Monday, April 4, 2011

Bedside Manners

“O God, I could be bounded in a nutshell, and count myself a king of infinite space—were it not that I have bad dreams.” Hamlet – Shakespeare

Hamlet realizes that the world outside exists even though he wishes to live in his self-defined universe, yet reality constantly knocks on the doors of his thought. It is that reality that we must address.

Half Full?

Does pessimism prevail in the modern medicine man? This is a question worth pondering over.  With the evolutionary predation of a mindset that grits its teeth to tear at the flesh of its unsuspecting prey-prosperity, life in medicine has evolved through fits and starts, of human ingenuity and failure, roiled in optimistic delights and the deep dark abyss of pessimism. It is a rollercoaster ride from the peaks of “humans can live for four hundred years” (The telomerase concept, although recent data seems to show a glimmer of hope by forcing a mutation on Telomerase causes malignant cell death in the lab) to the troughs of despair (Cancer is inherently incurable). Today we are in the throes of the latter. The desperation, fatigue and fear in our culture reflect that. Even as we are learning new genetic abnormalities related to a single cancer that tie multiple genes and epigenomic signals to synchronize multiple pathways to cell multiplication in a particular disease, we are finding that multiple pathways have a telephonic communication (cross-talk) between each other thus confounding the number of codes to decipher. Information is growing in leaps and bounds, but even with the harvest from these embarrassment of riches knowledge has yet to be decoded so that the “Yellow Brick Road” to success and cure can be followed. The one-gene-one-disease concept for all is definitely out. A roadblock no one saw coming. Thus the many moments of “Eureka” have transformed into firewalls against immediate success while public patience remains at a premium.

We write songs like, “the sun will come out tomorrow,” as a hope that tomorrow will be better then the doleful, soulless and uninspired day like today. Our music suffers the rant of today’s ills and is cherished and hummed by the millions of unsuspecting youth as the beat of the human march towards its ill-begotten destiny. We dress in high-priced rags and show each other the lack of respect as a march towards freedom from culture. We are inspired towards individual liberties without constraint of social ethos. 

The rise of the vampire series and the devotion by the youth to its adherence with noir-filled thinking and art all conspire to a modicum of psychical devolution of the generation. The dark negativity pervades the very fabric of life.

And would it be difficult to understand that a similar concept of life worms its way into medicine?
Cartoon by April Girouard

Lets begin with a conversation between a physician and a patient about the latter’s diagnosis, management and prognosis.

Doc: “I am sorry Mr. Jones, but I have some bad news for you.”
Mr. Jones: “Oh my God.”
Doc: “We have determined that you have cancer.”
Mr. Jones: “What does that mean?” “Am I going to die?”
Doc: “Mr. Jones we are all going to die one day.”
Mr. Jones: “But what about me?”
Doc: “We have certain treatments that might help.”
Mr. Jones: “When do we start?”
Doc: “There are a few preliminary tests we have to do before we can start.”
Mr. Jones: “Lets get going. I want to live.”
Doc: “I must tell you that there is a 30% chance that it may not work.”
Mr. Jones: “Oh!”
Doc: “It also has some side effects.”
Mr. Jones: “Like what?”
Doc: “50-80 percent chance that your immunity will be lost and subject you to infection. 30-40 percent chance that your blood clotting ability will be temporarily destroyed with a risk of bleeding and a 20-30 percent chance that your heart can be affected with a 10 percent risk of permanent heart-failure.”
Mr. Jones: “Oh my. Oh my!”
Doc: “It is also very expensive and your insurance may not cover all of it.”

Mr. Jones lies speechless in the hospital bed, bereft of all thoughts except the contemplation of the looming death.
This kind of conversation occurs daily in all hospitals across the world. It is the sad reminder of the nuances of human failings and frailty and of a lack of empathy. The culture of “being truthful” has adopted a modicum of feeling-less, soul-less monologues.

One wonders whether there is a way to impart the same truth in a better manner and would it achieve a better outcome?

It is well known that optimists live longer and healthier lives then their counterparts. “Imagery” studies done in children with Leukemia showed that those children with vivid imagination were able to get a quicker response to therapy. In adults similar results have borne out the benefits of enabling a positive attitude in patients. So, this approach of “truth-telling” in the bleakest of lights would constitute as a damper on the potentials of success.

How can this conversation mutate to a more patient friendly and optimistic view point?

Here goes a revised rendition of that interaction.

New Doc: “Master Jones we have a diagnosis.”
Master Jones: “What is it?”
New Doc: “It is a form of cancer.”
Master Jones: “Oh my. Am I going to die?”
New Doc: “Not if we can help it. We have a treatment that helps 7 out of 10 people live longer and healthier.”
Master Jones: “Great. When do we start?”
New Doc: We have a few preliminary tests that we will start today and we can conceivably begin the treatments within the next two days.”
Master Jones: “Get me started doc. I want to lick this here and now.”
New Doc: “There will be some rough days with the treatments but we will keep you informed and help you through the process.”
Master Jones: “I am ready!”

The previous scenario plays out in every field of medicine. It is the unfortunate predicate of an involuntary knee-jerk response to a cultural bent. The physicians of today are masked by the television culture of the irascible “House, M.D.”  They are motivated into medicine by the “Scrubs,” and the “Grey’s Anatomy” series rather than the life-saving, wound-healing, comfort-giving pragmatism of medicine. The seriousness of medicine is preyed upon by the utopian vision of “fun-and-frolic.” 

The realm of communication is “Twitter-based” half-sentences and “Facebook” wall-postings. The “face in the computer screen, bookishly-intelligent doctor” that never sees the patient nor understands the pain and suffering further hampers physician-patient communications. To him or her the word pain elicits a pharmacopoeia of “analgesics” to choose from and “suffering” evokes an equal list of “SSRIs.”  The gulf between the two widens and the isolation and alienation deepens.

Humanity has been endowed by the Lamarckian (French biologist  Jean-Baptiste Lamarck(1744–1829) evolutionary view of learning. Nurture bestows its own sets of levers and triggers. It is time to undo the present and learn the good from the past to forge a better future. The “Bedside Manners” of yesteryears make us humans and those same social graces that turned us into a compassionate force will work today. The central relevance of communication was not to have a stiff, un-pliable monologue but a sharing and layering of ideas between the physician and patient to pattern the individual threads into a management reality. Even when the horrors of rational density are thick with hopelessness, it is the empathic, caring and “shoulder-to-lean-on” mentality that serves the patient the best.

In an unfortunate atmosphere where swarms of unrelated thoughts are forced together in a unified plague of action, the suffering reality is hobbled under the morass of this illiquid, ill-timed, concrete nonsense.  When desires breed devilish monsters out of reality and we spend time to construct nonsensical and fictional models of thought rather then heed to what is real, the time to question has arrived. The time to lament is over. Real work needs to be done!

Time it was and what a time it was,
A time of innocence,
A time of confidences,
Long ago it must be, … “Old Friends” by Paul Simon

Imagery (self-hypnosis) as adjunct therapy in childhood cancer Clinical experience with 25 patients American Journal of Pediatric Hematology/Oncology Fall 1981-Vol 3 -Issue 3 
Gould, Stephen J. (2002). The Structure of Evolutionary Theory Harvard: Belknap Harvard. pp. 177–178

Gould, Stephen J. "Shades of Lamarck", reprinted in The Panda's Thumb (1980) pp.65-7

Better Bedside Manners By Laura Blue Wednesday, Sep. 05, 2007

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