in "nature."

Three days ago the Journal of the American Medical Association published an important study demonstrating that creating green spaces of grass and trees on what had been garbage-strewn abandoned lots has a positive mental health effect on the neighborhood. This was a methodologically rigorous, randomized study that is likely to convince skeptics that there's more than sentimental anecdote behind the endorsement of time in the woods as a promoter of health and well-being.

In an aggressively capitalist society, it only takes a few nanoseconds for good ideas to become "monetized" and the focus for snake oil style hype. On the web I found vendors hinting that walking in the forest will combat cancer. But despite the hype surrounding the forest bathing concept, if I were still in clinical practice I would add spending time in "nature" as a recommendation to many of my patients.

The Moral Vision of Primary Care

The underlying vision of primary care is to do what is needed to promote and restore health. Sometimes this requires referring patients to specialists, but more often it is done directly.

An article in today's New York Times about Dr. Nicole Gastala describes how the young physician, just out of residency and paying off her loans through practice in a community clinic in Marshalltown, Iowa, encountered the opiate epidemic and decided to do something about it. She did the required training to be licensed to prescribe buprenorphine so that she could provide medication assisted treatment to patients with opiate addiction. She got a federal grant that facilitated starting a program and hiring a nurse to join her in staffing it. She continues her own education via telemedicine with a clinic in Connecticut that provides consultation and education to primary care buprenorphine providers. She has strengthened her own capacity for acceptance of patients who relapse. And, as she and her husband prepare to move back to Chicago, she is taking steps to perpetuate the buprenorphine program.

For the past twenty years I've had the privilege of co-facilitating a "patient-doctor" seminar for superb primary care residents throughout the three years of their residency. They've reported how frequent it is to hear versions of "you're so smart and capable - why aren't you going into a medical specialty?" As I thought about their choice of primary care, the Buddhist concept of Bodhisattvas of Compassion came to mind. I've written before about the statue of Guanyin at the Boston Museum of Fine Arts. In Buddhist tradition, Bodhisattvas are enlightened beings who choose to remain among mortals to alleviate suffering.

This vision is available to any and all health professionals, and of course to others in professions like education. But in medicine I see primary care as the purest form of the "Bodhisattva-like commitment," since it puts the fewest filters between the individual physician and the full range of human suffering. The article in today's New York Times does not contain high falutin language, but the simple story of a young physician's post-residency practice gives a down to earth picture of the moral vision underlying primary care.

Addendum: The July 5th issue of the New England Journal of Medicine has an excellent article on "Primary Care and the Opioid-Overdose Crisis: Buprenorphine Myths and Realities." If you've read this far I urge you to follow the link to the NEJM article.

Loneliness and Health

It's easy to make jokes about the British "Minister of Loneliness," as Steven Colbert did when Theresa May announced creation of the new position this winter. But for several decades we've known that loneliness isn't a joke - it's a significant risk factor for poor health and premature death.

Here's how Vivek Murthy, the former Surgeon General, explains the health impact of loneliness:

...Over thousands of years, the value of social connection has become baked into our nervous system such that the absence of such a protective force creates a stress state in the body. Loneliness causes stress, and long-term or chronic stress leads to more frequent elevations of a key stress hormone, cortisol. It is also linked to higher levels of inflammation in the body. This in turn damages blood vessels and other tissues, increasing the risk of heart disease, diabetes, joint disease, depression, obesity, and premature death.

Understanding the toxicity of loneliness has implications for public policy and health care practice. The UK ministry exemplifies a public policy action. But my interest for this post is health care.

Physicians are overburdened with requirements, but asking about our patients' social connectedness is central to understanding them. Loneliness is often the result of illness. People who are ill may withdraw from the social world, and sometimes others may withdraw from them. And loneliness can cause vulnerability to illness and diminish the resilience we need to recover.

In my psychiatric practice I sometimes took out my prescription pad and wrote instructions like "talk with a friend at least once every day" to dramatize my belief that in many circumstances, persons could be more effective than pills. And I kept a file with resources patients mentioned: AA and NA groups, Alliance for the Mentally Ill support programs, and more. Over time this helped me suggest venues that aligned with my patients' temperaments for those who might benefit from the right kind of peer support.

When I was asked to start an HMO outpatient program for patients with chronic mental illness I surveyed the literature for guidance. While the term "loneliness" wasn't used, the most promising models were group-based programs with an informal, friendly and welcoming atmosphere. For several years I had the privilege of being the psychiatrist who met with the group. Patients could come as often or as rarely as they wished. When a patient had a question about medication of some other aspect of treatment, I could usually direct the question to another patient with first hand experience of the treatment in question. Patients often became friends.

The widening recognition of loneliness as a toxic state and meaningful social connection as a health promoting factor is a positive step for health care. But, unfortunately, valuable insights can be drowned in bureaucratic regulations. Reducing inquiry about loneliness to a required checklist of questions risks coming across to patients as sterile and perfunctory, and to physicians as one more requirement in the ever-lengthening list of externally driven expectations.

But when interest in the social texture of our patients' lives is part of the clinician and patient coming to know each other as human beings and collaborating in service of health, both parties will gain.

Medicine and Mysticism

Even before I knew that Guanyin was the Bodhisattva of Compassion I was drawn to her image in the Boston Museum of Fine Art. (In Buddhist tradition, Bodhisattvas are beings who delay reaching nirvana out of the wish to alleviate human suffering.)

My own recent experience with medical care leads me to see concepts like Bodhisattva and Guardian Angel as telling us something important about medicine.

   

                                         Guanyin - 
                          Bodhisattva of Compassion

Two months ago I wrote about the condition that had given me many months of pain, severely disturbed sleep, and difficulty walking (see here and here). My primary care physician referred me to a hematologist who made a presumptive diagnosis of a platelet dysfunction and prescribed a medication that acts on the bone marrow to slow down the platelet production process.

Prior to the diagnosis I'd assumed that the mysterious condition was not going to go away, but now, two months after starting the medication, the symptoms have almost entirely cleared up. I'll have to take the medication for the rest of my life, and some complications could emerge, but I feel like "myself" again.

So what do these experiences have to do with Guanyin?

The medication I'm taking requires careful monitoring to make sure it's doing what it's supposed to do with the platelets, but not causing too much decrease in white & red blood cells, which the bone marrow is also busy producing. We've checked the blood nine times between the day I started the medication and this week. The results go to my hematologist who writes to me on the secure email her practice uses to interpret the results and suggest how to handle the medication.

I counted her messages in my inbox: 13 messages and a total of 386 words. That's less than 50 words/week.

From my own experience as a physician I doubt that our exchanges required much time. But in addition to the instrumental importance of the guidance I received, I was aware of a strong sense of emotional support and of being cared for that the 386 words conveyed. I identified two sources for that feeling. The promptness and reliability of the hematologist's response after my blood tests elicited a sense of security. And the happiness she expressed as my symptoms improved elicited a sense that my well-being mattered.

That's what Guanyin stands for in Buddhist culture, and likewise for Guardian Angels since they first appeared in the Hebrew Bible. Within the theologies, Bodhisattvas and Guardian Angels were vehicles for conveying divine love to us vulnerable mortals.

Health care workers tap into the same psychological and cultural substrate. The feelings I've had as a patient are the reciprocal of the sense of mission I had as a physician. Recently, at the end of an appointment, a patient said "thank you," to which I replied with the same two words. When my patient asked me why I said "thank you," I explained that being a physician (or a nurse, social worker, physical therapist...) is a privilege, and that the act of healing required collaboration between the involved parties.

I believe that if we could interview Guanyin and Guardian Angels, they would tell us that they were grateful for their opportunity to minister. There's a "mystical" element in health care that market concepts like "consumer" and "provider" are woefully inadequate for understanding.

(See here for a post about why secular clinicians might want to use religious language in their practices, and here for a post about love in the patient-doctor relationship.)

A Personal View of the Medical Home concept

Into my mid 70s I felt remarkably fit. I was still playing tennis and taking my favorite hikes during the summer in Vermont. That changed when a mysterious problem I've written about in a couple of posts (here & here) set in.

As a result of the problem that developed, I've had more medical appointments in the last six months than in the previous 25 years. As someone with an interest in health policy & systems, my experience has sharpened my sense of what's required to make a "medical home" work. (For those who aren't familiar with the medical home concept, I've copied material from the Patient-Centered Primary Care Collaborative at the end of my post.)

Here's my patient's eye view of my experience:

1. In the fall of 2016 I was floundering as to what to do about the problem, Whatever was causing pain and discoloration of my left foot/ankle/lower leg was still a mystery. My primary care physician (PCP) suggested seeing a dermatologist, something I hadn't thought of myself.
2. The dermatologist said what she saw was unusual. She did a biopsy which, alas, came back as "non-specific changes," That meant we were still unsure. She could simply have sent me back to my PCP, but to her credit, she suggested that we get a second opinion from someone at the hospital my care group is associated with.
3. Initially the referral went to the referral coordinator and an appointment was set with a presumably thoroughly competent dermatologist, but one who did not have more experience than the one I had seen. I discussed this with my PCP. He called the chief of the department who recommended a senior colleague who he said "is especially good with complex cases."
4. I saw the recommended dermatologist who had some hypotheses about obscure possibilities and did two further biopsies which showed (a) clotting in the tiny blood vessels and (b) no inflammation. 
5. With a narrower set diagnostic possibilities, the second dermatologist wrote to my PCP, recommending that I see a hematologist and suggesting some further blood tests. My PCP agreed, and referred me to an excellent hematologist with whom I had shared patients before I retired from practice ten years ago.
6. By this time my blood count showed something new - an abnormal level of platelets, which are crucial for clotting. The hematologist prescribed a medication that acts on the bone marrow with the aim reducing the platelets. We've used the group's secure email to follow the counts and adjust the medication. We've only met in-person once, but the email communication has been very reliable.
7. As the platelets have come down, the lower leg and ankle problems have completely cleared up. But the toes have not, and in particular my left fourth toe was exquisitely painful. Last weekend I saw an ugly open sore on the toe. I didn't know what gangrene looked like, but my imagination ran away with unpleasant possibilities.
8. On Monday morning I was able to see an urgent care physician who allayed by fears and prescribed  oral and topical antibiotics. 
9. I informed the hematologist and my PCP about the situation to make sure we were all "on the same page."
10. Happily, the wound is improving, and the pain is markedly reduced. 

So what's the point of all these details?

For me it's this: in the same way that it takes a village to raise a child, it can take an "extended family" to treat a chronic condition. My experience has been one of receiving excellent continuity of care even though I've been bouncing between clinicians the way a pin ball bounces. But the clinicians were part of the same "family." They had access to the same electronic health record and communicated with each other - either directly or via my sending "FYI" updates to them. For the underlying chronic problem I've had my blood drawn at the practice's laboratory. The results get to the hematologist and to me within a few hours, and she has followed up with email advice very promptly.

My guess is that my treatment in the past few weeks has not occupied much physician time, but as a patient I have felt very attended to. When I was worried about toe pain and an open wound I was able to see a clinician promptly, and her findings went to my PCP and the hematologist I am working with.

I believe my experience shows how a "medical home" and "team care" can be more than euphemisms. Continuity of care doesn't require continuous appointments with a single physician. When a "medical home" functions the way a harmonious extended family does, it works!

Here's the material about the medical home concept for those who want to read about it in more detail:

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

In 2007, the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ). 

Features of the Medical Home

Adapted from the AHRQ definition, the PCPCC describes the medical home as an approach to the delivery of primary care that is:

• Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
   
• Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
   
• Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
   
• Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
   
• Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health

Adding Value by Talking More

A recent article in the New England Journal of Medicine - Adding Value by Talking More - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.

Here's the final paragraph of the article:

As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.

The otherwise excellent article omits one crucial element. Talking more with our patients also increases physician satisfaction. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.

I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of Avant -garde Health, a health care technology and analytics company founded by one of the authors.

Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a concierge model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.

The kind of work behind Adding Value by Talking More is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."

Access to health CARE vs access to health INSURANCE

A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (here & here). With my friend's permission I've copied the message s/he sent [I'm deliberately disguising gender], edited to protect confidentiality and to highlight the themes I want to emphasize:

Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of patients who are not MDs and/or are not in an integrated group practice such as the one you belong to. In my own experience, PCPs defer to specialists and won't contradict them. Further, the placebo effect of the PCP relationship is reduced if not nullified by the patient's difficulty in contacting the PCP over the phone. I can never get an appointment on short notice with my PCP; I can only count on seeing him if the appointment is made months in advance, or if I am in an emergency ward or am admitted to a hospital as an inpatient. If I have an immediate problem that is not an emergency (e.g., burn, sprain/suspected fracture, bronchitis), I have to work through two layers on the phone (secretary, medical assistant) -- and then the outcome will be an examination by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's Walk-In Clinic rather than even trying to reach my PCP's office by phone. Finally, your encomium to the email system doesn't apply to the sharing of medical records between hospitals on different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice groups that are located in one and the same hospital office building but that don't share the same medical records system.

My friend is well insured - s/he has no problem with insurance access. And the community where s/he  lives is replete with medical services.

In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.

My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience if they had the same skills I have in managing my care experience.

I anticipate that in the future, patients will routinely have electronic access to their own medical records. That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.

From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.

It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.

The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.

Chronic pain, Identity, and Health System Ethics

Prior to this past year my experience of pain had been with acute episodes. An especially painful and amusing episode occurred when I started a new job at the Massachusetts Mental Health Center after residency and fellowship. Between painting rooms in the house we were moving into and carrying boxes hither and yon I threw out my back. I lay on the floor, hardly able to move. A helpful neighbor called his PCP who came to the house. (It was 1970 and house calls actually happened.) I could see that he was regarding me with suspicion. Perhaps I was a newly arrived addict who was seeking an opiate fix. And when I started my new job, in some of my meetings I again lay on the floor, giving a rather odd impression of the new hospital ward supervisor.

The pain was severe - perhaps 9 or even 10 on the ubiquitous 0-10 scale. But I knew it would clear up before too long, and it didn't burrow into my psyche and sense of self. In the (slightly altered) words of the old spiritual, it "pained the body but not the soul."

Not so with the chronic pain I wrote about 3 days ago! It's not as severe as the back spasm, but the (a) chronicity and (b) uncertainty about if and when the pain will go away has (c) taught me lessons I only understood from the "outside" during my years of practice and (d) challenged my sense of identity.

Like many physicians, my default mode is to help others. Over the years, when asked "how are you?" my typical answer has been a hearty, upbeat "excellent!" So for the simplest of tasks - taking out the garbage and even putting on my pants (I have to protect the toes from contact with the pants leg - not easy to do) - to become difficult or impossible is a shocking change. My wife has taken over my "chores" cheerfully and uncomplainingly, but I feel ashamed at (my words) "not doing my part."

Before the foot/ankle/lower leg problem set in, I took an extended walk whenever the weather permitted, and played tennis with friends weekly. Sacrificing these activities isn't just a matter of losing forms of "recreation." Being an active, out-of-doors person has been part of who I am. These losses take another bite out of my sense of identity!

In a similar vein, I enjoy being at both of the two offices I use. But parking and walking to the office is difficult, and I can actually do most of my work from home, so I have been largely invisible at my work sites. My "productivity" may not be reduced, but collegiality is down, and loneliness is up.

Coping mechanisms are crucially important and put to the test. As an example, the toe/foot/ankle/lower leg pain is worst at night. When I try to sleep it wakes me up every 60-90 minutes. My initial reaction to these awakenings was anger, but that accomplished nothing useful and made it harder to get back to sleep. By an act of will I substituted humor - laughing at myself sitting in the dark massaging my foot and hobbling around to reduce the pain. Rather than saying "why the bleep is this happening to me" I say various forms of "what a ludicrous situation this is!"

This is a blog about organizational ethics. Readers may reasonably ask "what on earth does a painful foot and difficulty taking out the garbage have to do with organizational ethics?"

A lot!

Nowadays, organizations toot the horn about their commitment to "evidence based practice." Since the Hippocratic era, the practice with the strongest evidence of effectiveness is empathic listening. Organizations can encourage this stance or - all-to-often - squelch it with bureaucratic demands and processes that treat patients as targets for efficient "throughput."

Time pressure is a fact of life everywhere in health care, but there are skills we clinicians can develop to use time well, rather than having time use us. When I joined the mental health practice at the Harvard Community Health Plan HMO in 1975, the insurance limited the number of appointments we could have with our patients. Some clinicians put this limit front and center when they met new patients, by stressing what they couldn't do. Wise clinicians, however, approached new patients differently - "Let's first figure out what you need, and then see how we can best meet those needs." The HMO encouraged me and my colleagues to struggle with the challenge of remaining true to our mission while doing what was needed to make the necessary margin to keep the program going. (See here and here for examples of that work.)

Medical care ultimately comes down to the patient-clinician dyad, but more and more often the dyads occur in an organizational setting. Empathic listening is carried out by individuals, but organizations can encourage or thwart this deeply human process. That's where organizational ethics comes in!      

(A friend who knew about my left foot problem brought to my attention a superb article by the distinguished primary care physician Thomas Bodenheimer - "Lessons From My Left Foot." It's available at  http://www.annfammed.org/content/8/6/550.full.pdf)

Health System Ethics and my Left Foot

I haven't written a post for more than 6 weeks. My left foot/ankle/lower leg are a big part of the reason for the lapse. So I decided to write about my experience and connect it to the topic of this blog -  health system ethics.

Many physicians have written about their own experiences of illness. Here's my  story.

In the fall of 2015 my left big toe itched. I didn't pay much attention until it began to hurt and develop redness. My primary care physician (PCP) was on a medical leave for a serious medical problem, so I saw another physician in his practice group. By that time I had red blotches on my foot as well. The physician had two hypotheses:

   (1) It might be an early stage of "vasculitis" (inflammation of the blood vessels). She did some blood tests, all of which were normal, and referred me to a rheumatologist (a specialist in autoimmune and musculoskeletal conditions).
   (2) It might be a circulatory problem, and she referred me to a vascular surgeon.

The  rheumatologist did a thorough evaluation with many blood tests. Except for two minor abnormalities, all were normal. He concluded that I did not have a systemic illness.

The vascular surgeon also did a thorough evaluation and a CT scan to visualize blood flow to my legs and feet, which showed adequate circulation with no visible blockage.

Lesson # 1: The specialists were excellent, but when they didn't find a problem within their purview, I was left with a "what now?" question. Given the absence of my long term PCP I decided to be my own case manager. I believed more than ever in the importance of primary care as the key hub of the health care system.

The pain was better during the summer. Perhaps the warmer weather explained it. Whatever the explanation, I enjoyed the summer.

In the fall of 2016 the areas of red discoloration spread onto my left ankle and lower leg. Happily, my PCP returned to practice from his long term medical leave.

Lesson # 2: Apart from all of the valuable things PCPs do, at least for me, and I would guess for many others as well, there is a powerful placebo effect from having a solid relationship with a clinician one trusts for skill, knowledge, and a genuinely caring attitude.

On examining me and hearing my history, my PCP said - "This is really weird. I have no idea what's going on. I think we should involve a dermatologist." A couple of weeks later I saw a dermatologist who suggested a few possibilities and did a biopsy. The biopsy came back "non-specific" - i.e., it didn't tell us anything. She thought we should get a second opinion.

It took several weeks for this to be arranged. The very knowledgeable consultant I saw put forward some additional possibilities and recommended repeat biopsies. These showed (a) tiny clots in the small blood vessels and (b) no signs of an inflammatory/autoimmune process.

This told us what was happening, but not why it was happening.

Lesson # 3: Humility is a virtue. My PCP acknowledged having no idea of what was going on, but did have an idea of what to do next. The first dermatologist suggested getting a further consult within her own specialty. Their non-arrogance paid off!

On the basis of seeing blood vessel clots, the second dermatologist suggested that I  see a hematologist, who put together (a) the presence of clots and (b) the fact that in the previous month I had a mild elevation of my platelets (blood cells involved with clotting) that was (c) a bit higher on repeat measure. Before our appointment she had me do further blood tests. We'd been colleagues in the past and she sent me the following email:

"I had you do some special blood tests beforehand and, indeed, you have a JAK2 mutation which is present in people with Polycythemia Vera and Essential Thrombocythemia.  This likely explains your elevated platelet count. I will be suggesting starting Hydroxyurea pills – very easy and well tolerated, to bring down the platelets and hopefully prevent more problems in the future."

Lesson # 4: In the previous 14 months I'd seen 10 different physicians. Without good coordination, this would be a surefire recipe for chaos. When  my PCP returned he carried out the coordination function very well, but throughout the 14 months the secure email system my practice group uses was invaluable. I could write to one physician and copy the note to others. This aspect of the electronic infrastructure really paid off.

I've started the new medication (Hydroxyurea), but I'm very aware that we're still proceeding on the basis of hypotheses. Blaming the elevated platelets is a plausible explanation, but two elements don't fit. A year ago, after the problem was clearly underway, a blood test showed normal platelets. The hematologist speculated that "perhaps your platelets are more 'sticky' and clot more easily." That could be true, but it's a speculation. And if the platelets are the villains of the situation, why are the symptoms limited to my left foot/ankle/lower leg?

Lesson # 5:  In 1865, the French physiologist Claude Bernard, who, among other discoveries formulated the concept of homeostasis, wrote “physicians make therapeutic experiments daily on their patients . . . . [M]edicine by its nature is an experimental science, but it must apply the experimental method systematically.” When faced with illness and suffering, patients and physicians want certainty. But as Bernard recognized 150 years ago, certainty of the kind we can have in mathematics is not to be had in medicine. Patients, physicians, and the public, need to learn how to work with and live with the absence of bedrock certainty.

 In this post I haven't touched on the powerful psychological impact of chronic pain and disability. I'll do that in future posts. If you've read this far - thank you for your attention!

An Ethical Perspective on Shared Medical Appointments

Stories about shared medical appointments keep popping up in the news, most recently in this New York Times article. The format involves bringing together a group of patients - as many as 15, but typically 8 - 12 - with a doctor or nurse practitioner, for a 90 minute discussion of shared medical problems, such as diabetes. Although group visits are not for everyone, the response of patients who participate and clinicians who lead the sessions are generally quite positive.

Group visits arose to promote efficiency. Although current discussions describe the format as an innovation developed in response to the parlous state of contemporary medicine, in 1905 Dr. Joseph Hersey Pratt, a Boston physician, began to lead "classes" for patients with tuberculosis. Pratt documented results that were as good as the best sanataria, but his method fell into oblivion.

In 1975 I had the privilege of starting a group visit program for patients with chronic psychiatric ailments at the Harvard Community Health Plan HMO . I conducted the group in collaboration with an excellent psychiatric nurse. I spoke with patients individually and to the group as a whole. If I wanted to recommend a medication to patient A, I often asked patient B, who was taking the medication, to talk with A about it. It was set up as a "drop in" group. Patients could come every week or just intermittently.

Physicians who lead shared medical appointments experience a different relationship with patients than in the 1:1 format. The group is more informal, and the physician often acts as a facilitator of patient-to-patient exchange, rather than as an authority. The framework tends to bring out the humanity of clinicians and patients. It's difficult for the leaders to be cold, detached or pompous.

I don't know how well the aspiration for efficiency holds up, but I do know - from my own experience and from the literature - that group visits encourage a holistic, humane way of relating between doctors and patients. The rationale for the format tends to be presented in an apologetic manner: the health system is in a mess/physicians are too harried to pay enough attention/you'll get to spend more time with your doctor in a group. These statements are true. But apology undersells the value of shared medical appointments. For patients with chronic conditions that must be managed over time, the group format can bring out a patient's own strengths and initiative and allow physicians to tap into their capacity to care in a down-to-earth human manner in new ways.

That's an ethical achievement, not just a matter of efficiency!

[To learn more about shared medical appointments, a Massachusetts General Hospital guide to conducting group visits is here,  a description of the group visit program at the Cleveland Clinic is here, and a VA guide to setting  up a group visit program for patients with diabetes is here. If you would like pdf versions of my articles about Pratt and about the HMO group program, send me your email address via the comment function.]

All Physicians Should be Doing Palliative Care

Here's a condensed version of a recent conversation I had with a family member:

My family member: The hospital recommended that X should have palliative care. What is palliative care?
Me: Palliative care is a specialty that focuses on symptoms - helping people suffer less and feel better. It's for people who have serious ailments. Its aim is to improve the quality of life for patients and families.
My family member: I'm confused. Isn't that what every doctor is supposed to be doing?

The question pointed to a real problem. Helping people suffer less and feel better is indeed what every doctor who cares for patients is supposed to be doing. So even though I'm a fan of palliative care, we have to ask: why does it exist?

In my view, palliative care exists for three reasons - one good and two bad.

The good reason is that we've developed a lot of knowledge about controlling symptoms and improving quality of life, ranging from medicines and devices to psychological techniques to judicious use of community resources. Orchestrating all of these often requires a skill set beyond that of primary care physicians and subspecialists. Thus the emergence of a new specialty.

Bad reason #1 is the ethos of U.S. health care. It's displayed when we physicians, coming to the end of our potentially curative interventions, say "there's nothing more I can do for you." We should know better! 2,500 years ago Hippocrates taught us that our role was to:

One of my medical heroes is a clinician/basic scientist who cared for a dear friend of mine who had an incurable cancer. My friend came for an appointment after the last known treatment had failed. The physician said, "X, the best thing I can do for you now is to give you a hug." That's what he did. When I met the physician some years later and told him how much I admired him, he thanked me and immediately asked after my friend's spouse. Palliative care was part of what this physician expected of himself! I picture Hippocrates smiling and saying "you got it right."

Bad reason # 2 is time. When physicians ask each other about the most meaningful moments in our clinical careers, the stories are often about palliation - making contact, relieving suffering, bringing comfort. But the way we have structured medical roles makes it very difficult to spend the time required for giving good palliative attention. Rather than finding ways to make more humane practice possible, we've created the specialty of palliative care.

I have regular contact with primary care residents, and over the years a number have chosen further training in palliative care. It's not that they've turned against primary care - it's that they concluded that palliative care was the best way for them to practice medicine as they hoped to when they went to medical school. This is also why some physicians in practice choose the "concierge" format, in which they limit the size of their practice and make up for lost income by charging a fee for "belonging" to the practice.

But my belief that when we physicians care for patients we should all be doing palliative care isn't, alas, practical in 2016. I ended the dialogue by saying - "In principle you're right - every doctor should be doing that. But it isn't happening. Palliative care is a great idea for X. Go for it!"

Accountable Health Communities and Primary Care

Last month CMS announced an "Accountable Health Communities" initiative:

The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery.

I think the initiative is a very big deal!

The US health system is badly out of whack. 95% of the trillion dollars we spend on health care each year goes for acute medical treatment, but 60% or the preventable deaths are caused by "social" factors. In the brief appointments that are too characteristic of medical practice, it's difficult for physicians to learn about a patient's social circumstances. And I know from the brilliant and idealistic primary care residents I teach that they feel their training has not prepared them to know what to do in response to the stories they hear from their patients.

I believe the disconnect between what typical medical care involves and the existential circumstances of our patients' lives is a major contributor to the high rate of "burnout" and "demoralization" among physicians. When physicians and patients feel deeply connected, medical interventions are more effective and both parties experience intrinsic satisfaction. Sadly for all, this connection often does not occur.

Dr. Heidi Behforouz, a colleague at Harvard Medical School, has written usefully about "rethinking the social history." Here's her diagnosis of the problem young physicians like those I have the privilege of working with encounter:

Physicians often see patients with complex social situations as a burden — requiring extra work that is neither reimbursable nor central to our core clinical expertise. Unfortunately, we inculcate these attitudes in trainees, implicitly and explicitly, perhaps because  of our discomfort with hearing difficult stories or our sense of powerlessness or incompetence in addressing these root problems. Whereas biologic pathology may present specific targets for intervention, social or structural pathology is difficult to treat.

 The CMS "Accountable Health Communities" initiative is designed to explore organizational models that foster a stronger connection between the "medical" and "social" aspects of our patients' lives. Strong links to community resources, new skills for understanding social contexts, and improved tools for recording social information in a useful form, will all be required.

When health organizations move from being strictly "medical" to becoming "health communities," we'll have created settings in which medical, nursing, and other health professional students can learn how to do what William Osler urged a century ago: "the good physician treats the disease; the great physician treats the patient who has the disease."

Medical Scribes and the Patient-Doctor Relationship

I'd heard and read about the practice of bringing "scribes" into the exam room to allow the doctor to relate to the patient rather than to the keyboard. But I hadn't experienced the phenomenon until last week. 

Prior to my appointment I was told that the physician I was about to see (my primary care physician has been ill, and I was seeing a physician I'd never seen before) worked with a scribe. Would that be OK with me? It was. The medical issue involved my big toe and foot, and didn't feel enormously personal.

The photo (it isn't me) shows the scribe interacting with the laptop but clearly in the patient's line of vision. At my appointment, when I looked at the scribe he was looking at me - we made eye contact. He said nothing verbally or via facial expression, but was clearly a third person in the office. Since the focus of the examination was my foot - not a very personal exposure - and the questions weren't about intimate matters, I didn't mind having a non-clinical stranger in the room. But if either of those conditions were different, I would not have wanted the scribe to be present.

The impetus for using scribes is directly related to the electronic health record and the incentives from Medicare (and others) for using the EHR. If physicians are doing the entry, it's either during the appointment or after. Entering the notes during the appointment is more efficient, but leads to the common patient complaint that "the doctor is treating the computer instead of me." But entering the notes after the appointment requires additional time that is not reimbursed and makes the working day longer. 

During my years of psychiatric practice I regarded myself as a devoted clinician. I loved my patients. But from residency on I generally made my notes during the appointment. I found that if I waited until the end of the day I'd forgotten things, and after a busy day of appointments I felt burdened by the additional time requirement. I didn't resent staying later to see a patient with an urgent problem, but I did resent writing notes rather than heading home to be with my family.

I can't believe that voice recognition technology can't make it possible for doctors to dictate notes while seeing patients. It could be done in a way that helped the patient to understand our thinking. From residency on I always wrote my notes with the assumption that the patient would read them. The discipline this imposed was useful. As an example, it helped me in relating to people with paranoia. I didn't write "Mr. Jones is paranoid and delusional," but rather "Mr. Jones believes extra-terrestrials have implanted a chip in his brain. He understands that I do not share this view. We discussed why I believe taking anti-psychotic medication would help him in his life..." 

I found that people with paranoia appreciated that I recognized the possibility that (in this example) extra-terrestrials might be causing mischief, but that I found this extremely unlikely. We could frame using medication as a hypothesis - "whether or not there is a chip in your brain, I believe that you will sleep better and be less afraid after a few weeks..." rather than as the equivalent of "you're crazy and I'm sane so you should do what I say..."

Writing notes with the patient in the office allowed for discussion of what should be said. With someone I'll call Mr. Jones, it had taken quite a bit of time to elicit a clear picture of how much alcohol he used and how alcohol might be affecting his mood and his physical health. I explained why I thought it was important for his primary care physician to know about his alcohol use. We sat together in front of the terminal to compose my note. Mr. Jones baulked at the word "alcoholism," but accepted "alcohol problem." This wasn't just a piece of collaborative writing and editing - it was an integral part of the treatment process.

It seems to me that the burgeoning of medical scribes is a workaround pseudosolution for a broken health care system. Adding a third party to the appointment is better than burning out our physicians - an all-too-frequent occurrence. But the real fix would be a combination of more realistic expectations for documentation and improved electronic health record technology. 

Nuka & Organizational Ethics

Yesterday morning an email with the subject heading: "Strong Patient-Provider Relationships Drive Healthier Outcomes" appeared in my in-basket.  I might have thought - "ho hum, been there/know that" and deleted the message, except that it came from the Harvard Business Review. I was curious. What made business folks interested in a topic that every seasoned primary care clinician has known about for years?

It turned out that the authors have been doing  what business schools do so well - studying exemplary primary care systems as a basis for developing teaching cases. What struck me in the Business School findings was that the outstanding organizations they were reporting on had not simply preached about the importance of strong clinician-patient relationships: they had engineered the organizations themselves to encourage and facilitate excellent relationships.

In our teaching of medical students and other health professionals we emphasize the values and behavior patterns of individuals. This is an important starting point for health care ethics. But as the discussion of the Southcentral Foundation in Alaska demonstrated, a properly designed and managed organization can point clinicians in the right direction and make it easier for us to get there.

In the 1990s, Southcentral Foundation, well-described in an excellent article by Katherine Gottlieb, president and CEO, looked into its heart and reconceptualized its mission as being about relationships:

Alaska Native leadership recognized that the core product is something bigger than just tests, diagnoses, pills and procedures. It is about human beings and relationships – messy, human, longitudinal, personal, trusting, informing, respecting and accountable relationships...If a practice or organization really believes that the core product is relationship – that is, partnering to make a difference over time – a fundamental change is required. Where money and time are spent, what work staff members do, who is hired and how staff are trained – every action is intentionally designed to optimize relationships.

Southcentral calls its approach the "Nuka System of Care." "Nuka" is a native Alaskan word meaning "big living things." Gottlieb describes four key ideas driving the "big living" Nuka system:

1. "The customer drives everything." Southcentral thinks of those it serves as "customer/owners." The SCF approach goes well-beyond the current buzzword - "patient centered care" - which often connotes an empathic attitude but not redesign of services to meet patient preferences.
2. "All customers deserve to have a health care team they know and trust." It's easy to endorse this principle. What distinguishes SCF is the actions they take to facilitate trusting relationships, not simply their words. Words are cheap. Making the sentiment a reality takes sustained work over time.
3. "Customers should face no barriers when seeking care." 75-80% of the appointments are for same-day care. That says it all!
4. "Staff members and supporting infrastructure are vital to success." Again, what counts is well planned, consistent devotion to this aim at all levels of the organization.

The crucial insight arising from the Harvard Business School project, which is being conducted in collaboration with Center for Primary Care at Harvard Medical School, is that organizations are moral actors, just as individuals are. Strong clinical relationships promote trust and health. In a health system in which organizations play an ever increasing role, we need to focus on and strengthen the moral behavior or organizations as well as individuals.

[For readers who want to delve further into the concept of organizations as moral actors, see this article by my friend David Ozar, an early leader in thinking about the ethics of organizations.]

A Personal Experience with Medical Cost Containment

When I saw my primary care physician earlier this week he gave me a pep talk about scheduling the colonoscopy I'd been dawdling on doing. I decided it was time to follow his advice.

I had two reasons for being concerned about how much the colonoscopy would cost. First, from the self-centered perspective, my insurance includes a $1500 deductible, so I would be paying some or all of the cost on my own nickel. Second, from the perspective of a concerned citizen, I believe we all have a moral responsibility to (a) take care of our health (b) at the lowest cost to collective insurance funds. If the test cost more than my deductible my fellow insurees will be paying for my charges, and I should consider their financial well-being just as I consider my own.

I'd recently received notice that my self-insured employer offers a service called SaveOn, provided by Tandem Care, a five year old New Hampshire company that gives patients comparative cost information on services within their insurance network. If we're already scheduled to go to a "low cost" provider, we get a $10 reward simply for having called the SaveOn program. If we're scheduled for a high cost provider and choose to go to a lower cost provider instead, we get a reward of $25 to $75, depending on the cost of the procedure.

I receive my care from Harvard Vanguard Medical Associates, a large non-profit, multi-specialty group practice in Massachusetts. I preferred to have the colonoscopy done at the HVMA facility. Doing so would ensure the best coordination of information flow and followup. But suppose an alternative of good enough quality cost $500 less? Would coordination be worth that much additional cost to me?

I called the SaveOn service with some trepidation. The service itself was excellent. A nurse answered my call after one ring. She took my information efficiently and called me back within 15 minutes. Happily, the site I'd been referred to within the group practice was considered a "low cost provider." That spared me the challenge of (a) deciding how much additional cost continuity of care was worth to me and (b) chiding my medical team for being "high cost." The SaveOn nurse told me I'd receive a $10 check after the procedure was done.

Within the cockamamie U.S. health "system," Tandem Care/SaveOn are providing a valuable service. In our consumer role it helps us take care of ourselves at a lower cost. Even if our insurance does not include a deductible - something that is increasingly rare nowadays - the reward for choosing a lower cost provider is enough to matter to us. In our citizen role the program helps us reduce overall costs to the body politic, and, at the same time, educates us to think about costs in health care as we do in virtually every other aspect of our lives.

For decades, we in the U.S. have been searching desperately for ways to make health care less costly. None of the gimmicks we try will work unless we citizens embrace the effort. If we had a national system with a budget paid for via our taxes the way most other developed countries do we'd be invested in getting the most bang for our bucks. But in the highly fragmented "system" we have, the relationship between overall costs and the choices we make as individuals is largely invisible to us. My little experience with SaveOn shows how smart systems can help to make us less stupid about costs!

No Treatment as the Treatment of Choice

In the October 3 issue of JAMA, Allen Detsky and Amol Verma offered "A New Model for Medical Education: Celebrating Restraint." Restraint in medical practice is decidedly un-American. Not surprisingly, the authors are Canadian!

Detsky and Verma are concerned with both quality and cost. Here's the essence of their argument:

...we suggest complementing health care cost control initiatives by transforming the current approach used in medical education that primarily rewards meticulousness of clinical investigation to one that also celebrates appropriate restraint...Clinical teachers who are role models could embrace a new approach. They could emphasize teaching restraint, both to improve health care quality and to acknowledge the professional duty of resource stewardship.

The worship of obscure diagnoses is a longstanding part of US medical culture. It's exemplified by the "zebra joke," which I first heard as a medical student in the early 1960s:

Two senior physicians are walking alongside a wall. On the other side they hear galloping foot beats. One says to the other - "what's that?" His colleague replies "it must be a zebra."

Sometimes the search for zebras turns up a real striped quadruped. When that happens it makes a heroic story. More typically the search involves "zebra tests" which turn up "incidentalomas," abnormal findings that have no clinical significance, but which elicit further tests. Apart from the wasteful expenditures the search for zebras can produce, the process can create harmful complications - the side effects of unneeded biopsies or even surgeries, excessive radiation exposure, and more.

I'm a skeptic about medical maximalism and the search for zebras. In the early 1970s, supervising psychiatry residents who had been inculcated in concept of the 50 minute hour, I sometimes had dialogues like the following with my supervisees:

Me: What kind of treatment do you want to prescribe for the patient we've been discussing?
Resident: Twice a week intensive psychotherapy.
Me: How long would each session be, and how long would you want the treatment to last?
Resident: This seems kind of silly, but let's say 50 minutes per session for three years.
Me: That would be approximately 270 50 minute sessions. Do you think we could attain the same outcome if each session was 48 minutes and we had 85 sessions per year instead of 90.
Resident: This really does seem silly. But if you insist on the question, I suppose we could attain the same outcome or close to it.
Me: So even before we look at the techniques psychoanalysts like Peter Sifneos have developed for briefer treatment, we've reduced the cost by 10% without meaningful loss of quality. Not bad!

In 1981 I felt I'd encountered kindred spirits, when Allen Frances, who I've posted about before, and John Clarkin wrote "No Treatment as the Prescription of Choice." They weren't nihilists about treatment, but they correctly noted that psychiatric consultants almost always recommended treatment for the folks they evaluated. Frances and Clarkin suggested a typology of patients who would do better without treatment - patients who were not likely to benefit and for whom treatment might inadvertently be harmful.

As a student, some of the old timers I learned from taught me about the curative impact of "tincture of time." Some conditions will get better on their own if the patient is approached in an optimistic spirit and is willing to allow some time to pass. In non-acute situations where it's not clear what is going on, applying "tincture of time" can be a good diagnostic and therapeutic approach.

Sometimes patients push for this kind of low-interventionist approach. Many years ago I saw a young man who had briefly been hospitalized for what looked like an episode of schizophrenia. I suggested that we start an antipsychotic medication. He objected. He was convinced that the episode came from a recreational drug he'd used. We agreed to follow him - initially weekly, but ultimately every month or two. As best we could tell over the course of two years, he was right. We were both happy. With another patient whose history convinced me that she had bipolar illness, she made a similar argument and refused medication. I told her that I wasn't a worrier, but I was worried about her. I hoped I was wrong and she was right. We followed her status and got to know each other. Unfortunately, as I'd feared, she was wrong - a recurrent episode convinced her of that. But it worked better that she was convinced by her own experience, not simply by yielding to medical authority.

Detsky and Verma come across as wise clinicians. I'm on board with their counsel. I hope others join in. The model they propose would promote a salutary change in US medical culture.

Is it OK for GP's to have sex with their patients?

For anyone interested in the ethics of doctor-patient sex and the relationship between ethics and law, the recent 5-1 decision of the Supreme Court of Pennsylvania in Thierfelder v Wolfert makes fascinating reading. (If the details interest you, make sure to read Justice Todd's dissent - in my view she got the issue right!)

In 1996 David and Joanne Thierfelder became patients of Dr. Irwin Wolfert, a family physician. He treated them both for conditions that included low libido. In 2002 Ms. Thierfelder told Dr. Wolfert that he had "cured" her problems and was her "hero." They began a sexual relationship that lasted for a year. She became more anxious and depressed and finally ended the relationship in January 2003. She told her husband about the affair two months later, and together they brought malpractice action against Dr. Wolfert.

Dr. Wolfert argued that as a general practitioner he should not be held to the same standard as psychiatrists, for whom a clear duty not to have sexual involvement with patients had been recognized. The court accepted this view on the basis that psychiatrists are trained to recognize and deal with "transference" (reacting to current relationships, like Ms. Thierfelder's with Dr. Wolfert, in terms of past relationships). GPs, the court concluded, should not be held to the same duty of care, since they are not trained to do treatment based on dealing with transference. If they were held to this standard it would discourage them from providing mental health counseling to their patients, which would be a bad societal outcome.

The majority made clear that the fact that Dr. Wolfert's actions were seen as unethical within the medical profession did not mean that he had violated legally enforceable duty. The Pennsylvania Board of Medicine had in fact sanctioned Dr. Wolfert before the Supreme Court heard the case. (It ordered a three year suspension of his license, but stayed the suspension under terms that included professional development activities, 550 hours of community service, and a fine.)

The majority cited Korper v Weinstein, a case in my home state of Massachusetts. Dr. Weinstein had done a breast biopsy on Ms. Korper at the Harvard University Health Service. (It was benign.) After completing her followup care, the two had lunch together, and a consensual sexual relationship ensued. Dr. Weinstein was not involved in a further treatment relationship. When he ended the relationship two years later she brought action against him. The court opined:

Any trust and confidence she placed in the defendant as a person...even augmented by circumstances that made her emotionally dependent on him, did not create a fiduciary duty in the defendant to prevent the personal relationship that developed consensually between them, especially where he terminated the physician-patient relationship as soon as the personal relationship began.

In her dissent, Dr. Todd concluded that (a) general practitioners frequently provide mental health services and are allowed to do so by their licenses and (b) sexual relations with patients is explicitly prohibited by the medical community, with (c) the result that she had "no hesitation in concluding that general practice physicians who provide mental health disorders to patients have a duty to abstain from sexual relations with their patients...and that these physicians may be potentially liable in professional negligence actions for any harm to their patients - patients they pledged to take no action to harm - as a result of engaging in such conduct" (page 18 in the dissent).

I believe Dr. Todd, though outnumbered 5 to 1, was correct. It's widely known that sexual relationships with patients being treated for mental health conditions have high potential for causing harm. Treating mental health conditions is within the purview of general practitioners. The ethical standards of the profession are well-known to prohibit sexual relationships with current patients. It's hard to see why the allegation of malpractice should not have been judged on the basis of its facts, rather than being prevented from coming to trial. The facts would have shown that Dr. Wolfert breached a duty. But it would have to be further shown that this had directly led to damage to Ms. Thierfelder.

The majority did not argue that it's ethically acceptable for general practitioners to have a sexual relationship with patients they are treating for mental health conditions. But in my view their conclusion that seeing a duty not to do so sets too high a standard is insulting to GPs. Being sued for malpractice is every physician's nightmare, but implying that GPs don't have enough understanding of human psychology and the treatment process to know that sexual relations and mental health treatment don't go together is demeaning to their competence and maturity.

Jekyll and Hyde in Medical Practice

 I've written many times about how doctors who exploit patients sexually can provide excellent care to and be idolized by their other patients. I just learned from my friend Dr. Brian Hurwitz that the same can be true for doctors who murder their patients!

I first met Brian when I spent three months at the King's College London Centre for Medical Law and Ethics in 1992. He was doing an MA at the Centre, and allowed me to spend a fascinating day with him in his general practice surgery. For the past ten years he's been D'Oyly Carte Professor of Medicine and the Arts and Director of the Centre for the Humanities and Health at King's College.

Brian sent me a not-yet-published chapter he's written about Dr. Harold Shipman, the GP who was ultimately found to have been a serial killer who murdered more than 250 of his patients. The chapter included this remarkable quote from the son of one of the patients Dr. Shipman was found to have murdered:

I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.

Shipman never admitted his guilt and refused to talk with psychiatrists, as did his surviving family. He committed suicide in prison in 2004. Although many colleagues and members of the community where he practiced noted strange occurrences in Dr. Shipman's practice, no one was prepared to draw the retrospectively obvious conclusion - a trusted, beloved physician was killing his  patients!

I think the best comment about people like Shipman comes from "The Shadow," an old time radio detective whose adventures I followed as a child. (The Shadow had the gift of invisibility.)

Who knows what evil lurks in the hearts of men? The Shadow knows!

Medical Ethics and Blaming the Victim

A article on female genital pain got me thinking about one of my pet peeves in medicine – blaming the victim.

The condition – vulvodynia - was often blamed on the woman, as in saying “it’s a fear of sex,” “it’s in your head,” or “it’s classical hysteria.” Now it turns out that identifiable, but subtle, anatomical factors appear to cause it. Treatment has improved. Blame is diminishing.

I first heard clinical teachers say things like “the patient failed chemotherapy so we decided to try…” when I was in medical school. The people saying this were typically devoted caretakers. The implication that the treatment didn’t work because the patient “failed” was rooted in health jargon, not their hearts.

But the “patient failed” phrase isn’t just a piece of sloppy grammar. It shows something about the culture of health care, at least in the U.S.

The good thing the phrase reflects is just how responsible caretakers feel for patients. If the treatment doesn’t work we tend to feel guilty, even when we’ve done the best that can be done.

The bad thing the phrase reflects is our collective cowardice. Instead of acknowledging the sad fact that medicine, while powerful, is limited, we blame the patient. Medicine didn’t fail. The patient did.

Looking into what has been written about blaming the victim I came upon this moving 2004 exchange in The Oncologist:

TO THE EDITOR:

As a lung cancer patient and advocate, I have been enormously heartened the past few months with the recent discovery of the epidermal growth factor receptor (EGFR) mutation and its immediate and long-term implications for improved treatment and extended survival for people with lung and other cancers.

In reading about the promise and potential of this new finding in Dr. Bruce Chabner’s editorial, "The Miracle of Iressa" [1], I was jolted from my excitement by one particular phrase. Dr. Chabner stated that "...patients will continue to receive Iressa when they fail chemotherapy." When they fail chemotherapy? Have the patients really "failed" when chemotherapy drugs do not work? Of course they haven’t. So why use a phrase that implies blame?

Dr. Chabner, whom I know to be an excellent and sensitive oncologist, is far from alone in expressing the failure of cancer treatment in a less than patient-friendly way. This unfortunate convention is used in the medical literature, at professional conferences, and not surprisingly, in the clinic. It is common for oncologists to tell patients that they "failed drug X." By telling patients they failed to respond to treatment, doctors may increase the guilt that many patients already struggle with as a result of their cancer diagnoses. For others, like me, it becomes an annoying refrain. At minimum, it puts emotional distance between doctor and patient and undermines the doctor-patient relationship. Just imagine under the same circumstances if the patient said to the doctor, "You failed to give me the right drug to treat my cancer." The question isn’t who failed, but what failed.

I ask Dr. Chabner and The Oncologist readers to be mindful of the language used when discussing the failure of therapies in cancer patients. Something as simple as, "Drug X didn’t work for you, maybe this one will," is one example. There are numerous ways to express the failure of cancer treatment without failing the patient, too.Sincerely,

Karen Parles, MLS
Editor, www.LungCancerOnline.org
Executive Director, Lung Cancer Online Foundation

FROM THE EDITOR:

Our reader, Karen Parles, points out an important, and unfortunate, mistaken use of the word "failure" in my recent editorial, describing a patient’s lack of response to Iressa therapy [1]. The failure of treatment is not the patient’s fault in any regard. The fault lies with the current state of science, and our understanding of the disease. The convenient phrase "failure," so often used in our society to describe an unhappy outcome beyond the control of the individual, has no place in the context of unsuccessful treatment of a disease such as cancer. I apologize for myself and my colleagues, who so often confuse outcome with intent, and I thank Karen Parles for raising our consciousness to the all-important use and impact of our words.

I assure her that I have expunged "that phrase" from my vernacular ... and I urge my colleagues to do likewise.

Bruce Chabner, M.D.
Editor-in-Chief, The Oncologist
Clinical Director, Massachusetts General Hospital Cancer Center.

Hats off to Dr. Chabner! I hope our colleagues follow the example he's set.

The Role of Will Power in Medical Care

I've made a belated New Year's resolution - to read "Willpower: Rediscovering the Greatest Human Strength" - a book about how to make effective resolutions. I made my resolution while reading an article about it in a recent New York Times.

The basic ideas aren't rocket science. But they're practical, well articulated, and grounded in research:

1. Set a single clear goal - not an overwhelming program of total self-modification all at once.
2. Apply a strategic plan. The classic example is Odysseus. When he wanted to hear the sirens sing but to resist their charms he didn't just rely on will power - he had himself tied to the mast, and had his sailors put wax in their ears so they (a) could hear the sirens and (b) couldn't hear his demand to have the ropes taken off.
3. Develop a support team. Years ago a patient of mine described, with pleasure, how when he whined about stress in his AA group the group chanted, in unison, but with affection - "Tough Shit! Don't Drink!" Now, with the burgeoning of web supports, we can supplement the support process with social networking tools.
4. Monitor progress. Over the years there's been debate, for example, as to whether checking weight daily discourages would-be reducers, but evidence now suggests that for most people, regular feedback helps.
5. Don't overreact to lapses. The quality improvement mantra - "every defect is a treasure" - applies to managing ourselves. Falling off the wagon from time to time is almost inevitable. The key is to (a) learn what we can from the episode and (b) not interpret a lapse as a global defeat.
6. One day/hour/minute at a time. Years ago I asked a substance abuse counsellor colleague to join me and a patient who was struggling with alcoholism. She pointed out that if focusing on a day was too much, changing the time scale to "one hour at a time" or even "one minute at a time" could sometimes strengthen our capacity for control.
7. Give frequent rewards. Just focusing on control can be grim and joyless. Most of us need pleasurable payoffs for our efforts as well. The NYT article described a scale that will automatically make donations to a charity if we're meeting our weight target!

I applied most of these precepts in my work with patients suffering from chronic psychiatric conditions, but in a less systematic way than I would if I were starting over. The biggest change for patients and clinicians is the availability of all kinds of web-based tools that can supplement these ancient psychological insights. Scales can track and graph our weight. Pedometers count our steps. Social networking applications orchestrate our support group, supplement it when it needs augmentation, or replaces it altogether with responses we can design.

I ended my clinical practice four years ago, but at the turn of the year I received a series of communications from former patients. One asked me to buff up a voice mail message that has been a useful booster shot over time. Another asked for guidance about significant health-relevant New Year's resolutions. A third simply wanted to report on the status of the major areas we'd worked on for many years.

Many years ago, a patient whose well-being required strengthened assertiveness had identified the second serve in tennis as a valuable monitoring tool. This person's skills were excellent, but fear of double faulting led to a bloopy second serve. Some time after we ended treatment I was happy to receive a three word message: "Second serve humming!"

To care for patients with chronic conditions, we clinicians need to orchestrate the balance of patient self-management and the support and guidance we provide. This is a fascinating aspect of the art of medicine. It touches on the eternal philosophical conundrum of free will vs determinism. When we get the balance right it's usually clear and always satisfying.