Demystifying Medicine One Month at a Time

Tag: wisdom (Page 1 of 2)

Doctor Yenta Redux

The following post first appeared in 2010. I’m reprising it because I like it and I’m heading off the grid for a few days.

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god-versus-science-time-magazine-coverAs a doctor, I’m trained to do things:

I listen. I ask.

I examine, order, and test.

And then I assess.

I certainly try to treat. All too often, this includes prescribing.

What frequently gets lost in this paradigm is that on many occasions, the listening part is often enough.

Take Gene, for instance. He’s a retired biochemist. When I met him for the first time as a patient, I took a standard social history: I asked about employment, hobbies, and habits.

“I’m emeritus,” he explained, sitting hunched forward in the chair, looking out from Harry Caray spectacles.

“What does that actually mean?” I pushed.

He told me about his walks, his weekly lunches, his mail, his invitations, his memoirs. “Do you still do experiments?” I wondered.

“I dream about them every night,” he replied.

Pause.

His wistful admission pierced me. I felt helpless; there was nothing I could do about his loss. I ruminated on it for some time. Then I had a dream. An epiphany of sorts: Emeritus came to me to mean lonely.

I knew another emeritus: my rabbi. He, too, struggled to find the right balance between activity and restfulness in retirement. Why not bring them together to see what could happen?

Gene: an octogenarian Jew-turned-atheist; scientist; discoverer; and Renaissance man, passionate about music and art.

A.J.: an octogenarian rabblerousing Rabbi; social justice crusader; scholar; also a ‘fiend for culture’ (and his beloved White Sox!).

They were the same age. Of similar backgrounds. Neighbors for thirty years, though they’d never met.

I proposed a series of conversations. Interviews, really, in which I’d ask them about their lives. I wanted to understand their hopes, their dreams, their experiences through the tumult of the twentieth century. Gene was worried the rabbi would try to bring him back into the fold. When I obtained assurances of no proselytizing, the dates were set.

We met for a semester every Thursday on a quiet corner of campus. I brought the questions and the tape recorder. Thursdays with Gene & A.J., we jokingly called it.

I tried to hit the big themes: work, accomplishments; family; their philosophies, politics, faith, and philanthropy.

I’m not sure why I did it. I think I felt each man’s loneliness, and I hoped to lessen it by providing them companionship–with each other, and with me.

I also think I felt my own need for role models of well-lived lives. I hoped to nurture my non-medical self, by tapping into sprightly minds encased in enfeebled bodies and revealing their accrued wisdom.

It worked. A patient came to me with a problem and I did something: I helped him make a new friend.

Med Men

Dick Whit–er,…Don Draper. Medical role model?

It’s never really discussed.

We don’t learn it in med school. There are opaque references to it in residency.

Once we’re out, it slowly becomes an unpleasant realization. We give it other names, and ascribe the motivation (or lack thereof) to others–our patients.

It’s selling.

Patients look to us for medical advice. It’s a vulnerable state to be in. A generation ago, we simply told you what to do. And you did it.

Now we practice “shared decision making,” and make recommendations to you that you are free to accept or reject.

The conversations are seldom on the level. Most of you don’t want to outright defy us. You risk our….wrath? Our disfavor? Our disappointment (always my parents’ strongest weapon).

When you don’t follow our recommendations, we call you non-compliant.

The newer, more politically correct term, is non-adherent. Sometimes we just say you’re a “bad patient.”

But doctors are really (M)ad Men (and of course, increasingly, women). We have to sell you our ideas, even when you’ve become increasingly knowledgable and justifiably more critical.

The truth is, selling is easy most of the time: We believe in what we’re offering–intellectually and emotionally–and some of our ideas are so commonplace (colon cancer screening, treatment of high blood pressure, etc.) that you are receptive to the ideas. It’s a win-win.

It gets a lot harder when we don’t necessarily believe in what we have to offer, or are outright skeptical of something that you ask for.

Communication is one of the ‘competencies‘ on which we evaluate trainees. It’s vitally important. But we don’t teach it or evaluate it well.

Here’s a powerful example, appealing to both our minds and hearts, and making the complicated simple and appreciable even by a child.

I wish for better, more straightforward communication amongst all of us.

Medical Skepticism, vol. 5

MRI: Irv Fufflik's knee (used with his permission).

Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers’ elbows, shoulders and knees what Andy Warhol was to Campbell’s Soup.

The Times of New York trendspotted the following big medical news: doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it’s the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don’t need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:

  1. The details in an MRI are such that a radiologist almost never interprets a study as “normal.”
  2. The irregularities that make an MRI ‘abnormal’ seldom correlate to physical symptoms (more on this below).
  3. As an example: when a healthy runner goes for a jog, she’ll have evidence of ‘abnormal’ fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.

Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article:

The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc ‘herniations’ and ‘protrusions.’

What do we do with that information? Should we offer the volunteers surgery that they don’t need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don’t demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

Help Wanted: DIY Medicine

Taking medical care to the self level.

First there were contractors. Then came Home Depot.

Once we had accountants. Along came TurboTax.

Stockbrokers? E-trade.

Printers? Soon we had Kinkos, er, FedEx.

Even venerable old lawyers are being outsourced and replaced by do-it-yourself manuals and online services.

Which brings me to my profession. Medicine.

I’m researching a new frontier in health care: do-it-yourself medicine. As more information is available online, patients are empowered like never before.

The rise of the e-patient movement is one such example. But now, with direct-to-consumer lab testing and radiology, people are able to access medical services and consume them like any other commodity.

I’m interested in learning about people that obtain these services without the consultation of a medical professional.

Caveat: a lot has been written about cyberchondria, google-itis, and patients advocating for themselves and their loved ones with their doctors.

I’m looking for people out there that self-diagnose and treat but make every effort to steer clear of the medical establishment.

Are you such a person? Do you know one?

All information and stories will be held in strictest confidence. We’re trying to gauge the prevalence of this phenomenon in the world.

Comment on the blog or send tips/inquiries to GlassHospital [at] gmail [dot] com.

Remembering Gene

A tribute to a life well-lived.

Gene Goldwasser (1922-2010)

Gene Goldwasser died last week. [Obits here and here.]

He was 88, and he was my friend.

I wrote previously about a series of conversations I conducted with Gene and Rabbi A.J. Wolf a few years ago.

I met Gene one Spring day after calling to invite him to sit in on a class I was teaching to a small group of medical students about social issues in health care.

I’d read about him in a book called “The $800 Million Pill,” by Merrill Goozner. In the book, Goozner writes the story of Gene’s two decade hunt to isolate the hormone erythropoietin (EPO).

Part of the story relates how Gene tried to interest traditional big pharma companies in his discovery, only to be brushed aside. Instead, Gene wound up sharing his discovery with what became Amgen. The company went on to make a windfall from recombinant production of the hormone and licensing it as a drug for patients with anemia and kidney failure.

A molecular model of EPO. (photo from Wikipedia)

Gene never profited from his discovery, the way that scientists and inventors now clamor to patent everything in sight. He believed that his discovery should be shared with the public; after all, the government had funded his research career–he figured the taxpayers ought to get the benefit of his discovery.

Gene was old fashioned that way. He was also old fashioned in the way his interests outside of work were so protean. He was a fiend for culture, attending concerts and plays on an almost nightly basis until his health no longer permitted him to.

He told me of his great love for sailing, for travel, for reading. He even was a biographer, penning the story of his great mentor at the University of Chicago, Leon O. “Jake” Jacobson, M.D.

Gene fought prostate cancer for more than 20 years. He vastly outlived his life expectancy given the stage of the disease, and when it recurred this past summer he was grateful for the ‘second life’ he’d been given.

The cancer eventually caused his kidneys to fail, and rather than decide to start undergoing dialysis treatments, Gene and his wife Deone elected hospice and comfort care to cure. He spent his final days in their beautiful apartment, literally entertaining family and friends and saying his goodbyes.

After ten days at home, Gene drifted into a gentle coma, and died within two days, surrounded by his family.

He chose a good death.

Shortly before he died, Gene completed work on his own memoir. I can’t wait to read it.

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