Thursday, July 20, 2017

Self-Disclosure in the Clinic and the Classroom

As I mentioned in a recent post, I'm in Vermont while my wife teaches at the Middlebury College Bread Loaf School of English, a program in which the students are primarily high school and middle school English teachers.

Tomorrow I'll be leading a second workshop on "Making Ethics Part of High School and Middle School English Class."At the workshop on June 30th the teacher/students identified a topic they wanted to come back to: should they bring their own moral and political selves into the classroom, and if the answer is "yes," how should they do it?

I've never taught in high school or middle school and can't claim any direct expertise on how to deal with the question the teachers raised. But I've given a lot of thought to what is typically called "self-disclosure" in medical care and have written about it (see here). In contrasting the issue as it comes up in the clinic and the classroom, I see self-disclosure as a vastly tougher question for high school and middle school teachers than it is for physicians and other clinicians.

In the clinic, self-disclosure occurs largely in a 1:1 setting - the patient and the doctor. The major question for the physician is whether self disclosure will further the clinical objectives. Research suggests that the impulse behind self-disclosure is often fulfillment for the doctor more than benefit for the patient. The commonest risk is that the patient will feel less listened to and less rapport. The most serious risk is that physician self-disclosure will lead to a slippery slope of increasingly intimate interactions. Many situations that end with doctor-patient sex began with physician self-disclosure.

When we physicians contemplate self-disclosure we should ask ourselves three relatively straightforward questions. First, a bit of introspection: do we tend to talk about ourselves too much? If so, we should be especially on guard. Second, is there anything special about our relationship with this patient - such as a wish to impress the patient or to be his friend  - that draws us towards self-disclosure? Finally, what is the rationale for anticipating that self-disclosure will help the patient?

In high school and middle school, the teacher is an adult dealing with a classroom with 15 - 30 youngsters. Student reactions, of course, are likely to vary, so there's no way to guage the potential impact on every student in advance.  But the most challenging aspect is the school setting itself. Even if the patient-physician dyad occurs in an organizational setting like a clinic or group practice, it's primarily a two person relationship. By contrast, English class is just one piece of the student's relationship with the school. And in the background, the students' families properly regard themselves as having a central role in their child's education.

To prepare for the workshop I tried to imagine myself as a new high school or middle school teacher thinking about self-disclosure in the classroom. I pictured a series of steps to help me develop an approach:
  1. Talk with my experienced colleagues. How have they handled self-disclosure in their classes? What guidance can they give me?
  2. Talk with my department chair and perhaps the principal. They are responsible for and most knowledgeable about the school's relationship with its community. Are there issues of particular sensitivity to be aware of?
  3. Consider the environment the students come from. What is the cultural starting point for the class likely to be? How will this influence how the students hear me?
  4. Examine my own skills. Am I someone who students can feel comfortable questioning or challenging? Can I model a stance of curiosity and mutual respect?
I'm looking forward to learning from the teachers who will participate in the workshop. What a privilege it is to be able to explore ethics in the classroom with a group of experienced and devoted teachers!

Saturday, July 8, 2017

Psychiatrist-Patient Sex - plus a detective

When I was looking for audio books for my drive to Vermont, how could I resist Shrink  Rap, especially since the author was the wonderful Robert B. Parker of "Spenser" fame. Here's the blurb from the jacket:
Boston P.I. [private investigator] Sunny Randall is working as a bodyguard for popular romance writer Melanie Hall, who is being stalked by her psychiatrist ex-husband. Melanie was a patient before becoming his wife, but now she is absolutely terrified by him. To find out why, Sunny puts on a disguise and goes to the shrink for therapy.
The most-read posts on this blog are those under the tab of "doctor-patient sex," and I was eager to see Parker's take on the topic.

Melanie Joan Hall is a wildly successful chick lit writer and, like her heroines, a romantic soul. She falls in love with her psychiatrist (Dr. Melvin) whose practice is entirely composed of needy female souls like herself. Dr. Melvin allows an erotic transference to form, but then instead of using it as an opportunity to minister to Melanie Joan, he exploits it for sex and control. 

Melvin has sex with many patients, but he singles Melanie Joan out for marriage. Although he's a thoroughly evil character, Melanie Joan only catches on when he invites two of his friends to participate in what the narrative calls a "gang bang." Until the "gang bang" moment Melanie Joan has been entranced by what she calls the "master/slave" relationship. But when the potential "gang bang" shocks her into recognizing Dr. Melvin's evilness, she flees. Melvin goes off the deep end and stalks her. Enter private eye Sunny Randall.

Sunny seeks out Dr. Max Copeland, a skillful and ethical psychiatrist, to help her strategize about Melvin. Sunny tells herself she's seeing Copeland for advice, not therapy, but Copeland engages her in self-reflection as well. He's a superb therapist - respectful, insightful, and entirely focused on helping his detective-patient. He obviously likes and admires Sunny, who is brave, honest, funny, and emotionally open, but unlike Melvin he is scrupulous in using his interaction with her to develop a therapeutic alliance.

Parker has excellent insight into the ways patients may idealize a therapist who listens to them attentively. Sunny herself feels the pull when she becomes a "patient" in Melvin's practice. I won't give away how she cracks the case - it's scary and humorous. But when she expresses her puzzlement at how in the early phase of their "therapy" Melvin was actually helpful to her, Copeland responds as I have to comments on earlier posts - physicians who exploit patients A, B and C may also have skills that allow them to practice very competently with patients D, E, and F.

Shrink Rap brought to mind Dressed to Kill. a Brian DePalma film I saw in 1980. I'd not heard of the film until a young woman patient brought it up in a therapy session. She said it reminded her of her treatment. When she went on to mention that the psychiatrist in the film murdered his patient, I remember feeling horrified. Alas, I can't remember what I said to my patient, but I resolved to see the film. I won't give away DePalma's Hitchcockian plot in case you decide to see it, but my patient got the film story right. The psychiatrists really does murder his patient.

Parker and DePalma render the dark side of our fantasies about psychiatrists. The cultural figures who - in our upbeat moods - we see as wise and powerful healers, turn into monsters when they choose to use their power for evil aims. It's the same dynamic as the wolf in Little Red Riding Hood - a loving grandmother on the outside but ravenous wolf within.

Sadly, the stories Parker and DePalma tell so well aren't restricted to myth. The reason my posts on doctor-patient sex have garnered so much readership is that the myth plays itself out in life. The problem isn't new. 2500 years ago Hippocrates asked physicians to pledge fidelity to their patients' well-being, and to eschew sexual exploitation. Hippocrates understood that just as the wolf gives in to temptation when he sees Little Red Riding Hood and her basket of food as tempting morsels, physicians of his day, and ours, are exposed to temptation as they practice their art.

The reason the Hippocratic oath has survived for 2500 years is that Hippocrates saw medicine as a sacred calling that requires an impeccable standard of ethics. Parker and DePalma's engaging stories show what can happen when the oath is ignored.

Sunday, July 2, 2017

Teaching Ethics in High School and Middle School

I'm again in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of 4-5 summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

For the past five summers I've been doing a workshop on "Making Ethics Part of High School and Middle School English Class." The idea for the workshop came from recognizing that my underlying goals for teaching medical ethics were similar to the teachers' goals for their students in English class. Working with the teacher-students at Bread Loaf is a pleasure and a privilege. Their commitment to fostering development in their students is similar to the commitment to fostering health and well-being I see in the medical students and residents I work with.

This year the topic we chose to focus on was an experience several of the teachers had (a) teaching courses that explicitly included "justice" or "ethics" in the course objectives and finding (b) that the courses didn't work well. We asked: what was the problem and what could be done about it?

The group identified three main reasons the "justice"/"ethics" courses fell flat:
  1. Adolescent cognitive development. Kids of every age show great variation, but teen age thinking tends to be black/white, with the result that for many the idea that thoughtful people may reasonably differ is a foreign notion. Discussions of ethical and political dilemmas may seem to them like a "politically correct waste of time." I'm still embarrassed at a piece of my own black/white thinking from when I was 17. My parents, born in 1905 & 1907, were from a martini-drinking generation, and the practice they and their friends had of drinking several martinis after work and forgetting that there was a child in the home (me), led me to a very moralistic view of alcohol. So when my friends proposed going out for beer when I was a first year college student, I replied "If we're going out for alcohol, why stop there? Why don't we go directly to heroin?"
  2. The school environment. Kids recurrently encounter high stakes tests. Many feel that their future depends on getting good grades, which means "getting the right answer." Their anticipation of being judged inhibits curiosity and limits the pleasure they might take in deliberating about moral dilemmas. Some years ago when medical ethics was an elective at Harvard Medical School (now it's part of the required curriculum) I had designed a session on "personal mission in medicine." I thought it was a great plan, so when the class completely bombed I was puzzled and asked the students to help me figure out what the problem was. The students told me what I'd missed: "This is our first semester in medical school. Our mission is not to flunk out. We have no interest in speculating about what our mission  should be 5-10 years from now!"
  3. Culture of narcissism. Several teachers commented on a culture of narcissism symbolized by the popularity of "selfies." This isn't a new idea. Christopher Lasch popularized it in his prescient 1979 book subtitled "American Life in an Age of Diminishing Expectations." The teachers felt that social media reinforced the longstanding cultural pattern. I was especially struck by the observations of two teachers who also coached high school sports teams. Both commented on the decline of "teamness" and the tendency for young athletes to be preoccupied with their own goals and achievements.
The participants exchanged tips on what teachers can do to bring moral reflection to life for their high school and middle school students:
  1. Careful planning. It's important to find works of literature that entice teenagers into moral reflection. Two teachers mentioned The Ones Who Walk Away from Omelas, a short story by Ursula Le Guin I'd never heard of, no less read. It's a moral fable that can be seen as challenging capitalism and the division between the rich and the poor. (The story is just 4 pages - I encourage you to follow the link.) Other teachers emphasized the value of "warm-up exercises" like improv to get the students loosened up and readier to experience curiosity about themselves and others.
  2. Role modeling. It's important for teachers to demonstrate open mindedness, readiness to be questioned & challenged, and interest in the views of others in their interactions with the class.
  3. Drawing on established frameworks. One of the teachers leads a course called "Theory of Knowledge," which is part of the International Baccalaureate curriculum. The course focuses on what it means to claim to "know" something and what forms of evidence apply in different realms of activity. It encourages students to examine their own presuppositions and to recognize their biases. Another teacher uses the Harkness approach - a discussion method developed at Phillips Exeter Academy. Since a central goal in ethics teaching is to cultivate the habit of thoughtful inquiry into the basis of views held by self and others, it makes sense for teachers to do this themselves by learning from each other about how best to pursue this important goal.
  4. Trust the students. Open, thoughtful deliberation requires activity on the part of the high school/middle school students. Telling them what's required doesn't do this, just as telling an athlete how to carry out a skill doesn't take the place of practice. The term "safe space" was used to describe the aim of fostering an environment that supports curiosity and inquiry. Of course, teenagers, like all human beings, are not always trustworthy. This part  of the discussion reminded me of one of my clinical rules of thumb - start with the most optimistic hypothesis that is safe and prudent and retreat from it as necessary. Thus if a patient with depression was not suicidal or at risk in other ways, we could start with the hypothesis that the condition would be readily reversible. If that proved true - great! If it didn't we'd move on to a more demanding approach.
Over the years of my work with high school and middle school teachers, I've come more and more to 
see their work as similar to health care in the shared aim of enhancing human capacity. If health care is a sacred calling, which I believe it very much is, so is the work the teachers are doing!

Sunday, May 14, 2017

Medicine and Mysticism

Even before I knew that Guanyin was the Bodhisattva of Compassion I was drawn to her image in the Boston Museum of Fine Art. (In Buddhist tradition, Bodhisattvas are beings who delay reaching nirvana out of the wish to alleviate human suffering.)

My own recent experience with medical care leads me to see concepts like Bodhisattva and Guardian Angel as telling us something important about medicine.


   
                                         Guanyin - 
                          Bodhisattva of Compassion

Two months ago I wrote about the condition that had given me many months of pain, severely disturbed sleep, and difficulty walking (see here and here). My primary care physician referred me to a hematologist who made a presumptive diagnosis of a platelet dysfunction and prescribed a medication that acts on the bone marrow to slow down the platelet production process.

Prior to the diagnosis I'd assumed that the mysterious condition was not going to go away, but now, two months after starting the medication, the symptoms have almost entirely cleared up. I'll have to take the medication for the rest of my life, and some complications could emerge, but I feel like "myself" again.

So what do these experiences have to do with Guanyin?

The medication I'm taking requires careful monitoring to make sure it's doing what it's supposed to do with the platelets, but not causing too much decrease in white & red blood cells, which the bone marrow is also busy producing. We've checked the blood nine times between the day I started the medication and this week. The results go to my hematologist who writes to me on the secure email her practice uses to interpret the results and suggest how to handle the medication.

I counted her messages in my inbox: 13 messages and a total of 386 words. That's less than 50 words/week.

From my own experience as a physician I doubt that our exchanges required much time. But in addition to the instrumental importance of the guidance I received, I was aware of a strong sense of emotional support and of being cared for that the 386 words conveyed. I identified two sources for that feeling. The promptness and reliability of the hematologist's response after my blood tests elicited a sense of security. And the happiness she expressed as my symptoms improved elicited a sense that my well-being mattered.

That's what Guanyin stands for in Buddhist culture, and likewise for Guardian Angels since they first appeared in the Hebrew Bible. Within the theologies, Bodhisattvas and Guardian Angels were vehicles for conveying divine love to us vulnerable mortals.

Health care workers tap into the same psychological and cultural substrate. The feelings I've had as a patient are the reciprocal of the sense of mission I had as a physician. Recently, at the end of an appointment, a patient said "thank you," to which I replied with the same two words. When my patient asked me why I said "thank you," I explained that being a physician (or a nurse, social worker, physical therapist...) is a privilege, and that the act of healing required collaboration between the involved parties.

I believe that if we could interview Guanyin and Guardian Angels, they would tell us that they were grateful for their opportunity to minister. There's a "mystical" element in health care that market concepts like "consumer" and "provider" are woefully inadequate for understanding.

(See here for a post about why secular clinicians might want to use religious language in their practices, and here for a post about love in the patient-doctor relationship.)







Monday, April 17, 2017

More Pharmaceutical Industry Price Gouging`

A recent New York Times article tells us that Lannett, a large generic drug maker, is echoing other companies I have written about in raising prices on its products by several hundred percent. Here's what Arthur Bedrosian, Lannett CEO, told a group of investors:
According to the investors, Mr. Bedrosian was asked if the price-hike business model in the drug industry was over. He chuckled and said no, adding that he had tripled the price of one of Lannett’s drugs that very morning. He did not identify which one, the investors said.
Mr. Bedrosian's "chuckle" may remind you of Donald Trump's cheerful boast about how he could grab women by the "pussy."

The market loves Lannett, which provides yet another example of market failure. In the future the market may ultimately punish Lannett the way it punished Valeant (see here and here) and Turing Pharmaceuticals, but by the time that happens patients will have been hurt and public and private payers will have been bilked of billions.

The NYT cites studies showing that when there are fewer than five competitors, our national theology of the wisdom of markets doesn't hold. That suggests a regulatory strategy that allows price regulation in the absence of adequate competition. Let's hope that Congress is prepared to act on the basis of protecting patients and the public from the kind of legal larceny the Mr. Bedrosian is chuckling about!

Saturday, April 8, 2017

A Personal View of the Medical Home concept

Into my mid 70s I felt remarkably fit. I was still playing tennis and taking my favorite hikes during the summer in Vermont. That changed when a mysterious problem I've written about in a couple of posts (here & here) set in.

As a result of the problem that developed, I've had more medical appointments in the last six months than in the previous 25 years. As someone with an interest in health policy & systems, my experience has sharpened my sense of what's required to make a "medical home" work. (For those who aren't familiar with the medical home concept, I've copied material from the Patient-Centered Primary Care Collaborative at the end of my post.)

Here's my patient's eye view of my experience:
  1. In the fall of 2016 I was floundering as to what to do about the problem, Whatever was causing pain and discoloration of my left foot/ankle/lower leg was still a mystery. My primary care physician (PCP) suggested seeing a dermatologist, something I hadn't thought of myself.
  2. The dermatologist said what she saw was unusual. She did a biopsy which, alas, came back as "non-specific changes," That meant we were still unsure. She could simply have sent me back to my PCP, but to her credit, she suggested that we get a second opinion from someone at the hospital my care group is associated with.
  3. Initially the referral went to the referral coordinator and an appointment was set with a presumably thoroughly competent dermatologist, but one who did not have more experience than the one I had seen. I discussed this with my PCP. He called the chief of the department who recommended a senior colleague who he said "is especially good with complex cases."
  4. I saw the recommended dermatologist who had some hypotheses about obscure possibilities and did two further biopsies which showed (a) clotting in the tiny blood vessels and (b) no inflammation. 
  5. With a narrower set diagnostic possibilities, the second dermatologist wrote to my PCP, recommending that I see a hematologist and suggesting some further blood tests. My PCP agreed, and referred me to an excellent hematologist with whom I had shared patients before I retired from practice ten years ago.
  6. By this time my blood count showed something new - an abnormal level of platelets, which are crucial for clotting. The hematologist prescribed a medication that acts on the bone marrow with the aim reducing the platelets. We've used the group's secure email to follow the counts and adjust the medication. We've only met in-person once, but the email communication has been very reliable.
  7. As the platelets have come down, the lower leg and ankle problems have completely cleared up. But the toes have not, and in particular my left fourth toe was exquisitely painful. Last weekend I saw an ugly open sore on the toe. I didn't know what gangrene looked like, but my imagination ran away with unpleasant possibilities.
  8. On Monday morning I was able to see an urgent care physician who allayed by fears and prescribed  oral and topical antibiotics. 
  9. I informed the hematologist and my PCP about the situation to make sure we were all "on the same page."
  10. Happily, the wound is improving, and the pain is markedly reduced. 
So what's the point of all these details?

For me it's this: in the same way that it takes a village to raise a child, it can take an "extended family" to treat a chronic condition. My experience has been one of receiving excellent continuity of care even though I've been bouncing between clinicians the way a pin ball bounces. But the clinicians were part of the same "family." They had access to the same electronic health record and communicated with each other - either directly or via my sending "FYI" updates to them. For the underlying chronic problem I've had my blood drawn at the practice's laboratory. The results get to the hematologist and to me within a few hours, and she has followed up with email advice very promptly.

My guess is that my treatment in the past few weeks has not occupied much physician time, but as a patient I have felt very attended to. When I was worried about toe pain and an open wound I was able to see a clinician promptly, and her findings went to my PCP and the hematologist I am working with.

I believe my experience shows how a "medical home" and "team care" can be more than euphemisms. Continuity of care doesn't require continuous appointments with a single physician. When a "medical home" functions the way a harmonious extended family does, it works!

Here's the material about the medical home concept for those who want to read about it in more detail:

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.
In 2007, the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ)

Features of the Medical Home

Adapted from the AHRQ definition, the PCPCC describes the medical home as an approach to the delivery of primary care that is:
  • Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
     
  • Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
     
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
     
  • Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
     
  • Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health

Tuesday, March 21, 2017

Adding Value by Talking More

A recent article in the New England Journal of Medicine - Adding Value by Talking More - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.

Here's the final paragraph of the article:

As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.
The otherwise excellent article omits one crucial element. Talking more with our patients also increases physician satisfaction. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.

I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of Avant -garde Health, a health care technology and analytics company founded by one of the authors.

Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a concierge model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.

The kind of work behind Adding Value by Talking More is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."

Sunday, March 19, 2017

Access to health CARE vs access to health INSURANCE

A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (here & here). With my friend's permission I've copied the message s/he sent [I'm deliberately disguising gender], edited to protect confidentiality and to highlight the themes I want to emphasize:
Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of patients who are not MDs and/or are not in an integrated group practice such as the one you belong to. In my own experience, PCPs defer to specialists and won't contradict them. Further, the placebo effect of the PCP relationship is reduced if not nullified by the patient's difficulty in contacting the PCP over the phone. I can never get an appointment on short notice with my PCP; I can only count on seeing him if the appointment is made months in advance, or if I am in an emergency ward or am admitted to a hospital as an inpatient. If I have an immediate problem that is not an emergency (e.g., burn, sprain/suspected fracture, bronchitis), I have to work through two layers on the phone (secretary, medical assistant) -- and then the outcome will be an examination by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's Walk-In Clinic rather than even trying to reach my PCP's office by phone. Finally, your encomium to the email system doesn't apply to the sharing of medical records between hospitals on different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice groups that are located in one and the same hospital office building but that don't share the same medical records system.
My friend is well insured - s/he has no problem with insurance access. And the community where s/he  lives is replete with medical services.

In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.

My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience if they had the same skills I have in managing my care experience.

I anticipate that in the future, patients will routinely have electronic access to their own medical records. That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.

From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.

It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.

The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.

Wednesday, March 15, 2017

Chronic pain, Identity, and Health System Ethics

Prior to this past year my experience of pain had been with acute episodes. An especially painful and amusing episode occurred when I started a new job at the Massachusetts Mental Health Center after residency and fellowship. Between painting rooms in the house we were moving into and carrying boxes hither and yon I threw out my back. I lay on the floor, hardly able to move. A helpful neighbor called his PCP who came to the house. (It was 1970 and house calls actually happened.) I could see that he was regarding me with suspicion. Perhaps I was a newly arrived addict who was seeking an opiate fix. And when I started my new job, in some of my meetings I again lay on the floor, giving a rather odd impression of the new hospital ward supervisor.

The pain was severe - perhaps 9 or even 10 on the ubiquitous 0-10 scale. But I knew it would clear up before too long, and it didn't burrow into my psyche and sense of self. In the (slightly altered) words of the old spiritual, it "pained the body but not the soul."

Not so with the chronic pain I wrote about 3 days ago! It's not as severe as the back spasm, but the (a) chronicity and (b) uncertainty about if and when the pain will go away has (c) taught me lessons I only understood from the "outside" during my years of practice and (d) challenged my sense of identity.

Like many physicians, my default mode is to help others. Over the years, when asked "how are you?" my typical answer has been a hearty, upbeat "excellent!" So for the simplest of tasks - taking out the garbage and even putting on my pants (I have to protect the toes from contact with the pants leg - not easy to do) - to become difficult or impossible is a shocking change. My wife has taken over my "chores" cheerfully and uncomplainingly, but I feel ashamed at (my words) "not doing my part."

Before the foot/ankle/lower leg problem set in, I took an extended walk whenever the weather permitted, and played tennis with friends weekly. Sacrificing these activities isn't just a matter of losing forms of "recreation." Being an active, out-of-doors person has been part of who I am. These losses take another bite out of my sense of identity!

In a similar vein, I enjoy being at both of the two offices I use. But parking and walking to the office is difficult, and I can actually do most of my work from home, so I have been largely invisible at my work sites. My "productivity" may not be reduced, but collegiality is down, and loneliness is up.

Coping mechanisms are crucially important and put to the test. As an example, the toe/foot/ankle/lower leg pain is worst at night. When I try to sleep it wakes me up every 60-90 minutes. My initial reaction to these awakenings was anger, but that accomplished nothing useful and made it harder to get back to sleep. By an act of will I substituted humor - laughing at myself sitting in the dark massaging my foot and hobbling around to reduce the pain. Rather than saying "why the bleep is this happening to me" I say various forms of "what a ludicrous situation this is!"

This is a blog about organizational ethics. Readers may reasonably ask "what on earth does a painful foot and difficulty taking out the garbage have to do with organizational ethics?"

A lot!

Nowadays, organizations toot the horn about their commitment to "evidence based practice." Since the Hippocratic era, the practice with the strongest evidence of effectiveness is empathic listening. Organizations can encourage this stance or - all-to-often - squelch it with bureaucratic demands and processes that treat patients as targets for efficient "throughput."

Time pressure is a fact of life everywhere in health care, but there are skills we clinicians can develop to use time well, rather than having time use us. When I joined the mental health practice at the Harvard Community Health Plan HMO in 1975, the insurance limited the number of appointments we could have with our patients. Some clinicians put this limit front and center when they met new patients, by stressing what they couldn't do. Wise clinicians, however, approached new patients differently - "Let's first figure out what you need, and then see how we can best meet those needs." The HMO encouraged me and my colleagues to struggle with the challenge of remaining true to our mission while doing what was needed to make the necessary margin to keep the program going. (See here and here for examples of that work.)

Medical care ultimately comes down to the patient-clinician dyad, but more and more often the dyads occur in an organizational setting. Empathic listening is carried out by individuals, but organizations can encourage or thwart this deeply human process. That's where organizational ethics comes in!      

(A friend who knew about my left foot problem brought to my attention a superb article by the distinguished primary care physician Thomas Bodenheimer - "Lessons From My Left Foot." It's available at  http://www.annfammed.org/content/8/6/550.full.pdf)

Sunday, March 12, 2017

Health System Ethics and my Left Foot

I haven't written a post for more than 6 weeks. My left foot/ankle/lower leg are a big part of the reason for the lapse. So I decided to write about my experience and connect it to the topic of this blog -  health system ethics.

Many physicians have written about their own experiences of illness. Here's my  story.

In the fall of 2015 my left big toe itched. I didn't pay much attention until it began to hurt and develop redness. My primary care physician (PCP) was on a medical leave for a serious medical problem, so I saw another physician in his practice group. By that time I had red blotches on my foot as well. The physician had two hypotheses:

   (1) It might be an early stage of "vasculitis" (inflammation of the blood vessels). She did some blood tests, all of which were normal, and referred me to a rheumatologist (a specialist in autoimmune and musculoskeletal conditions).
   (2) It might be a circulatory problem, and she referred me to a vascular surgeon.

The  rheumatologist did a thorough evaluation with many blood tests. Except for two minor abnormalities, all were normal. He concluded that I did not have a systemic illness.

The vascular surgeon also did a thorough evaluation and a CT scan to visualize blood flow to my legs and feet, which showed adequate circulation with no visible blockage.
Lesson # 1: The specialists were excellent, but when they didn't find a problem within their purview, I was left with a "what now?" question. Given the absence of my long term PCP I decided to be my own case manager. I believed more than ever in the importance of primary care as the key hub of the health care system.
The pain was better during the summer. Perhaps the warmer weather explained it. Whatever the explanation, I enjoyed the summer.

In the fall of 2016 the areas of red discoloration spread onto my left ankle and lower leg. Happily, my PCP returned to practice from his long term medical leave.
Lesson # 2: Apart from all of the valuable things PCPs do, at least for me, and I would guess for many others as well, there is a powerful placebo effect from having a solid relationship with a clinician one trusts for skill, knowledge, and a genuinely caring attitude.
On examining me and hearing my history, my PCP said - "This is really weird. I have no idea what's going on. I think we should involve a dermatologist." A couple of weeks later I saw a dermatologist who suggested a few possibilities and did a biopsy. The biopsy came back "non-specific" - i.e., it didn't tell us anything. She thought we should get a second opinion.

It took several weeks for this to be arranged. The very knowledgeable consultant I saw put forward some additional possibilities and recommended repeat biopsies. These showed (a) tiny clots in the small blood vessels and (b) no signs of an inflammatory/autoimmune process.

This told us what was happening, but not why it was happening.
Lesson # 3: Humility is a virtue. My PCP acknowledged having no idea of what was going on, but did have an idea of what to do next. The first dermatologist suggested getting a further consult within her own specialty. Their non-arrogance paid off!
On the basis of seeing blood vessel clots, the second dermatologist suggested that I  see a hematologist, who put together (a) the presence of clots and (b) the fact that in the previous month I had a mild elevation of my platelets (blood cells involved with clotting) that was (c) a bit higher on repeat measure. Before our appointment she had me do further blood tests. We'd been colleagues in the past and she sent me the following email:

"I had you do some special blood tests beforehand and, indeed, you have a JAK2 mutation which is present in people with Polycythemia Vera and Essential Thrombocythemia.  This likely explains your elevated platelet count. I will be suggesting starting Hydroxyurea pills – very easy and well tolerated, to bring down the platelets and hopefully prevent more problems in the future."
Lesson # 4: In the previous 14 months I'd seen 10 different physicians. Without good coordination, this would be a surefire recipe for chaos. When  my PCP returned he carried out the coordination function very well, but throughout the 14 months the secure email system my practice group uses was invaluable. I could write to one physician and copy the note to others. This aspect of the electronic infrastructure really paid off.
I've started the new medication (Hydroxyurea), but I'm very aware that we're still proceeding on the basis of hypotheses. Blaming the elevated platelets is a plausible explanation, but two elements don't fit. A year ago, after the problem was clearly underway, a blood test showed normal platelets. The hematologist speculated that "perhaps your platelets are more 'sticky' and clot more easily." That could be true, but it's a speculation. And if the platelets are the villains of the situation, why are the symptoms limited to my left foot/ankle/lower leg?
Lesson # 5:  In 1865, the French physiologist Claude Bernard, who, among other discoveries formulated the concept of homeostasis, wrote “physicians make therapeutic experiments daily on their patients . . . . [M]edicine by its nature is an experimental science, but it must apply the experimental method systematically.” When faced with illness and suffering, patients and physicians want certainty. But as Bernard recognized 150 years ago, certainty of the kind we can have in mathematics is not to be had in medicine. Patients, physicians, and the public, need to learn how to work with and live with the absence of bedrock certainty.
 In this post I haven't touched on the powerful psychological impact of chronic pain and disability. I'll do that in future posts. If you've read this far - thank you for your attention!

Thursday, January 26, 2017

Retirement from Clinical Practice

Next week I have the privilege of facilitating a meeting on retirement sponsored by the Massachusetts Psychiatric Society. On two counts I was happy to be invited to do this.

First, from the perspective of this blog, medical societies are significant organizational players in the world of health care ethics. A well-functioning medical society helps newly minted physicians find their way into practice, provides guidance throughout the active phases of clinical careers, and supports colleagues in concluding their practices in ways that work as well as possible for our patients and for our own well-being. If a medical society isn't strengthening the ethics of its members it's not doing its job!

Second, the invitation prodded me to review my own experience of retirement from clinical practice, with the aim of distilling some comments to launch a group discussion. These are my major thoughts so far:

DREAD: Even though I was only practicing 1/3 time, I was frightened at the prospect of clinical retirement. My fear showed up in two visual images. I identified with King Antaeus, the figure in Greek mythology who derived his strength from the earth. He challenged Hercules to a wrestling match. Each time Hercules threw Antaeus to the ground, Antaeus's strength was renewed. Hercules caught on, held Antaeus in the air and crushed him to death. In one version of the story he hurled Antaeus into space, where he became a constellation. In the other image I saw myself as a sailboat utterly becalmed and helpless. Both images conveyed a feeling that my vitality and worth as a human being came from my role as a practicing physician.

MENTORING: I asked to meet with a colleague who was 10-15 years older, who to my eye was negotiating his life in an admirable manner. I told him about my fear of ending clinical practice. He told me he'd had similar concerns, but was surprised to find an element of relief when he stopped practicing, even though he'd never thought of practice as a strain to be relieved. He gave me some other practical tips, but I still remember with gratitude his reassurance about my fears.
MONEY: The meetings my wife and I had with our financial advisor were crucial. Confidence that we wouldn't go down the tubes financially was necessary for proceeding with the retirement plan, but not sufficient in itself to assuage my fears.
ENERGY: When on Friday August 31, 2007, I acknowledged to myself that I was really going to end my practice at the turn of the year, a surprising thing happened. In a desultory way I'd imagined starting a blog about ethics at an undetermined time in the future. But when I pinned down the date by which I would end my practice, without any forethought I went to Google and put in "start a blog." The inner experience was as if a stream that had been flowing in one direction (clinical practice/identity as a clinician) shifted into a new direction (the blog and the beginning of a new identity). I started this blog that day.
DISORIENTATION: When I was working full time my days were organized - especially on days when I saw patients. For clinicians, our schedule of patients tells us why we should get up in the morning. Trying to help people who are suffering assuages doubts about our purpose in life. 
LONELINESS: Retiring from clinical practice didn't mean retiring from professional activities. I continued my cherished academic position and leadership of the Harvard Pilgrim Health Care ethics program. These activities provided important and valued human connections. But I missed the richness of clinical life - connections with my long term patients and colleagues.

I'm proud of the Massachusetts Psychiatric Society for its attention to the penultimate phase of clinical career and grateful for the opportunity to participate. The health professions are devoted to the well-being of patients and the public health. If clinical retirement is handled well, these values can be pursued in new ways after physicians hand up their clinical hats.

Sunday, January 22, 2017

Affordable Care in Rural India

I just returned from India, where I visited Flame University (the name is derived from "Foundation for Liberal  and Management Education") in Pune.

At a meeting with Professor D.S. Rao, Provost and Dean of the Flame School of Business, I learned about Yeshasvini, a cooperative health insurance venture for farmers in the state of Karnataka. At the depressing moment where the new U.S. administration  is preparing to tear down President Obama's extension of health insurance to a wider population, it was heartening to learn about a program working to advance Obama's ideals by insuring the poorest of the Indian poor.

India does not have a tradition of paying for health care through insurance. The majority of health care is still paid for on an out-of-pocket basis. Even though costs are much lower than in the U.S., for the large population of rural poor, modern health care is unaffordable.

Yeshavini, started in 2003, offers a limited insurance package to members of rural farm cooperatives on a prepaid basis for less than $5 per year per insured person! The state of Karnataka matches some or all of the farmers' payments. Karnataka, approximately the size of Nebraska, has a population of 64 million. As of 2014-2015, 3.8 million were enrolledin Yeshasvini.

Yeshavini's mission is noble:
"To bring health care of International Standards within the reach of every cooperative farmer of Karnataka. We are committed to the achievement & maintenance of excellence in health care for the benefit of farmer cooperator."
Even in India, $10/ year cannot provide "health care of International Standards." The package is largely for surgical services at 550 participating hospitals. Non-surgical treatment for cancer and diabetes is  not covered. But hazards faced by farmers like snake bites. goring by bulls, and accidents involving agricultural machinery are.

From a U.S. perspective, Yeshasvini is best thought about as a "proof of concept." In 1969 when I first encountered the concept of prepaid health care delivered by the not-for-profit Harvard Community Health Plan to a defined population on a prepaid basis, I thought this was the right way to provide modern health care. I still do. I joined the group in 1975, and while I ended my practice in 2008, I still get my own  care from the group and I work with it on establishing its new ethics program.

Somewhere between the pared-down Yeshasvini program in Karnataka that is affordable to poor farmers but covers too little and the super-comprehensive U.S. programs that cover too much and are a stretch for all but the wealthiest, is the golden mean of health care. But Yeshasvini supports the view that health care should be (a) population oriented, (b) prepaid, and (c) not-for-profit.

That's a perspective likely to come under attack from the newly installed Republican administration!