DOCTORS & EMPATHY — A Teachable Moment ?

A recent NYTimes article by Pauline Chen http://well.blogs.nytimes.com/2012/06/21/can-doctors-learn-empathy/?ref=health seems to have received wide readership and commentary and for good reason.  The perception that my fellow physicians suffer from a lack of it is enough reason to discuss it further. Can it be taught?  The conclusion of the article is –yes.  I'm not entirely convinced of that point.  But should it be part of a training curriculum?–Of course.  I certainly can't hurt. 

The fact that it needs to be taught is unfortunate.  To me the empathic personality should precede the decision to enter the healing arts.  I know that many in the public arena believe that we all entered medicine for money and prestige.  I'm sure some of my colleagues did.  But in 2012 those students who seek money had better look elsewhere. 

Ironically, I am told that the "best and brightest" students are seeking Wall Street careers.  Really?  I would hate to think that careers in medicine and Wall Street are interchangeable based on dollar denominated factors. 

Perhaps this is leads to the bigger issue anyway. I have no doubt that the "screening" process for prospective doctors is flawed.  The undergraduate pre-med grind rewards students who excel in math and science–not the humanities.  Is there little wonder that some physicians appear to be automatons or borderline Asperger types to their patients? Those who can "ace" standardized exams make it to med school.  Where is the  Emotional Quotient (EQ) evaluation?  Where is the empathy exam? 

 And then there is the training path of residency and fellowship which leads to practice.  The "fraternity hazing" aspects of grueling hours and dehumanization of the prospective physicians may have been lessened since my days.  But the process unquestionably leads to an "empathy" draining effect on its participants. 

I found the need to re-gain my "humanity "once my practice began.  It was certainly not encouraged by the process itself.  Other issues strain the bonds of empathic connection.  Believe it or not malpractice claims cannot be reduced by compassionate care.  Surprised?  Unfortunate outcomes dictate the initiating of such claims.  The most mutually rewarding doctor/patient relationship is quickly dismantled by a friend or relative to insists that your doctor "messed up" and that a monetary reward is possible.

Perhaps the issue should also involve the eventual professional direction that physicians take.  The MD/PhD lab researcher and teaching professor do not need to deal with patients on the intimate level that private practitioners do.  Pathologists do not speak to patients.  Anesthesiologists and radiologists may do so on a care by case basis.  Perhaps the personality type should find the practice type that best suits their EQ.  Easy, no.  But awareness never hurts.

Empathy may be best defined as compassion with caring.  It is more than an emotion because it directs us to act and recommend in a specific way.  It manifests in the ability to "read" the patient and best fulfill their needs and expectations.  But equally important is the ability to communicate and exchange ideas with our patients.  The most brilliant, compassionate, empathetic physician who cannot speak in simple language or respond directly to their concerns will not acheive the personal connection.

This touches on the newest trend in medicine–Patient Preference.  It has emerged as a dynamic challenge to pure Evidence Based Medicine which promoted  plans of treatment based upon the latest "scientific evidence". 

The challenge for contemporary physicians is how to integrate the two.  I fully support the contention that empathy training cannot hurt.

MYSTIC ENVY — I’m OK With It

Recently I saw one of my patients who was dealing with the suicide of her daughter.  She described her desire to see  Lynn, the medium I have written about, in order to obtain some healing.  After a brief discussion of Lynn's talents, my patient reminded me that I had previously described myself as suffering from mystic envy.

I had to agree.  It was a self-proclaimed title.  Though I had read about NDE, ADE, medium readings etc. for years, it wasn't until I met individuals who had them, and spoken to them face to face that I realized they were real.  It became an issue of credibility and I wrote about the credibility quotient (CQ) as being incredibly important.  This was not necessary for those who had the experiences.  They had no doubt of the their reality. But it was indespensible for those, like me, who had not—those of us who have mystic envy

I have come to believe that psychic/mediumship is a talent.  Like any other talent it can be developed or ignored.  Hard work is required to perfect this natural ability.  Just as with sports or music, talent is necessary in order to become truly proficient and although practice and study is mandatory, without the natural ability, it will very likely not occur. 

 I have accepted the fact that I just don't have it.  I do not have obvious clairvoyant or psychic ability.  I do not talk to the dead.  I don't see them.  They do not come to me because they know that. 

My mystic envy is just that.  I believe I would like to have this ability.  But I also know that it can be a two edged sword.  I have seen the TV show Psychic Kids and witnessed how difficulty and traumatizing this "gift" can be to them.  They do not possess the modalities for dealing with such uninvited insight into people and places, past, present and future.

But apparently I do have a role in the process.  Mine is to make connections for those who need them.  I will introduce the concept to individuals who are suffering through their bereavement.   I might suggest they consider seeing a medium.  Those who have often return with considerable resolution of their suffering.  They seem uplifted, much less depressed.  The medium will offer them such specific information about their deceased loved one that they must agree that a connection has taken place.

So I assume that my mystic envy will remain.  But I'm OK with it.  I have another role to perform.

WARLIKE OR PEACE-LOVING — Who Are We ?

The latest edition of Discover  (June 2012)  investigates a fundamental question about human nature–are we inherently warlike or are we ultimately peace loving beings? 

The twin articles are written by biologist E. O. Wilson who promulgates the bellicose perspective and John Horgan who argues that war is not inevitable.  Unfortunately I believe the preponderance of evidence, both historical and evolutionary point to our species, homo sapiens, as profoundly aggressive and warlike. I agree with Wilson that history is replete with endless examples of brutality, genocide, ruthless slaughter of innocents, etc. etc.  It has to do with, what I believe, is a tribal gene. 

Peace seems to occur only after we have completely exhausted ourselves through orgies of death and destruction.

The quality that probably allowed us to conquer and destroy our physically more powerful cousins, the Neanderthal, produced in its offspring (us) a quality of ruthlessness that is unmatched in the animal kingdom. 

The study of our evolutionary cousins the chimpanzees reveals how frighteningly similar their single file silent march into enemy territory seems.  They cleverly avoid larger more powerful rival troops but seek to enlarge their own territory at all costs.  Rival chimps once captured are brutally ripped apart. 

 Horgan, on the other hand, points to our less aggressive but genetically related cousins, the bonobo chimps.  They are notoriously famous for their highly sexual dealings with friends and foe. " Make love not war "  is clearly their mantra.  It would be preferable to be in Horgan's camp.   And it would certainly preferable to have inherited the bonobos ingrained sexual release for possible aggression.

 Unfortunately human history reveals the flaw in his argument.  Wilson is, sadly, correct.  We are beasts who are capable of love for those within our tribe, and brutal aggression towards anyone we deem our rivals.  Our capability of dehumanizing the "other" allows otherwise normal, ethical, self-proclaimed civilized beings to brutalize other human beings. Genocides, holocausts, mass exterminations are undertaken by "normal" members of our species.  They are not psychotic or metally deranged.  They are operating under the auspices of a tribal gene. 

Is there any hope whatsoever for eventual peace?  Perhaps the first step is to recognize who we are. 

There is also hope that we teach our children that war and killing does not have to occur.  Children who experience others from different racial and religious groups and who recognize their common humanity are much more likely to be tolerant of those who are "different" later in life.  Sadly, reports of children being brainwashed that the "other" is their mortal enemy will only feed into the unrelenting path our species has followed.

 We are literally brothers and sisters.

 Our DNAs are virtually identical. We need to remind ourselves that the human drive to find differences among each other is powerful and pernicious because it is usually unrecognized.  We cover it over with proclamations and descriptions of the "other" as completely different from ourselves. We inherently fear the "other".  That fear turns into rage because anger feels better than retreat and passivity. Rage turns into genocide and war.

 Outsiders to a conflict may observe little difference between warring African tribes, the citizens of Northern Ireland, Arabs and Israelis.  Ah, but we look for those differences and rest assured we find them–time and again.

The cycle can only be broken when ALL of humanity awakens to its futility.  One side is reluctant to make peace when the "other" remains a threat.  And so the cycle continues.

Sadly, unless our species experience some cosmic revelation of insight,  we are doomed to follow the path that Wilson and our chimp ancestors have laid out for us.

PHILOSOPHY VS SCIENCE — What’s the Problem ?

As a self-proclaimed metaphysician (student of metaphysics–the branch of philosophy which explores the nature of reality) as well as a physician, I was pleased to read Jim Holt's piece in the New York Times http://www.nytimes.com/2012/06/10/opinion/sunday/what-physics-learns-from-philosophy.html?pag    He addresses some of the nastiness that has passed between philosophers and scientists in recent publications.   Although scientists often consider their approach (the scientific method)  to uncovering the nature of reality to be superior to those of philosophers, in truth, they have been exploring philosophical questions since the first "scientist" lifted up a rock or starred into the starry night sky.

 It does seem  that much of contemporary physics such as quantum theory, string theory, ,dark matter and energy, multiple universe theory is philosophically "frustrating".  By that I mean the scientific theories are not easily supported by scientific evidence.  They make mathematical and theoretical sense but have yet to be "proved" in the more traditional, standard methods of scientific experimentation. Even more unsettling is a belief among some scientists that certain theories (such as the multiverse) may be inherently untestable!

  Also, the theories mentioned seem contrary to what is referred to as common sense. They lead us into a universe that makes science fiction seem tame.  Quantum theorists have been known to  admit that if anyone claims to truly understand it and its metaphysical implications they are kidding themselves.

An interesting graph placing scientific knowledge over time with a comprehensive understanding of the universe would lead to a strange paradox.  Until the beginning of the 20th century, scientific explanations seemed to reduce the mystery of how the universe worked.  There was a level of logic that the average individual could follow.  But beginning with the 20th century and extending into the 21st century, science is deep into theories that are producing more mystery, not less. 

 Ultimately we may or may not be capable of wrapping our minds around where science is leading us, but recognizing their own frustration, some scientists would rather NOT explore the philosophical implications of their work. 

 Still, as human beings with  human awareness, we cannot help but try make sense of the universe around us.   As Nietzsche is quoted in the piece, "As the circle of science grows larger, it touches paradox at more places." 

Attempting to deal with the paradox is philosophy.  The two disciplines are interconnected. Turf battles merely reflect human egocentric nonsense.  The mysteries that exist are fodder for both scientific and philosophical exploration.  They should be joint ventures.

THE ART OF MEDICINE — How To Inform / How To Listen

New England Journal of Medicine  – May 3rd edition– Vol.366, No. 18 leads with an important article entitled Evidence, Preferences, Recommendations–Finding the Right Balance in Patient Care by doctors Quill and Holloway. 

 It deals with two emerging but potentially conflicting approaches to health care and the doctor/patient relationship–evidence-based medicine and patient preference based medicine.  There are times when the two approaches seems in conjunction.  There are times when they seem diametrically opposed to each other.  This article attempts to bridge the gap. 

Essentially it requires the physician to be aware of the latest in evidence-based scientific research and to offer it to the patient and their families.  The patient and families must be allowed to air their questions about the risks versus the benefits of what medical science has deemed the "latest" information. They will be forced to explore their own religious, ethical beliefs about illness, recovery, and death.  Families will need to work through differences of opinions among themselves and make every effort to offer the physician a consensus approach to such highly charged issues. 

The physician must also be open to listening to the patient and families own research on the subject of the disease or condition being treated.  We cannot dismiss any of it without addressing the medical basis for their questions.  I will often use the phrase, "information is in great abundance on the internet, knowledge is in short supply".  It is up to the physician to guide the medical information component of the dialogue. The challenge in bridging this doctor-patient gap is communication. 

 Doctors speak a different language from patients.  I have been shocked at times to hear my colleagues seem literally unable to explain a medical procedure or condition without using other esoteric medical terms.  They are literally unable to place themselves in the position of the average person.  Physicians need to be more sensitive to how we explain medical conditions without speaking down to our patients or becoming annoyed with their questions. 

These are deeply emotional and even spiritual issues. We need to be sensistive to how patients and families react to what we tell them.  In many ways the conversation needs to be about the individual patient, their overall physical, cognitive, emotional state of being.  Appropriate advice must be individualized and based on the patient's preferences. 

We are capable of doing more to patients than we should be doing.  This is the challenge of practicing medicine in the 21st century.  It is not pure science.  There are no mathematical equations or algorithms that will work here.  We must face up to the biases and beliefs of both doctor and patient. 

 This is the art of medicine.  It is the best effort of human beings to deal with the realities of sickness and death.  It will always be an imperfect task but it is all that we truly have and we should respect the process.

THE TROUBLE WITH DOCTORS — Is Other Doctors …..

OK  Here we go again.

Another article published by a physician who criticizes how physicians practice. 

 Peter B. Bach offers us his opinion http://www.nytimes.com/2012/06/05/health/views/essay-urging-doctors-to-do-less-may-fall-on-deaf-ears.html?ref=health  that physicians order tests out of a sense of "knowing best" rather than following medical research.  His words may appeal to a public who doesn't trust the medical profession anyway.  Unfortunately, his argument is flawed. 

When will society come to understand that they can't expect to sue doctors for imperfection and not expect them to order more tests than they would like. In truth,  the odds of finding an abnormality on CT scan, mammography or repeated procedures, although unlikely, do exist.  Failure to diagnosis one case out of a thousand, or two thousand or ten thousand will result in a malpractice claim.  Defending oneself, no matter how often, is an emotional and economic burden that lead to the predominant mode of medical practice–defensive medicine. The American health care system is paying for this, all of us.

 And besides, Bach is just plain wrong when it comes to screening for colon cancer.  Flexible sigmoidoscopy will not diagnose the vast majority of colon polyps and cancers that occur beyond its reach.  And guess what—-gastroenterologists will get sued for missing them.  Just as Obama conveniently decreed that defensive medicine is not responsible for health care expenditures, saying it doesn't make it so.  Until there is comprehensive tort reform, until the trial lawyers stop dictating legislative and judicial policy, there will be no change.  So continue to read articles blaming physicians for the cost of health care.  Just be aware of what factors are at play in the real world.

WHEN DEATH IS HEALING — Revisited

I had an opportunity to read some of the comments on my last posting which explored Michael Wolff's personal experience with aging and deterioration and death. 

Although I applaud his efforts to bring light to a subject long shrouded in darkness and despair, I do not necessarily embrace all of his positions.  When referring to Long Term Care insurance, I personally believe it is a reasonable "investment".  No one ever wants to pay for insurance.  It always seems like a waste of money.  But when the time comes to provide for what it is intended to do, those who don't have it will likely regret it. 

I also need to emphasize a personal perspective.

Age alone should not be a determinant of medical care.  I have personally referred an 87 year old woman for colon surgery diagnosing cancer.  She was phenomenally alert and otherwise healthy.  She had no evidence of metastases and tolerated laparoscopic colon resection remarkably well.  My impression was that she had an excellent quality of life, was mentally alert and could easily live another 10 to 15 years or more.  

 My own aunt is nearly 102 but of such mental acuity and awareness that to not address her medical concerns would be unconscionable.

On the other hand, if I had  a 40 or 50 year old patient with dementia, multiple medical problems, bedridden and with a horrendous prognosis, I would not even recommend a diagnostic colonoscopy. Provide comfort, support and defer dangerous and costly testing which will not alter this particular patients quality of life.

 I only hope the time does not arrive when decisions about health care and other therapeutic modalities will be based on age.  Each person is unique.  Each medical decision needs to be addressed as such.  

 I do believe, however, that we need to face the reality that all existence is temporary.  We are born, we live, we die.  How we  experience each one of these stages remains personal and profound. 

Death is not always the brutal enemy that needs to be defeated at all costs.  For those who suffer, who no longer can function without extreme difficulty, to those whose life offers no quality–then death of the physical body can come as a blessing. 

 To those of us who believe that we are spiritual beings who are having a physical experience, death is re-birth into another existence.  Although it is not something we hasten, it is a truth we must accept with serenity and equanimity.

WHEN DEATH IS HEALING — A Remarkable Personal Piece

http://nymag.com/news/features/parent-health-care-2012-5/  The  personal, passionate and painful piece in New York Magazine by Michael Wolff needs to be read by everyone you know.  The article is deeply moving, profoundly important and amazingly frank. 

He writes about an experience that many of us have already had and which many more will have. It is about a son's love for his mother and the suffering that both endure as she fades from self-awareness.

 It has to do with the prolongation of existence by means of medical technology in which  quality of life becomes an after thought.  It has to do with the enormous amount of financial resources now dedicated to keeping chronically ill and demented loved-ones "alive".  

 By promoting longevity and technologically inhibiting death, we have created a new biological status held by an ever-growing part of the nation, a no-exit state…..nearly as remote from life as death, but which, unlike death, requires vast service, indentured servitude really, and resources.    It is quite clear that Wolff loves his mother.  Some of his statements required him to be intensely open and honest with his feelings.  Many individuals in his circumstance could not allow themselves to admit what he writes.  Yet there is so much truth in this article that it needs to be openly discussed by everyone. 

Unfortunately, every individual case is unique, yet similar to others.  Decisions regarding end of life are never easy.  Family members may disagree with each other.  The patient may express their wishes for end of life care but then be out voted by those who are left to make medical decisions.  Physicians often fail to play a supportive role in these difficult times.  They may reveal their own personal inadequacies and lack of training in dealing with death and dying.  

Is there ever a place for euthanasia here?  Is life to be maintained by all means when there is no longer the quality of existence that defined who we were?  These are questions without easy answers.   When it came to the end of both my parents life I was adamant about not hospitalizing them  and bringing in hospice as soon as possible.  For the most part my family was in agreement.  This doesn't always happen. 

 It is never too late to begin the difficult but necessary dialogue as a society which may provide the guidance we all so desperately need.