THE UNCARING DOCTOR — Weakness or Strength ?

Your favorite meta-physician here has been pondering the question of empathy and the medical community for decades.

In the past I wrote about the pre-med selection process which, I fear, selects for the more studious, analytical and compulsive among potential applicants.  The more intuitive, free-thinking and perhaps empathic young folk just don't make it through the process.

A fascinating article in Scientific American by Haque and Waytz http://www.scientificamerican.com/article.cfm?id=doctors-and-dehumanization-effect explores the science behind physician empathy.

In the study they perform  functional magnetic resonance imaging (fMRI) on physicians performing painful procedures on patients.  Compared to controls, physician's brains reveal less empathy.

The observations in the article imply that physicians begin medical school with a considerable amount of empathy ( ? evidence for this assertion) and gradually learn to suppress it during training.

They also speak of the balance between the empathic response and the cognitive, decision making aspects of a physician's role.

 As a self-proclaimed empathic physician I do understand the condundrum we face. 

Two days ago I saw a patient whose GYN found a rectal tumor.  Her fear was palpable and I knew she should not wait the usual interval for further testing.  I squeezed her into my busy schedule for colonoscopy the next day.  Unfortunately the findings were as we both feared and I had to tell her and her husband that I found a tumor in her rectum.  Clearly I could show empathy in the manner in which I spoke to them.  I lowered my voice, came close and touched their shoulders.  But I knew that what they needed to hear from me in the next moment was the "next move".  They needed direction because they were in a state of shock.  I tend to lead my patients in that manner.  I know they are immediately filled with fear and worry about the future so I attempt to  provide a strong direction for them.   I suggest that they focus only on what needs to be done next.  I do not believe it is in their best interest to confront a teary-eyed physician who only mirrors their own panic.  A physician who feels "too" emotionally connected with their patients may lose the impartial, objective cognitive approach which is needed at such times.  Yet without enough empathy they may allow a patient to suffer more than necessary.

 I had them schedule at CAT scan immediately and make an appointment to see a colo-rectal surgeon ASAP.  I have instructed my nurses to make sure she gets seen this week by a surgeon.  Because of my relationship with this particular surgical group and my insistence I know this will happen.

The point here is that empathy and detachment must co-exist in a dynamic balance.  I believe that there are physicians who do care but for reasons that may be subconscious or arising from their own fears are unable to transmit and communicate that concern to their patients.    In other words the perception of an uncaring, unfeeling physician may reflect an inability or unwillingness to commincate this precarious, nuanced and  balanced position.

It is a difficult but necessary aspect of medical practice.  Just as in other aspects of life there are individuals who are better at expressing feelings and empathy than others. 

 When it comes to life and death health issues the difficulty becomes exaggerated yet finding the correct balance is crucially important.

G U T B U G S , S T R E S S & I B S– A Possible Link

To begin to understand IBS and its multifactorial causes and treatments is to bring insight into the nature of the relationship between the mind and the body.

The relationship between emotional stress and IBS is easily recognized and acknowledged.  

One of the more recent explorations and contributions to understanding the nature and treatment of IBS is the role of the gut flora (known as the microbiota) of the intestinal tract.

The role of probiotics and selected antibiotics (xifaxan) in the treatment of some patients with IBS brings the "bug" contribution to the pathogenesis (cause) of IBS.

But how can we possibly link the two elements together into a cohesive understanding of IBS.  Is it possible that the gut flora modifies or modulates the effects of stress on the patient with IBS?

Preliminary investigations from the article in Scientific American by Robert Martone http://www.scientificamerican.com/article.cfm?id=the-neuroscience-of-gut may bring some insight into this relationship.

It seems, first of all, that gut microbes influence the development of the brain.

While human beings possess 30,000 genes we are inhabited by over 3 million bacterial genes.

Genes that influence anxiety have been identified and it is postulated that bacterial genes influence peptides secreted in the gut which also reach the central nervous system.

With this insight it is not difficult to speculate that the gut microflora influence how the gut nervous system modulates stress hormones  as well.

It seems as if the science is about to catch up with the clinical observations. 

This is nothing new in the history of medicine.

CONVERSATION WITH A RELIGIOUS MAN —

I am always fascinated by a conversation with a religious individual, especially someone who is clearly an intellectual. 

Recently, a dinner party of a dear friend I had the opportunity to converse with a highly intelligent, former editor of the religion department of a well known weekly news magazine. ( His name and magazine name are irrelevant to the discussion)

He is a devout Catholic and I was fascinated to hear his defense of his religious beliefs and even some of the Church's religious dogma.  When I asked him about the future of celibacy his response was something to the effect that the structure of the church would deteriorate if a married priest ever got divorced.  He followed this up by discussing how women priests would threaten the foundation of the church's structure as well.

I knew that I could never raise the notion that embracing sexuality was a spiritual point of view and perhaps more "holy" than abstinence.  This would challenge a core belief of his.  It would have been dismissed as wrong without further discussion.

When I mentioned that Episcopalians had abandoned celibacy he pointed to there declining membership.

Now I could have had a similar discussion with an Orthodox Jew as to whether maintaining a kosher life style was relevant in a modern age.  His response would have been similar.  Such basic tenents of belief are not grounds for examination.  They must be accepted as is.

My individual problem with fundamentalist religious beliefs is that I regard them all as historically devised and humanly derived.  

Now I do understand the value of a religious community, shared values, customs and rituals.  But I personally cannot justify belonging to such if I cannot firmly hold their precepts or prayers as valuable to me.

I do embrace a spiritual dimension to reality.  But my personal emphasis is on thoughts and deeds rather than formalities and ritual.  I found Bill Maher's film Religulous rather telling in its observations.

To me the spiritual path is about intention and actions.  Ritual, holidays, ceremonies can be useful but secondary. The challenge of life is to overcome adversity and maintain a loving attention to all that exists.  This is not easy especially in a world in which certain forces  threatens the very existence of those who do not share their religious identity. 

The balance between love and self-protection is itself powerfully challenging. 

  It would be useful if religious individuals of all persuasions would be open to dialogue with consideration of  opposing perspectives.  There may be some who are,  but despite their intellectual capabilities when it comes to religious beliefs I believe their minds have already been made up.

MISERY LOVES COMPANY — Live in NJ and Stay Alive

In the ultimate of ironies, living in New Jersey, if you are depressed, may actually keep you alive!

In a bizarre and disturbing article from the New York Times  by Tara Parker-Pope, it seems that countries and states with the highest degree of "happiness" also lead with the highest rates of suicide.

Apparently the contrast between the apparently joyful and the rest of humanity can actually make those on the lower end of the "happiness" quotient feel even worse about their conditions in life.

Scandinavian countries such as Denmark and Sweden score high on measures of happiness and life satisfaction also have increased rates of suicide.

For us Jerseyites the results are somehow comforting.  Despite bringing up the rear on happiness quotient,  number 47 (you can thank taxes, "The Jersey Shore" and Snooki for that) we are also  47th in suicide.  Yeah!

So here's another great reason to love our state.  They should include this in future promotional material. 

 Live in Jersey and live!

The G O D Series — Qutoes — # 3

**  God, "the still, small voice — 1 Kings 19:12

 

**  I have called God a struggling artist — Isaac Bahevis Singer, writer

 

**  We know when God is experienced, this is an event as real as an immediate sense perception or as one's own personality — Erwin Schrodinger, physicist

 

**  To invoke God as the blanket explanation of the unexplained is to make God the friend of ignorance.  If God is to be found, it must surely be through what we discover about the world not what we fail to discover — Paul Davies, physicist

BACTERIA RULE !! — The Human Petri Dish / Microbiota

Bacteria have always had bad press.  They have  been deemed the cause of disease, plagues, mass destruction.  And to be sure certain bacteria can be the cause of much disease and human suffering.

But what is rarely appreciated is how intimately connected each one of us is with bacteria.  These are the lowly one celled creatures who do not even possess a cell nucleus.  They are known as prokaryocytes vs eukaryoctes ( who do posses a cell nucleus).

Yet we now understand that our relationship with them is mutually beneficial and necessary.  While the average human being is composed of 10 trillion cells.  Our bodies are colonized by 100 trillion bacteria. http://www.nytimes.com/2011/04/21/science/21gut.html?hp 

They populate our intestinal tract in such massive numbers that our stool is predominately bacteria.  They coat our skin to such a degree that if we could only visualize bacteria, we would still retain our entire physical form and body structure.

They process food products, produce vitamins, metabolize what we ingest.  They also keep our immune systems purring and defend our bodies against malignancies and their toxic cousins.  We exist in symbiotic relationship with them.

In fact they inhabit every cell of our body.  The eukaryocytic cells of which our bodies are composesd are powered by mitochondria (remember Bio 101 ?)  Mitochondria posses unique DNA which differs from our own nuclear DNA.  A billion or more years ago they were free living bacteria that became incorporated in our cells.  They power the engine of life for us all to this day.

Symbiosis is the name of the game.  We are mutually interdependent.  For my patients with Irritable Bowel Syndrome, manipulating their own gut bacteria with probiotics or nonabsorbable antibiotics ( like XIFAXAN) can markedly improve their gut function.

So let us recognize the majesty of nature in all its forms, including its most basic forms–bacteria.

The G O D Series — Quotes — # 2

 **God is closest to those with broken hearts—Hasidic saying

 

**  God is real since he produces real effects—William James, philosopher, psychologist, physician

 

**  God is dead: but considering the state of the species man is in, there will perhaps be caves, for ages yet in which his shadow will be shown—Friedrich W. Nietzsche, philosopher

 

** "Where does God exist", "Everywhere" the Hasidic students replied, "No, said the wise Rebbe, God exists only where man lets him in.

 

**I said to the almond tree, 'Sister, speak to me of God' and the almond tree blossomed—St. Francis (told by Nikos Kazantzakis)

CIVIL RIGHTS & SOCIAL JUSTICE — A PASSOVER OBSERVATION

I was about to sit down at a Passover Seder last evening (we changed the date to make it more convenient–not too religious) and I had a thought that I shared with the large group who was there.

It is based on the observation that Jews have been active in the early days of the Civil Rights movement as well as other social conscious movements.  They have also been active in the formative periods of communism and socialism.

 But I am not discussing liberal or left-leaning politics specifically.  I  also  differentiate between the idealistic, utopian theory of leftist philosophy and the practical and historical results, seemingly antithetical to the idealism from which they arose.

But my point was simply that Jews are constantly reminded of the pain of slavery during heir annual Passover Seder.  The story of slavery and the exodus is indelibly embedded in the consciousness of most Jewish children.

It would seem only natural that this awareness would translate into civil rights and social action movements.  The influence on Jewish thought comes from a place of remembrance.  The participants at the Seder are instructed to feel as if they were personally liberated from slavery.

That is a powerful notion and one which can lead to standing up against injustice wherever it exists.

THE BASIS OF BELIEF — Faith vs Evidence

What is the basis of your beliefs?  We all have them.  Whether we are true believers in a particular religion or devout skeptics, there is some metaphysical underlying principle we all adhere to.  We may not necessarily be aware of what that basis is.

We may be followers of the four "R's" I wrote about in my book.  The first is Reception–what we receive from from our upbringing, family, our heritage, tradition.  The second is Reason— what our logical minds bring to the table of our experience.  The third is Revelation–those special moments of clarity which are few and far between.  Many of us may never even have this experience.  And fourth is Resonance –I use that term term as a summation of the others–what "feels" right and true to us.

The four "R's" can be summarized as the struggle between faith and evidence.  We ultimately do rest our beliefs on some degree of faith, even the most ardent skeptics often rely on the truth's of science for the basis of their beliefs.  But even when evidence and reason are addressed we need to be cognizant of the truth that the search for ultimate truth may lead us down false alleyways and mazes.

We need to be flexible and resilient enough to continuously question where what we believe and alter our beliefs accordingly.

The famous Buddhist Kalama Sutra embodies this approach.  In my book I referred to it as the Metaphysician's Motto.  In this translation it appears.

Do not believe what you have heard.

Do not believe in tradition because it is handed down many generations. 

 Do not believe in anything that has been spoken of many times. 

 Do not believe because the written statements come from some old sage. 

 Do not believe in conjecture. 

Do not believe in the authority of teachers or elders. 

But after careful observation and analysis, when it agrees with reason and it will benefit one and all, than accept it and live by it.

Key to this perspective is the last line.  It is practical and wise–all metpahysical beliefs should provide relief from suffering to all beings–not just a member of a tribe, religion, country.  This would immediately cause the rejection of any fundamentalist, racist, genocidal belief which causes any harm to any living being.  

The Nazis were atheists yet their belief system led them to destroy human life.  Jihadists are religious, yet their belief system leads them to do the same in the name of another plane of existence.  The source of the belief becomes irrelevant.  The ends do not justify the means.

Look for the evidnece for your beliefs but understand that the philosophy you embrace must lead to peace and serenity for all beings–in the world we inhabit, in the present moment.

The G O D Series — Pondering the Ultimate Consciousness in Quotes— 1

I have a problem with God.  I cannot wrap my mind around the concept and those regular readers know that my belief system is not based on faith but on evidence.

So where is the evidence for the existence of God, the ultimate Consciousness?  Well lets first dispose of the Biblical version or that of any other Holy book.  It is all human interpretation to be sure.  But what is behind the veil?

Perhaps the following quotes will encourage the discussion.

 

*God….he is everywhere revealed in all that exists, and nowhere more powerfully, it seems to me, than in the molecular machinery of life and consciousness—-Chet Raymo, skeptic

*I want to know how God created the world….I want to know His thoughts, the rest are details—-Albert Einstein, physicist

*God sleeps in the minerals, awakens in the plants, walks in the animals and thinks in you—-Hindu proverb

*If the soul could have known God without the World, the World would never have been created—-Meister Eckhart, Christian mystic