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ÒDaddy, can I stop being worried now?ÓText from my daughter “Should I worry about Ebola”

Text back from me “Are you considering moving to west Africa?”

My first class in medical school was in our freshman auditorium. The Dean (or someone who looked old, must have been about 50) came up to the podium and said: “This is a great time to be a doctor. When I was sitting in your seat, the person at the podium had us look to our left and to our right and then said “Of the three of you, one will not be here by the end of the 4 years because of tuberculosis.” You, fortunately, do not have to worry about that.”

Tuberculosis, I thought. What the heck is that and of course I’m going to worry about it (I remain uninfected to date).

When I was a third year medical student, AIDS hit New Orleans. I remember being on an infectious disease rotation and going into the emergency room where an emaciated man with blue tumors (Kaposi’s sarcoma, I now know) all over his body was in “isolation.” The isolation, in this case, was no one placed in the bed next to him (it was an open bay ward) and yellow CAUTION tape placed across the entrance to the bay where he had been placed. My attending, who remains a role model to me, tore the tape down and said “Whatever you THINK you are doing with this tape it is accomplishing nothing except dehumanizing this person who is ill.” The patient died. None of us on the health care team became ill.

Ebola virus is the latest illness to capture the public’s attention. Confined to west Africa unless those ill are transported, it has claimed the lives of 1427 people, about 10% of whom are health workers. Apparently my daughter’s text was prompted by the news reports associated with the transport of the American physician to Atlanta. Spurred on by movies like “Outbreak” and breathless news reports from Dakar by Ofeibea Quist-Arcton (pronunciation found here), folks here are concerned WAY out of proportion to what they should be (unless their neighbors are west African health care workers who just got back and appear mighty sick). Americans should worry about a lot of things: their diet, their lack of physical activity, their use of tobacco and guns. “Ebola” should be appear on the list below “death from bee sting” (100 Americans annually)

Turns out that Ebola is big news because people tend to make many decisions based on feeling and belief rather than based on a calculated risk assessment.  Psychologists have coined the term “Dread Factor” for the combination of

  • perceived lack of control,
  • catastrophic potential,
  • fatal consequences, and
  • the inequitable distribution of risks and benefits.

Ebola (0 deaths in America) hits the sweet spot. We humans worry more about what we can’t control, especially if the long term consequences are unknown, the potential risk is believed to be high, and there is nothing we can do to mitigate it. In “Perception of Risk Posed by Extreme Events” Peter Slovic points out that, probably as a result of eons of programming, we worry excessively about things such as a satellite falling out of the sky and hitting us (0 human deaths so far) and worry very little about backyard swimming pools (10 Americans die A DAY). Makes setting public health policy difficult. If you don’t believe me, look at the backlash regarding Michelle Obama’s healthy children initiative to reduce obesity (1375 American deaths A DAY).

Fine, you say, I know that smoking is unhealthy. What I don’t want to do is die from Ebola.What can I do? Turns out, a lot.

As a health care consumer, make your concerns known. If not dying from Ebola is the most important thing to you, let your doctor know. He or she might suggest something simple, like avoiding travel to the remote villages of west Africa. Meanwhile, take some time to understand why worrying about other elements of your physical well-being might be more useful in the long run.

As a health care professional, don’t just dismiss your patients’ concerns. Listen to them and provide information about why these fears might be unfounded. By the same token, don’t take advantage of your patients’ irrational fears. Providing excessive testing is expensive and often is less helpful than a frank discussion on risks.

We humans react instinctively (on feelings) and intellectually (based on rules and empirical evidence). We often make decisions based on feelings (I am unsafe and need a gun) that run counter to evidence (a person with a gun is 22 times more likely to kill a family member than a bad guy).

As physicians, much of what we do (and don’t do) affects health in a limited fashion. Perhaps we need to get better at helping people to overcome their own barriers to achieving health instead of offering tests for scary things we know aren’t going to happen because “the patients want them.”

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What kind of bed side manner do you want your doctor to have? I have to teach a class tomorrow in “doctor” attitudes to 1st year medical students, so all I should  have to do is poll my family, friends and neighbors, put together a list of do’s and don’ts on a handout, project it on a slide show, and walk away to applause. Would that it were that easy.

Empathy, the ability to see and understand another person’s point-of-view and share the associated feelings, is an important trait for doctors to have. Teaching this is hard work. I was struck by an interview between Krista Tipett and Frances Kissling on the program On Being this morning while coming back from rounding in the hospital. Ms Kissling, a Catholic pro-choice advocate,  was asked why she thought homosexuality was being rapidly accepted in our society while the abortion fight was continuing. She answered that, in part, many people had trouble developing empathy for a person seeking to terminate a pregnancy:

In the case of abortion, you are dealing always with the destruction of life. It may not be life that is personal; it may not be of the highest value. It doesn’t, in my opinion, have rights, but I think particularly as time has passed, we are all striving to create a world, where most of us are striving to create a world in which life in all its forms is fostered and nurtured. And abortion in some ways goes against that. So if you have a kind of absolutism, you know, if you don’t contextualize it and you just look at it even if you’re not looking at it as murder or killing, you know, in the grossest terms, but simply as the interruption of life processes that we would prefer under other circumstances go forward, it always has a dimension of loss to it. …I would say is the other difference is that abortion is something that enters a person’s life at a specific moment and leaves it very quickly. … And for most people, most of us don’t want to think about abortion, and even women who have abortions don’t want to think about abortion all of the time. They don’t make — they don’t want to make abortion, for the most part, a defining part of who they are and their identity.

What I would like is to have our medical students able to demonstrate empathy with a patient who is seeking their counsel and guidance, even though they may not personally approve of the choices at hand. Why is this hard? Training for health professionals occurs at times of stress for both the learner and the patient. We have traditionally learned how to enter into such a relationship by being placed in clinical situations and reacting. Here is a description of one learner’s experience:

At the end of his third year, Chatterjee describes what he witnessed:

“I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips.

“I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident.

“I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night.

“I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

Medical students very quickly develop a “us against them” mentality. Rather than a nuanced world view where suffering is placed in context and healing takes into account the whole person, the “extraordinary becomes the mundane”

They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor

It is now believed that preparing students for this experience leads to less depersonalization and more empathy than the traditional training methods. Empathetic care givers should lead to exchanges between doctors and patients based on mutual understanding. There is even a recent study proving this.

In the study, groups of established physician-teachers from five different academic medical centers met at least twice a month. During the meetings, the doctors either practiced skills designed to enhance compassion, or reflected on their own work through discussion and narrative writing.

After 18 months, residents and medical students at each of the medical centers evaluated the physician-teachers, as well as a “control group” of faculty, on such matters as listening carefully and connecting with others, teaching communication and relationship-building skills, and inspiring the adoption of caring attitudes toward patients.

At all five sites, those physician-teachers who participated in the program consistently outscored the controls.

We are just beginning on this journey here at South Alabama. The exercise I do tomorrow will use the movie The Doctor to demonstrate empathy. Over the two years we work with the class to get them to understand what they are going to see as they move into their clinical experience and give them some tools to cope. Even more helpful would be formal groups that meet during the clinical years (known as Balint Groups) to help learners understand they are not alone and to guide them as they develop their own nuanced viewpoints, but I’m afraid that would be asking too much.

We have a professionalism exercise within the Health Sciences division at the University of South Alabama of which I play a small part. This exercise places students from nursing, allied health, pharmacy, and medicine together in a room and they are given a case scenario with no correct answer but one in which a difficult decision will almost certainly need to be made by the treating clinician. The case that I want to bring to your attention today is one not involving a breast mass. In this case, the patient reports that she has a lot of fear and concern about cancer and requests that her clinician order a mammogram to assuage her fears. The only problem is that her insurance will not pay for a “screening” mammogram, only for one in which a breast mass is detected on physical exam. In the educational exercise, students are assigned to either defend “lying” about a mass to get a mammogram paid for or “denying” the patient access to a mammogram paid for by her insurance. At the end of the exercise, the students vote on what they would do (mostly stick it to the insurance company) and then we all go home to wonder what we will really do when the time comes.

Susan Reverby has a new book out about the Tuskegee Syphilis Study and she happened to be in Mobile this past week to lecture about it. The study itself was a longitudinal prospective study in which African-American men from rural Alabama who had been identified as having latent syphilis during a previous study and were not treated adequately (because there were questions about the need for treatment and no money for treating these gentlemen) were identified. They were then followed over time to see what happened to them by the Public Health Service. The Public Health Service attempted, over the intervening 40 years, to withhold or deny treatment to the subjects even after penicillin was in widespread use. The study was made public in 1972 and created a scandal ultimately resulting in an apology offered by President Clinton to the survivors on behalf of the United States in 1997. The study has had a lasting impact on the black community with a profound impact on HIV/AIDS detection and treatment. In Bad Blood, another book about the Study, it is reported that community workers report mistrust of public health institutions within the African-American community. Alpha Thomas of the Dallas Urban League testified before the National Commission on AIDS: “So many African-American people I work with do not trust hospitals or any of the other community health care service providers because of that Tuskegee Experiment”

What does this have to do with health care reform and people doing what they can to get tests paid for? Dr Reverby’s review of the medical records, the writings and oral histories of the time and subsequently by the “subjects” and the investigators has led her to another conclusion as well. She has found that “the men thought of themselves as patients obtaining needed medical care for what was known as “bad blood” from the government’s doctors. The PHS physicians never told these men they were actually research subjects being followed in a “no treatment” study. Instead, the researchers explained that the aspirins, tonics, and diagnostic spinal taps given were “free treatment.” In a county with only 16 doctors whose prices the men could rarely afford, a government program of free care enticed them. The study’s nurse kept visiting the men’s homes and helping them to get medical care for other ills. The study’s subjects and controls were also promised money for decent burials in exchange for the use of their bodies for autopsy after their deaths.” She also believes it is likely that many of the “investigators” such as Dr Reginald James and Nurse Rivers may have helped to get these gentlemen needed care under the guise of the “study.”

 Her findings are that “these men living in rural Alabama came forward for treatment not because they were uneducated and easily duped by their government, but because they needed health care for themselves and their families. They (as with increasing numbers of Americans today)  had no real access to the medical care they required, could not pay for what was available, and had to find it where possible.

She and I both feel that this study is as much an object lesson on the lengths people will go and the harm they will expose themselves to as they seek out adequate health care as it is a lesson in the ethics of research. When President Obama argues for affordable and accountable health care, it is in the hopes of creating a system which will keep people from having to sell their health in order to afford health care. When medical bills account for 62% of bankruptcies, it is clear that people will endanger their long-term physical and financial wellbeing to acquire good health. Government almost certainly should play a role in helping its citizens obtain and keep quality health care (as even Bill Kristol admits it can do).

I am teaching a class tomorrow entitled “Health Care Reform” to the first year medical students. I pulled out my slides from last year (January, had just come back from DC, was convinced that we would have something on the President’s desk by July) and made some changes. The good news was that I only had to add a couple of pieces of information to the talk. The bad news is that we don’t have change yet, but it may be closer than we think.

Why don’t we yet have health care reform? There was an article in the New Yorker  several years back that did a very nice job of describing the concept of moral hazard and why there is a policy dispute about health care as a social good. Gladwell points out that many feel (most fall on the “conservative” end of the spectrum although not all) that the uninsured who pay cash rarely have no health care expenses and  the very wealthy spend a lot on health care. In a market system those paying cash are paying closest to the true  value so it must be that those who are wealthy view health care as a luxury item. It would not be morally right to give all Americans access to this luxury.

The RAND corporation performed an experiment in the 1990s to see whether this would be the case. They found:

In general, the reduction in services induced by cost sharing had no adverse effect on participants’ health. However, there were exceptions. The poorest and sickest 6 percent of the sample at the start of the experiment had better outcomes under the free plan for 4 of the 30 conditions measured. Specifically,

  • Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension.
  • Free care marginally improved vision for the poorest patients.
  • Free care also increased the likelihood among the poorest patients of receiving needed dental care.
  • Serious symptoms were less prevalent for poorer people on the free plan.
  • Cost sharing also had some beneficial effects. Participants in cost sharing plans worried less about their health and had fewer restricted-activity days (including time spent in seeking medical care).

In addition,  the experiment examined whether shouldering more of their own health care costs leads people to take better care of themselves. It did not. Risky behaviors were not affected — rates of smoking and obesity, for instance, did not change.

(An article in this week’s New England Journal of Medicine finds that increased cost sharing on the outpatient side in Medicare patients leads to delayed care and more hospital care as well. People tend to be penny wise and pound foolish when it comes to their health. A lesson learned in the 1930s and one of the reason that a group of physicians founded Blue Cross)

Mr Gladwell points out that the real objection to universal coverage, from a policy standpoint, is that some people (those with disease) will consume more resources than they will have been predicted to pay for. In other words, the objection is that resources are redistributed  from those who are healthy to those who are unhealthy. Susan Channick expanded this in an article on why we will never have a single payer system in this country. She lists the reasons as inertia, path dependence, the expense of the Medicare program, the American belief in looking to the private sector for solutions to even large social problems, the fear of big government coupled with the belief that government is the problem rather than the solution, the political preference for incrementalism over fundamental change, and cultural beliefs such as the belief that while all Americans enjoy equality of opportunity, only those able to capitalize on the opportunity are entitled to enjoy its fruits. This last one is the most profound, as the implication is that we Americans who are healthy deserve to be healthy and owe nothing to our unhealthy neighbors.

In an article in the New England Journal, Thomas Murray points out that the Judeo-Christian tradition as articulated in the Bible includes the concept of “stewardship.”  He says that “Landowners are instructed in Leviticus: “When you reap the harvest of your land, you shall not reap to the very edges of your field, or gather the gleanings of your harvest; you shall leave them for the poor and the alien.” The obligation is not limitless: the landowner does not have to prepare a meal for the “poor and the alien,” does not have to surrender the entire crop, and should protect the land to ensure that it remains productive. But when food is more than sufficient to feed all, allowing some people to starve is indecent and represents a failure to live up to universal moral duties.” Lets all try to live up to that standard.

Live a simple and a temperate life, that you may give all your powers to your profession. Medicine is a jealous mistress; she will be satisfied with no less. 

THAYER WS. OSLER THE TEACHER, IN OSLER AND OTHER PAPERS,  

One of my internal medicine attendings, Dr George Burch,  relayed this aphorism to us while we were in our first pre-clinical year at Tulane. The power of the medical education process is illustrated in the fact that I can still see myself in that auditorium watching this (seemingly very old) man offer this and the advice on how to counteract the siren call of medicine…”get a good book and sit under a tree and read.” 

Although we’d like to believe otherwise, Osler was correct. Being a doctor still entails a lot of study prior to completing training. Although the hours that are required in training for direct patient care are limited to 80 in a week, there is no limit to the amount of study time learners must put in to learn their craft. As a program director, I have tools that I use to assess student’s and resident’s medical knowledge and their ability to synthesize it into patient care. There is no substitute for study and preparation. 

Once out of training, physicians must maintain their clinical skills. They did so traditionally through meeting attendance, journal reading, and informally through conversations in the doctors’ lounge. Now things are more formalized with continuing education credits being offered for using the right tools to look up information regarding patient care, as well as our Board requiring us to take specialized instruction to maintain certification. 

All of this takes time. Internal Medicine specialists, when polled, reported spending about 3.3 hours per week on reading. The part of the evidence based practice incorporated into the new model of care in Family Medicine will require data input and physician and staff education. At this time, none of these efforts result in money into the physicians pocket (back to the mistress…) 

Why put up with it? Aside from the fact that it pays pretty well, I find that it really is an interesting way to spend a day. I get to work with people who occasionally want to be healthier. I get to learn about stuff in the news (and occasionally be in the news). Every now and again though, I pick up a good non-medical book and think about Dr Burch. 

   

 

 

 

I woke up to read the newspaper’s (how 1980’s) account of why American society should not support health care for all (and if you go to the comments you can see how Mr Goldberg’s supporters feel about their fellow Americans on other issues as well). I also read the newspaper’s accounts of deserving sick folks, the diseases that they became afflicted with due to no fault of their own (peripartum cardiomyopathy, non-Hodgkins lymphoma, post-traumatic stress disorder), their trials regarding maneuvering the health care delivery system, and the ability of the dysfunctional health care delivery system to allow the resilience of the human spirit to shine through. Since I don’t like to believe that the purpose of my life is to provide a path to sainthood for others, I choose not to dwell on these things today.

Instead, I am thankful for my health and that of my family. I am thankful that we have had the privilege of living and raising a family in the same neighborhood (with many of the same neighbors) for the past 20 years. I am thankful we have had the responsibility of maintaining a house in Mobile’s historic district for those 20 years as well. Professionally, I am blessed to have been a part in the training of over 100 Family Medicine residents and countless medical students. I have also been blessed to have been a part of my patient’s lives for 20 years as well and have helped them both to maintain their health and navigate this bizarre sytem when their illness requires it.

I am also thankful that I have the opportunity to yell at the newspaper every morning with my coffee…

01carey600It was my hope that by this time we would have help from the feds to enhance primary care training, changes in residency funding to direct money to primary care departments, and management fees which would help us to pay for the care we deliver to our 750 diabetic patients among other things. Instead, we are in the middle of what appears to be a rather mean-spirited discussion regarding the age-old question of just who is my brother’s keeper.This has gotten me to thinking about the problem of the commons

Garret Hardin described a scene in an English common pasture “Picture a pasture open to all. It is to be expected that each herdsman will try to keep as many cattle as possible on the commons.” He then describes his vision of what will happen if all are allowed access unchecked.  “Adding together the component partial utilities, the rational herdsman concludes that the only sensible course for him to pursue is to add another animal to his herd. And another; and another…. But this is the conclusion reached by each and every rational herdsman sharing a commons. Therein is the tragedy. Each man is locked into a system that compels him to increase his herd without limit–in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”

Garrett has since been somewhat discredited. It is not clear that the resources as they appeared limited were so in actuality. This seems to be, however, the fear of the Republicans with healthcare. They seem convinced (and I have to admit that there is some evidence to support this) that those who are now uninsured (and have no current access to the commons) once given access will consume unlimited resources. Interestingly, they feel like those who now receive Medicare are entitled to unlimited access to the health care commons…an interesting stance.

What is really interesting is that Ezekiel Emanuel has been accused of formulating “death panels” as a solution to the problem of the healthcare commons. What has articulated is a way out of this problem of the commons. He clearly believes (as do I) that a certain amount of the “health care commons”  should belong to all of us. To solve the problem of overuse, he suggests that we would have to select what is included in our “commons”. If we don’t want to be in a group that funds terminations for example, we don’t select that group. I would like to see this further articulated as it seems preferable over people who have no money for health care dying in the street to me.

Living on the coast can be hard but not as hard as it once was. While we were scrambling to make sure that all of the prescriptions were updated for our patients who suffer from chronic illnesses and that folks that needed to evacuate were able to leave the city in time, I was reminded of what life was like in Mobile for physicians in an earlier time. Storms would not only bring wind and rain but the aftermath would bring Yellow Fever.  No one understood why Yellow Fever would appear but they all knew that it was related to stagnant water and that hurricanes brought large amounts of that. Some physicians, clergy, nurses, and other would stay while all of the general populace that could would leave the city. The “Can’t-get-away” club, in fact, formed as a support group for those who felt compelled to stay, often at their own peril.

It was not until the 1890’s that William Gorgas, a Mobile native, identified the relationship between the outbreaks of yellow fever and the presence of the Aides aegypti mosquitos, making possible the eradication of yellow fever. Today, the Mobile County Health Department maintains a very active mosquito control program and people flee from Mobile for a concern over flooding and a loss of creature comforts more often than for a fear of death from infectious disease. Physicians continue stay and care for the sick, exhibiting a strong sense of responsibility in the face of these storms and their aftermath.

In addition to teaching residents Family Medicine, I am the course director for the Fundamentals of Doctoring course that is in our first and second year student curriculum. I have the responsibility of offering instruction in “professionalism” to these proto-physicians. Preparing for the course this semester and participating in the instruction being offered over the past 3 weeks has allowed me to reflect on training in professionalism both at the medical student and the residency level.

1) Technical competence is expected: Earle Scarlett observes that the non-technical skills are important in part because the technical skills are expected. It is important to us as a profession to assure our patients a technical product that is predictable, safe and reliable.

2) We must not only say we subjugate our needs to the needs of others, but do it: All of us are almost guaranteed the opportunity to a good income when compared to others in our community and our country. Patients are glad for us to make this living but feel betrayed when they discover that decisions were made with the pocketbook. The medical home concept  will allow primary care docs to provide for the health of the community with the incentives aligned correctly.

3) We must be committed to continuing learning and excellence: Prior to the founding of Family Medicine as a specialty, it was assumed that physicians would maintain their knowledge base (or that medical knowledge was static upon completion of residency). Physicians did not share their dirty little secret that medical knowledge was not static but their learing was often dependant on visiting pharmaceutical representatives. Family Medicine was the first specialty to include a retesting of knowledge on a periodic basis. As a specialty we now have several different mechanisms that assure members are maintaining their knowledge and ablity to apply such knowledge.

4) Humanismis in: Time and again we are reminded of the need to communicate with patients at so many different levels. Learning how to communicate effectively and actively doing so leads to improved patient satisfaction, less litigation, and happier physicians. This communication is not limited to being a conversationalist but needs to include the values of honesty, integrety, caring, compassion, altruism, respect, and trustworthiness. These values are difficult (but not impossible) to teach and get little attention in medical schools.

5) We need to be hard on ourselves: The licensing bodies have begun to pay much more attention to performance in training, in part because of increasing evidence that problems in school predict subsequent problems. One of the hallmarks of a profession is accountability and self reflection. As a program director, I find it much easier to work with a resident who has a knowledge base deficit than one that is “non-cognitive”. I hope that the increased emphasis in medical school will lead to improvements at all levels of the profession.

The picture at the beginning of this post demonstrates a hallmark of medical education. It reflects that once trained, physicians see the world differently.

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