May 2009 Archives
The word "empathy" is getting interesting play these days. At times it even sounds like a pejorative. President Obama used the word frequently while campaigning and since being in office. In the context of choosing a Supreme Court nominee, he said that ideally such a person should understand Americans' problems and have empathy for their fellow beings. But he's also talked about empathy (in Atlanta in Jan 09) in the context of its absence: "We have an empathy deficit when we're still sending our children down corridors of shame--schools in forgotten corners of America where the color of your skin still affects the content of your education . . . when there is Scooter Libby justice for some and Jena justice for others . . . when homeless veterans sleep on the streets . . ."
Most dictionaries will define empathy as "the intellectual identification with or the vicarious experiencing of the feelings, thoughts, or attitudes of another." Yet, for some, like Senator Orrin Hatch, President Obama's saying "empathy" when talking about judicial appointments is seen as a "code" for appointing a left leaning liberal. Instead of being seen as an admirable quality that describes someone with a visceral understanding of the human condition and especially of human suffering, it is seen as a bias.
To be fair, it could be that Republicans reflexively and correctly see the President's use of "empathy" as being empathy not for all people, but for some people, or even (in their view) the wrong people: for mothers instead of the unborn, for unions instead of big business, for the homeless and unemployed rather than for the well-off or even for the middle-class tax payer.
It did not help that Judge Sotomayor once said in a speech, "I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than the white male who hasn't lived that life." This would seem reasonable, but only if the issue at hand involved Latina women. What if the issue had to do with white men with un-rich experiences? One sees the slippery slope she is on.
As someone not in the legal field, it seems to me that if the law were absolutely cut and dry, and if the process of being a judge meant simply following algorithms, being impartial, ensuring that justice was done and procedure followed, then empathy would be irrelevant. But since judges always seem to be writing 'opinions' and disagreeing with each other, clearly, there is a human factor at work. In that case, broad empathy, a Shakespearean breadth of interest in all people, in the wise and the foolish, in the misanthrope and the saint, in politicians and the public who suffer them would surely be a good thing.
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I began my internship in 1980 at a Veterans Administration hospital in Johnson City Tennessee--the Mountain Home VA. To this day I don't think I have seen a more beautiful campus with quaint brick buildings, lush lawns, dogwood lining the main avenue, and white southern mansions in which the doctors lived.
But most beautiful and poignant was the cemetery, just to the right of the main entrance. Established in 1903 as a tribute to this corner of the "Volunteer" state that had contributed 30,000 volunteer soldiers to the Union, it was maintained beautifully. I would walk through that cemetery with reverence, the pages of history becoming more real when I read the names on headstones of men who had died in the civil war and every war since.
There was a plaque in the cemetery bearing these lines without attribution:
ON FAME'S ETERNAL CAMPING-GROUND
THEIR SILENT TENTS ARE SPREAD
AND GLORY GUARDS WITH SOLEMN ROUND
THE BIVOUAC OF THE DEAD.
I returned some years later as a specialist to work at that VA and I lived in one of the grand antebellum houses (or maybe they were post bellum--but they fit my idea of what antebellum looks like). I loved the old open wards, which, even though they were outmoded and needed to be replaced by semi-private rooms, seemed to recreate for the patients the intimacy, the camaraderie and the supportive environment of a barracks. I could often get from the patient in the next bed the low down on his neighbor's progress through the night.
My patients in those first days of my internship were largely World War II veterans, in their late fifties and sixties at the time. I recall the generosity of their spirit to us young physicians, and the stories they traded of service in North Africa, or the Pacific theater, or landing at Normandy. I wonder now how many of them are still with us--so much time has passed.
Tonight while writing this piece, I reached for my first book (which I have rarely gone back to because I immediately want to change things); it was the true story of AIDS arriving in that idyllic corner of east Tennessee.
Read MoreJohn Sotos is a physician well known in medical circles for his book, ZEBRA CARDS: AN AID TO OBSCURE DIAGNOSIS. We tell our medical students, "When you hear hoofbeats think horses, not zebras," or, common things occur commonly. But John has had a lifelong interest in rare diseases--zebras. (He is also a medical consultant for the TV show HOUSE.)
Recently, I heard John make the case in a lecture that Abraham Lincoln suffered from a rare endocrine disorder called MEN2b (Multiple Endocrine Neoplasia Type 2b) in which most patients will die of cancer of the thyroid if the thyroid is not removed. John argues that at the time of his death, Lincoln was dying. Indeed, if one looks at Lincolns pictures
from January 1864
and then a few months later in February 1865,
it does appear that he has lost weight and reports from that time suggest he was greatly fatigued. One characteristic of this syndrome is the presence of mucosal neuromas--little bumps on the lips. Close examination of photographs such as the one below suggests that he did have these.
John's talk provoked some heated debate. For more details see John's book THE PHYSICAL LINCOLN. Photographs are courtesy of John Sotos. The Grand Army of the Republic museum in Philadelphia has a pillowcase with Lincoln's blood on it, and DNA from that could conceivably prove or disprove this hypothesis. (It could also prove or disprove another hypothesis that states Lincoln had another condition, namely Marfan's syndrome.) For now, the museum has decided to wait on DNA testing.
There have been hundreds of books about Lincoln. In fact, the Library of Congress catalog suggests that a new book about Lincoln comes out every 5 days or so. If indeed Lincoln had a disease whose manifestations had much to do with his behavior, and which might explain the early deaths of his mother and of his son--seminal events in any life--then in a sense, all previous biographies are inaccurate.
But is this a slippery slope? Are historians to become forensic anthropologists?
Would Abe have wanted the DNA testing done?
One day there might be a test that could tell us what he would have decided.
Sincere thanks for all the comments, and the healthy debate. Democracy and civil discourse at work!
To respond to a few points from "A Concerned Physician" :
Of course, I am all for preventive medicine! Drugs for hypertension to prevent stroke, Vit A for blindness. . . who could be against that.? But if you put forth the hypothesis that preventive care will SAVE money (as the President proposes) . . . well, I'm sorry to tell you that the evidence (yes, evidence!) isn't there. The fact is if we do the right thing, cover everyone, get everybody to have regular check-ups, you will prolong life and uncover lots of treatable conditions that need investigaton, consultations and more treatment. I'm all for that. But it wont save money.
So please do read the article by Marmor et al titled, "The Obama Administartion's Options for Health Care Cost Control: Hope vs Reality" in the Annals of Internal Medicine (which I hope you will agree is ). The Congressinal Budget Office's reports projects little savings in this fashion.
As for IT and Electronic Medical Record (EMR), I'm no Luddite. I use it and can't remember what life was like before EMR. But again, if the thesis is that computerized records will SAVE money . . . well, I'm sorry but the evidence does not back that up. The Congressional Budget Office estimates that EMR will reduce national health care spending only "by an estimated $8 billion over the 2010-2019 period (or by less than one tenth of 1%)". In other words we are proposing to spend 20 plus billion to achieve these savings. [See the 08 Congressional Budget Office report, "Evidence on the Costs and Benefits of Health Information Technology "- -our taxes at work to produce these studies for us to read and hopefully save goverment from wasting tax money.]
The other problem which is more subjective and qualitative, is the effect the computer has on distancing physicians from the patient. I visited an ER with a friend recently, and nurses, docs, lab techs were interrogating the patient over their shoulder while making entries in the computer! It went on for hours. It was subjectively a poor experience overall for the patient, but if you were to study her record, I've no doubt it would shine and glisten like a jewel! The iPatient got wonderful care, while the real patient left disillusioned with medicine. I do think the EMR impedes medical education. (the link is to an article in PLoS) .
Finally, I don't think we we disagree on what we'd like for our patients, or on the benefits (from the time of Edward Jenner and small pox vaccine) of good science to find the best ways to treat and diagnose patients. But what I find annoying is the slavishness to that non-sequitir, "Evidence Based Medicine" that seems to shortcut critical thinking: I've seen too many patients railroaded into the "critical pathway" for pneumonia based on the best of evidence-based medicine, and by every metric the physicians did well and the hospital is pleased. The only problem was the patient didn't have pneumonia, but heart failure! A little more face time and less haste to plug people into EBM algorithms as if we are herding sheep down chutes would do much for patient satisfaction and improve medical care. We simply have no idea of the costs of those kinds of medical errors, of wrong diagnoses from people not spending time examining and interrogating the patient and re-examining and re-interrogating the patient.
So, to "Concerned Physician: I'm equally concerned. Alas, contolling costs, as our parents taught us, is best done by cutting costs, not by pie in the sky schemes that are postulated to save money. The remedy is painful but necessary.
p.s. I happily accept your label that my conclusions are drawn from ignorance. At least you and I will have the joy of not being alone! (-:
05/14/09 9:22 AM
If "Evidence Based Medicine" is like "Sex Based Intercourse" then "Comparative Effectiveness Medicine" is like . . .?
President Obama is in a bit of a bind, lets face it with his laudable goal to have health coverage for all uninsured Americans. The health care math is simple: we already spend a ton on health care and his goal will require spending more. His options are to generate new revenue, or the other option (the needed option, I would say) is to cut costs. But you saw what happened to Hilary years ago when she tried that. To quote from a great series of articles in the Annals of Internal Medicine, "A dollar spent on medical care is a dollar of income for someone." Cutting costs means cutting income for lots of different players and they won't be happy, and yet there seems to be no other way.
But President Obama thinks he can raise money largely through three methods that no one has proven can save money:
1) Investing in Information Technology: I don't see how that saves money but it does ensure that America's doctors will get better tans on their faces from long exposure to screen glow; the iPatient in the computer will get great care while the patient in the bed will wonder where the doctors are.
2) Preventive medicine: Studies actually suggest this usually costs more money, despite all the theories of how it should save money
3) And finally the President wants to invest in "Comparative Effectiveness" research so that we only pay for what works.
What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed.
I worry that "Comparative Effectiveness" or "CE" is going to be the next medical buzz word, just like "Evidence Based Medicine" or "EBM" has been the buzz word for a decade. "Evidence Based Medicine" is a term which makes about as much sense as "Sex-based intercourse"--Were we practicing based on zodiac signs before EBM came along? (By the way, I borrowed "sex based intercourse" after hearing a prominent chair of medicine say it--I don't know if he coined it, but I thought it was brilliant). Soon we'll have a generation of physicians who are CE experts to bump out the EBM experts.
Lets take away the incentives to do to patient and instead create incentives to do for patients, to be with patients. We don't need to do comparative effectiveness trials to see if that works; we can just ask patients.
I love medical riddles. (I don't mean the "Why-did-the-doctor-give-up-his-practice?" --"Because-he-lost-his-patien-ce!" kind of riddle). I mean the kind that one wrestles with, the kind that is instructive, a teacher's tool, a way to make the student reason, formulate hypotheses, go to the book, research and eliminate possibilities . . . and come to the answer. Such riddles have a hallowed place in medicine--I remember these riddles only because I was asked them as a student and I learned something in trying to solve them.
So I'll often ask a medical student or resident, "Why do we say, 'Beware of the patient with a glass eye and a big liver?'"
If the student were to reason this out, the steps ideally might go something like this:
I wonder why the patient had a glass eye in the first place.
I suppose it could be trauma . . . could be a malignancy.
At this juncture the student might look up malignancies that occur in the eye and that justify removing an eye.
A melanoma in the eye is a common reason to remove an eye. (Or used to be--it has changed a bit with new treatment).
Now . . . how might I connect this to a big liver?
Hmmm. If melanoma metastasized to the liver, then they probably would never have taken the eye out in the first place and replaced it with a prosthetic eye.
At this point the student might look in a textbook or in UpToDate and find that ocular melanoma is famous for recurring years later with distant metastases. When it does return it often presents with new tumors in the liver. Bingo!
Ideally that's how a student would reason. If however the student were to decide to "google" the question by typing in "glass eye and big liver" as I just did, the first hit is NEJM: Solution to a Medical Mystery, which gives the answer to a photoquiz the New England Journal of Medicine put in its pages in 1997, showing an elderly lady with one eye that was clearly yellow with jaundice and the other which was pearly white. (The latter had to be a glass eye because there is no earthly reason for jaundice in just one eye. And she was jaundiced because she had melanoma metastases in the liver.) A total of 928 readers had the correct answer. No surprise I suppose because it's an old riddle.
If the Journal were to repeat the photoquiz with a similar patient in the years to come, Google would lead the readers right to the answer.
Which is why when I offered a new riddle to my students last week while we were rounding, I emphatically added, "Don't Google!" Nothing at all against Google--we're proud of Google at Stanford, and indeed my kid brother works there. But the point of the riddle is to search your brain, not Google. To reason and to come to the answer for the right reasons . . not just to come to the answer.
In case you're curious, the riddle I gave my students and which they are supposed to report on this week is:
A man walks into a bar, offers to keep his head completely submerged in a bucket of water for twenty minutes and if he doesnt he will buy drinks all around and if he does the patrons must stand him a round of drinks. He does and so they do. The question is how did he do it?
A clue? No hidden tracheostomy, and yes it's a medical condition that allows him to do this. And remember, don't google this riddle!
There are moments as a teacher when I'm conscious that I'm trotting out the same exact phrase my Professor used with me years ago. It's an eerie feeling, as if my old mentor is not just in the room, but in my shoes, using me as his mouthpiece. It happened yesterday when I was at the bedside, showing my students how to feel a patient's spleen which happened to be quite enlarged.
Anyone can feel a big liver. Sitting as it does under the right lower ribs, the liver when it enlarges isn't shy and makes itself known to even the most amateurish of probers. But the swollen spleen is more elusive. It is set back deep in the belly, under the left rib cage; it has to be three times its normal size to be felt, and even then it often lacks a distinct edge and is easily missed by the inexperienced examiner.
As a student I couldn't convince myself that I'd felt the spleen, even when it was known to be massively enlarged. I began to doubt myself. One day my teacher, his hands on the patient's belly, had me lay my fingers over his fingers. Then he slid his fingers out from under mine, instructing me not to budge. "Don't try to palpate the spleen, but instead let the spleen come and palpate your fingers! Don't dig! There is no gold there." As the patient took a deep breath, her diaphragm contracted and pushed the spleen down and my waiting fingers felt a gentle nudge, like a whale bumping into a boat. Let the spleen come to your fingers! It was a brilliant pearl of his own invention. For me it was an extraordinary moment, a breakthrough. It was as if he'd put himself in my shoes, anticipated the difficulty and also shared mydelight in success.
Read MoreIn my previous post I used a phrase from a Lee Robinson poem that had the line "finding each other nose to nose."
That prompted Bill to write:
" . . . reminded me of visiting New Zealand for an international peroxidase meeting. The organizers had the opening ceremony follow Maori tradition (because we were on Maori land in Akaroa). The ceremony included singing etc, but with the Auslanders kept separate from the natives, divided by an imaginary line. We were not permitted to pass until the proper time. Individually we came forward, described from where we came (both geographically & biologically...the names and origins of our parents) and touching noses (actually sharing breath) with one of the welcoming natives. I'm pretty self-conscious & thought I'd panic....but I didn't. Quite the opposite, I thought it was a beautiful expression of humanity; what's more intimate than sharing a breath with another?"
What Bill described is a great example of ritual, a subject that interests me in the context of the bedside examination of the patient. Rituals, anthropologists will tell us, are about transformation. The rituals we use for marriage, baptism or inaugurating a President are as elaborate as they are because we associate the ritual with a major life passage, the crossing of a critical threshold, or in other words, with transformation.
Examining the patient at the bedside has all the critical ingredients of a ritual: it is usually performed in a special space (the doctor's office or the hospital bed); it involves one person baring his or her soul and then baring his or her body and allowing another person the privilege of touch; the person examining is often wearing a special uniform (the white coat) and performs a systematic examination where the steps are somewhat mysterious to the patient and using instruments that are the tokens and talismans of the profession. If done well, skillfully and respectfully, the ritual earns the trust of the patient, and it also lays the foundation for the patient-physician relationship. If done poorly, or cursorily, or sloppily (applying stethoscope to the clothing and not to the bare skin), it does the opposite--it creates mistrust, or even a sense of being disrepcted.
In beginning this blog, I wanted to find a way to salute you the reader, to reach around your monitor and say hello. A poet friend, Lee Robinson, just sent me her new collection, "Creed" and she begins the book with the lines:
"Shall we begin, you and I, two
strangers finding each other nose to
nose . . ."
She's captured my sense of awe at this moment. For friends who know me, a blog must seem an improbable venture. After all, as a physician I have railed against the " iPatient" --the virtual patient we are busy caring for in the computer, while the patient in the bed is ignored, reduced to an icon--and I have argued that presence (human and not machine, real and not virtual) at the bedside is everything in medicine. But a blog allows me another kind of presence, with you, wherever you happen to be.
So here is the deal, a creed of sorts:
- I'll write personally, and about things that move me, and more about persons than things.
- Though I am fascinated by knowledge, I am even more fascinated by wisdom. (As T.S Eliot put it, "where is the wisdom we have lost in knowledge, where is the knowledge we have lost in information"), and will be looking to find wisdom in this sea of information.
- Medicine may be the lens through which I see the world, but since I think of medicine as "life +", a place where life is exaggerated and seen at its most vital and poignant, I'll be writing about life more than I will be writing about medicine.
- And last but not least, for this to be a conversation, you will have to reach around that monitor and say something.
So here's to an eventful journey. We can't get there till we begin, so what say we begin?
Abraham Verghese
