“I Hate Doctors”

A visitor came today to my blog from Google with the search words “I hate doctors”. While, I don’t know the true motivation and concern of this visitor, I think that this visitor’s search terms are consistent with the ambivalent feeling people have about doctors. Whether it is fair to characterize this ambivalence in the extremes of “love” and “hate” or some more moderate terms can be considered but obviously the ambivalence is a realistic phenomenon.

Why are we loved? Is it because, even if we cannot always meet the patient’s desires, we have a potential of bringing hope to the patient? Is it because most of us radiate a feeling of care and understanding? Patients may start out shaking our hands but there are times later on in the relationship when they actually hug us. Why are they doing that? Is it to show we really are connected emotionally and spiritually?

Why are we hated? Is it because we are the ones who find the bad spots in the patient’s body and give the bad news? Is it because some of us don’t live up to the patient’s expectations either in competency, thoughtfulness or concern? Is it because some of us still exude a paternalistic smell in a consumer and patient autonomous atmosphere?

Why are we both loved and hated? Is it because each patient, their condition and their experience both with illness and doctors are different? Is it because doctors are human and have their ups and down cognitively and emotionally and this may vary their appearance towards the patient?


To whatever degree we are either loved, hated or both, here is the takeaway message: this response of our patients should be a marker that we should not ignore. By paying attention to the patient’s words and behavior toward us as a kind of feedback regarding our own words and behavior, we may learn about our practice and ourselves and perhaps improve. We all remember being graded in residency, medical school and earlier by our teachers. Now as we practice medicine, we should remember we are still being graded but by our patients and their families and be prepared to learn from it. ..Maurice.

IMPORTANT NOTICE:
AS OF DECEMBER 22 2008 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "I HATE DOCTORS":CHAPTER 2 TO CONTINUE COMMENTS. ..Maurice.

About Miracles: “When I Hear the Dead Singing”

I have just returned from an ethics consult this afternoon regarding a terminal cancer patient whose family is waiting but also praying for a miracle. So interest in miracles, our recent topic, is alive and well. In this regard, I found a poem titled "A Poem About Miracles" in which the Canadian poet Alden Nowlan discovers a miracle when listening to a recording and to his astonishment he hears the dead singing. ..Maurice.

"A Poem About Miracles”
by Alden Nowlan

Why don't the records go blank
the instant the singer dies?
Oh, I know there are explanations
but they don't convince me
I'm still surprised
When I hear the dead singing
As for orchestra's
I expect the Instruments
To fall silent one by one
as the musicians succumb
to cancer and heart disease
so that toward the end
I turn on a disc
labelled Gotterdammerung
and all that comes out
is the sound of one sick old man
scraping a shaky bow
across an out-of-tune fiddle.

(Note: This poem is thought to be in the public domain)

Unintended Humor: Bad Chart Writing

Physicians learn in medical school to take a careful and complete history and perform a thorough physical exam. But this is only one aspect of what physicians do. The other part is actually writing down what information they obtained. And this is when mistakes can occur.. not necessarily on purpose. The mistakes occur because many physicians really don’t understand grammar (how to write) or they are just plain rushed or tired. Doctors should be reminded to read what they just wrote and ask themselves: “Is this what I really wanted to say?”
.
What you see below are examples of such writing. The physician is trying to express something important and real but unfortunately how it is expressed is grossly misleading and often, as seen in these examples, humorous. Anyone have any other examples? ..Maurice.

EXAMPLES OF BAD CHART WRITING

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. She has no rigors or shaking chills, but her husband states she was very
hot in bed last night.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day the knee was better, and on the third day it
disappeared.

7. The patient is tearful and crying constantly. She also appears to be
depressed.

8. The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without my permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but
forgetful.

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she
got a divorce.

19. I saw your patient today, who is still under our car for physical
therapy.

What are Miracles?

There would seem to be truth in Bob Koepp's comment in the last posting when he wrote: "Patients should not be discouraged from hoping for miracles, but they should be given to understand that miracles are not the province of medicine. Doctors don't know how to perform miracles, and they don't know how to create the conditions in which miracles might occur. Whatever doctors or the rest of us mere mortals might have it in our power to bring about, it's not miracles." Thus physicians can control only factors related to the laws of nature. This view of Bob's would be consistent with that in an article titled "Miracles: What Is a Miracle?" which I discovered at the website of
The Global Oneness Committment where this and other aspects of spirituality and religion are described. Here is the brief article:

A miracle can be defined as an event contrary to, but not a violation of, a law of nature. If 'violation' is not being used in a technical sense, then a miracle can still be described as a violation of a law of nature - where 'violation' would mean something like "contrary to what could have happened had nature been the only force operative." An event may be contrary to a law of nature without thereby invalidating it, if non-natural forces cause it. This follows from the fact that laws of nature do not describe, nor are they intended to describe, the logically possible. They only describe the physically possible. Even if the laws of nature were logically necessary, there could be events contrary to those laws if it is assumed that the scope of those laws is limited. Apart from belief in miracles, one is left with a system of beliefs that has had and will continue to have enormous significance - good and bad - for people's lives. However, for the majority of persons for whom these beliefs have that significance, religion could no longer function in the way it does if they became convinced of the falsity of their beliefs. What one is practicing may be similar in significant respects to the religious tradition, but one will not be practicing that religion, nor will one properly be regarded as a believer. Prayers are empowered by a clear mind and heart, and purity of intention. With clarity, our consciousness aligns with higher consciousness, where the forces of nature and laws of creation operate according to divine order. Understanding Miracles"Those things are properly called miracles which are done by divine agency beyond the order commonly observed in nature ( praeter ordinem communiter observatum in rebus )." A miracle, metaphysically speaking, is never a mere coincidence - no matter how extraordinary or significant. If you miss a plane and the plane crashes, that is not a miracle unless God intervened in the natural course of events causing you to miss the flight! A miracle is a supernaturally (divinely) caused event - an event (ordinarily) different from what would have occurred in the normal ('natural') course of events. It is a divine overriding of, or interference with, the natural order. As such, it need not be extraordinary, marvelous or significant, and it must be something other than a coincidence, no matter how remarkable - unless the 'coincidence' itself is caused by divine intervention (i.e., not really a coincidence at all). Miracles, however, are ordinarily understood to be not just products of divine intervention in the natural order, but extraordinary, marvelous and significant as well. Thus, Aquinas says a miracle is "beyond the order commonly observed" and Dr. Eric Mascall says that the word 'miracle' signifies in Christian theology a striking interposition of divine power by which the operations of the ordinary course of nature are overruled, suspended, or modified. Technically speaking miracles are not violations of such laws but instead are positive instances of those laws. This is because laws of nature do not, and are not meant to, account for or describe events with supernatural causes - but only those with natural causes. Once some event is assumed to have a supernatural cause it is, by that very fact, outside the scope of laws of nature altogether and so cannot violate them. Only if one disregards the possibility of supernatural causes, can known exceptions to laws possibly be regarded as violations of laws. However, in such a case there might be better reason to suppose that the exception simply shows what was taken to be a law is not really a law, rather than, the exception is a violation of a genuine law of nature. If a miracle is not a violation of a law of nature, then how is it to be defined in relation to laws of nature?

What physicians have left for them to attempt to create a miracle would be to pray with and for the patient to have a miracle occur. "Praying with the patient" is that a role for the physician? .. ahh! But that is another topic for ethical discussion, later. ..Maurice.

Attempting Miracle Cures with Unproven Treatments: Should Doctors Do It?

Let’s get down to brass tacks regarding miracles in medicine. We need to review the ethics of an issue physicians can face in their career. Patients and their families are looking for miracle cures when the illness has been treated, the treatment and additional treatment fails or as in the case of some diseases, such as symptomatic rabies, there is no treatment but only death. And the patient or their family will look at the physician and say “how about trying…?”, “I read about..”, “What else can you prescribe..?” How should the physician respond when the physician suspects the prognosis is nil. Should the physician respond frankly with “I have done all I can do.. there is nothing else to do for a cure.. but I can make you comfortable..”? Or should the physician under pressure from the patient and family not give up and perhaps concur with their requests or recommend a treatment that is unproven? After all, is there anything to lose? This action will demonstrate to the patient and family that the physician has their true interest at heart, he or she has listened to them and is willing to enter this adventure with them. Should this make the physician feel more comfortable and have no regrets regarding the outcome? Would the comfort also extend to the idea that there might be less chance for malpractice liability as initiated by the family?

But what is there to lose? What about providing an unproven therapy? Is there a scientific or an ethical rationale for experimenting a theory on a single patient? If the response is successful, what does this prove? And if not? Or does this not matter? What are the burdens to the use of unproven therapy in such cases as I have described? Would the toxicity kill the patient and not the underlying disease? Or should we look at the harms of treatment as irrelevant if the benefit is a miraculous recovery? What are other potential losses we can consider? How about an element of the profession of medicine that deals with society’s understanding that physicians practice under scientific principles and not as some irrational “witch doctor”? Would medicine lose society’s respect? And another question: who will pay for the unproven treatment? This deals also with justice and shepherding scarce resources such as providing that care and treatment is available to other patients? Would patients lose something they need by the act of utilizing unproven treatment on another patient?

Many questions but what are the answers? Miracles are miracles because they may be hoped for but realistically never expected to happen and if occurring are simply unexplainable. How far, if ever, should physicians go to reach for a miracle? ..Maurice.

More on Medical Miracles

I think the discussion of medical miracles which has been going on in the Comment section of my last post is worthy of publishing as a new post. And so here it is...
..Maurice.



At Wed Jun 22, 07:29:19 PM 2005, Maurice Bernstein, M.D. said...

For those interested in music therapy, there is the website of the Healing Music Organization. The organization is described as follows: "The Healing Music Organization (HMO) provides information, resources, tools, and a forum for dialogue to people interested in the healing power of sound and music. The Healing Music Organization serves as a bridge between the worlds of spirituality, art, and medicine by honoring the value of each modality. We support the concept of miracles in healing when the body, mind and spirit learn to harmonize together and resonate with the vast energy of the universe." Some interesting research results regarding music, sound and vibration are described on the site.

There is no doubt that music plays a major role in our life from iPod, dance parties, concerts and even "elevator music". As with poetry and humor, it is hard to know to what extent these media are truely therapeutic for disease as a part of alternate therapy in the individual patient. But since they all, in a proper titration, often appear to relieve stress, that in itself is a good. ..Maurice.


At Thu Jun 23, 12:24:38 PM 2005, Bob Koepp said...

Music, poety, dance, close friendships -- all these and many more have a place in helping us to maintain or recover our health. But miracles? I have a few problems here, not the least of which is trying to get clear about just what a miracle is.

For example, the Healing Music Organization that Maurice mentions seems to view miracles as somehow related to what can happen "when the body, mind and spirit learn to harmonize together and resonate with the vast energy of the universe." Let's suppose that such harmonic resonance actually occurs, and actually correlates with healing not otherwise attributable to medical interventions or the natural restorative, regenerative capacities of organisms. Wouldn't the assumed connection to getting into the "universal groove" suggest that there's something wholly natural (i.e., non-miraculous) taking place?

Just wondering.


At Thu Jun 23, 05:21:01 PM 2005, Alyssa Uphoff said...

The birth of a baby is “wholly natural” but do we think that it is inappropriate for parents to call the new addition their “little miracle”?

In my experience, the feeling that something is miraculous (or not) is entirely up to the individual. The same exact event can be viewed by multiple people: for one: it may be a miracle, for another: serendipity, you: a scientific or natural course of events. I don’t think that we should discount patients, or their families, when they believe a miracle has occurred or are hoping for one to occur. If a person with cancer improves and goes into remission, someone might say that it is thanks to the chemo, radiation, surgery, or some other treatment. For someone else, that can be a miraculous event. A woman was sure she would die, but she didn’t. Maybe she believes God worked through the medicine. Or touched her divinely and healed her. I don’t think that anyone should try to take that from her.

I think that it is more complicated when serious injury and terminal conditions are on the line. Very often in a consultation, after a lengthy discussion regarding why it a certain treatment was no longer helping, a patient’s family member can see that they are losing ground in the fight to “save” the patient, and will look at the physician and say, “But doctor, don’t you believe in miracles?” Almost every doctor I know said, “No.” For many people in the medical community, the word miracle is extremely dangerous. Families sometimes use their hope for a miracle recovery as ammunition to keep a patient on artificial treatments, even when there is insurmountable evidence that their loved one will not survive, will never again regain consciousness, that a limb must be amputated, etc., etc.

In my opinion, discounting a person’s hope for a miracle is an insensitive and unwise move. So what if it is illogical and unreasonable? While illness can be academically internalized by those people on the treatment team, many families feel like they are lost and outnumbered. They are pushed to make life and death decisions that for which they are not prepared. They cannot get their way with an academically fueled battle, so they bring out the irrational “miracle.” I found though that acknowledging their hope helped us make more headway. If you open up the discussion of hope and spirituality then the family can sometimes feel less alienated and angry.



At Thu Jun 23, 08:28:38 PM 2005, Bob Koepp said...

I certainly didn't intend to suggest that there aren't very many interesting and valuable perspectives from which people can view events. And of course people apply the term 'miracle' to all sorts of events. I'm even quite willing to explore the therapeutic value of harmonic resonances, an idea at least as old as Pythagoras.

But there's also a long and sordid history of miraculous cures and flim flam that plays on the vulnerabilities of sick people. When an organization endorses the "concept of miracles in healing", it is time to be vigilant.


At Thu Jun 23, 08:59:15 PM 2005, Alyssa Uphoff said...

I agree that the way that HMO characterized their mission seems to play on those vulnerabilities.

Poetry in Medicine (2)

Continuing on with this thread, I have found two writings related to the use and benefit of poetry in general medicine and psychiatry. With regard primarily to its use in psychiatry read "Poetry as Therapy" by Perie J. Longo, PhD.

In Poetry As Healer, Deborah L. Shelton, covers some of the history and research into the use of poetry as therapy. Also, the experience of Dr.Rafael Campo is quoted as in this excerpt:

"I can't tell you how many times patients have come in and said a poem has changed their understanding of the experience [of their illness]," said Rafael Campo, MD, assistant professor of internal medicine at Beth Israel-Deaconess Medical Center. "Poetry has the power to say that others have been through this, that you can live with it too." As a physician-poet, he understands the importance of that message. For example, "a breast cancer diagnosis is a terrifying experience for many people," said Dr. Campo, who discusses poetry with about a third of his patients. "But here's something -- a poem -- that will give a different perspective on the experience. You're engaging the patient and letting them know you see them as a whole person and not just a lump in a breast."
… Poetry can facilitate effective communication and empathy, said Dr. Campo. And that's an important part of being a good doctor. "Empathic care providers provide the best care to patients, and poetry is a useful means for exploring empathy and forming those connections with patients," he said.

Thinking about all this, I wrote the following poem. Maybe it will be therapeutic to someone.


Woeful Toeful

There once was a man who'd shout
"I have this God-awful gout!"
His Doc wrote this rhyme,
That he repeated time after time,
And his gout just faded out, faded out.

Anyone want to try to write another poem? ..Maurice.

Poetry in Medicine

Recent previous postings dealt with the possible role of humor in medicine. I would like to bring up the topic now of poetry in medicine and what it may represent. As many of you know, publication of poems relating to medicine is a regular feature in the Journal of the American Medical Association. What is it about medicine and disease that stimulates poetry writing and what effect does reading such poems carry? I found one discussion of the topic in
Community Ethics , the Newsletter of the Consortium Ethics Program of the University of Pittsburgh titled “Why Poetry in Health Care?” and written by Eugene Hirsch, M.D. Here is an excerpt. Notice how writing poetry by this physician has provided him with a means of expressing what to him is most meaningful in his medical practice.

I suppose most poets write for more esoteric reasons. But, as a physician, I wanted to learn to come to terms with life without trying to control it - at least enough to resist losing my identity through the absorbing seduction of impersonal medical technology. Some physicians are fulfilled by centering their lives around tangible problems and systems rather than the intangible nuances which accompany long term interactions with people and their functioning. Indeed, in taking nebulous paths, I sometimes think I have failed in important aspects of medicine. With my limited ability to follow tangible guideposts in the rapid fire of clinical processing, I have gravitated toward patients with altered function and chronic medical problems rather than acute ones, keeping company with my geriatrician peers and with the imaginations of philosophers and English teachers. Indeed, I have wondered how it is that as humans we tend so well to fostering value-free hard science, yet seem so helpless in stimulating value-laden, humanistic progress in our affective and societal selves.

What does writing poetry accomplish for the writer whether a physician or a patient? Clearly, at least it provides a means of emotional ventilation that can be considered therapeutic to whatever the role of the author. I think also it becomes an educational tool for the reader, in that aspects of being a patient or treating a patient which may previously have been unrecognized by the reader can now become apparent. And with that knowledge, the reader will be more understanding of medical issues that will be personally encountered later.
Let me give you my comments about what I think is the medical value of poems such as the following two which were written and posted here by me last year.

July 22, 2004-
Unspoken Translation
by Maurice Bernstein, M.D.

“I have this”
She talked through a translator with a language I don’t know
“And it burns”
She pulls up her shirt and points to her kidney
“I am worried”
Why? I ask through a translator
“I am unmarried and have a small child”
Are you worried about your kidney? The translator speaks for me
Tears fill her eyes and move down her cheeks and
I don’t need a translator to tell me more.

This poem was based on a recent patient encounter. I have been frustrated by the need and process of translation as a means of communicating with patients. I wanted to show that there are times when empathetic observation can be sufficient to understand the patient.

August 29, 2004-
Uninvited Guest
By Maurice Bernstein, M.D.

Oh, Culex, you uninvited guest
Who kissed me, spreading your exotic gift
And leaving me weak, feverish, seeing double
And becoming suddenly a modern statistic.

Oh, Culex, where are you now?
What life are you going to challenge next?
Stay away. I'll be back.
And, you know, Culex, I have never been to Uganda.

Here I was sickened by West Nile virus infection and frustrated and angry by the degree of sickness from some small creature without any warning to which I could not react. As a patient, I wanted to ventilate my anger and I think I did this, in part, through writing this poem as I returned from the hospital.

What is your take on poetry in medicine? And do you have a poem to share you wrote as a healthcare provider or that came from you or someone else as a patient? ..Maurice.

More Hippocratic Aphorisms

Aphorism is a short, pithy statement of an evident truth concerned with life or nature. Hippocrates wrote a series of aphorisms on medical practice. They became handy hints for the physicians of the time (400 BCE). Perhaps they represented a tool analogous to what medical interns have carried around in their pockets—the Merck Manual. Many aphorisms dealt with the art of purging since very few other treatments were available then. Prognostication between curable and incurable conditions was a common issue in the aphorisms. The first Hippocratic aphorisms was the topic of the last posting. Here are some more aphorisms of a general nature as extracted from http://classics.mit.edu. To read a translation of them all go to the link.

Aphorisms by Hippocrates and translated by Francis Adams

Section II-19.-In acute diseases it is not quite safe to prognosticate either death or recovery.

Section II-33. In every disease it is a good sign when the patient's intellect is sound, and he is disposed to take whatever food is offered to him; but the contrary is bad.

Section II-44. Persons who are naturally very fat are apt to die earlier than those who are slender.


Section II-52 When doing everything according to indications, although things may not turn out agreeably to indication, we should not change to another while the original appearances remain.

Section VII-43. A woman does not become ambidextrous.

Section VII-87. Those diseases, which medicines do not cure, iron (the knife?) cures; those which iron cannot cure, fire cures; and those which fire cannot cure, are to be reckoned wholly incurable.

Any comments on your interpretation of the significance of these views of Hippocrates? ..Maurice.

“Too Little Life, Too Much Medicine"

Bioethicist Albert R. Jonsen, Ph.D., Professor Emeritus of Ethics in Medicine, School of Medicine at the University of Washington gave a talk day before yesterday at UCLA titled “Too Little Life, Too Much Medicine” in which he dissected the First Aphorism of Hippocrates in terms of modern medicine and the futility debate. I thought it would be valuable to give a little thought to this reinterpretation by Dr. Jonsen. The following is based directly on the talk and handout.

The First Aphorism of Hippocrates reads “Life is short; the art is long. Opportunity is fleeting, experience perilous and judgment is difficult. The physician must be ready, not only to do his duty himself, but to secure the cooperation of the patient, attendants and of externals.” The Classic Interpretation was that “one’s life is too short to learn all one needs to know about medicine. Therefore, take chances, don’t rely on experience and take responsibility for the consequences.”

Dr. Jonsen’s reinterpretation for modern medicine includes:
“Human life, not the doctor’s life, is always too short. [There are always doctors around.] There is always plenty of medical science and skill. The nature of science and technology is [considered] infinite and infallible. Therefore sometimes there is more medicine than life can bear.”

The point of the lecture, I think, was to remind us all is that medical technology has developed to such an extent in maintaining life, that just because technology has the potential to do what it can do is reason in itself to always employ it despite any other factors which might warrant its non-use. I can think of the current example of the case of Terri Schiavo, where the technology of being able to provide a life-sustaining potion of fluid and nutriments to someone who is unable to swallow on their own and can maintain life is reason enough to continue this technology in the patient even in the face of permanent unconsciousness and unawareness. One can see this irrational use of medical technology in other examples of treatments which will not achieve the goal the patient might have wanted but because it is there, use it! The push to use it comes from patients, families and even the companies that developed the technology or drug. And, under pressure from them, the physician may throw experience away and prescribe the therapy.

I didn’t read Dr. Jonsen as advocating diminishing the progression of the advancement of science and technology but just warning us of the possibility of its ethically non-beneficent effects in medical practice. ..Maurice.

Medical Decisions: In Whose Best Interest at End-of-Life and PVS?

Today, on ABC’s “Good Morning America”, physician and Senator Bill Frist commenting on the autopsy results of Terri Schiavo said “She had devastating brain damage, and with that, the chapter's closed." But is the chapter really closed?

Today, Gov. Jeb Bush said he might ask a state attorney to investigate allegations that Terri Schiavo's husband waited more than an hour to call 911 after her 1990 collapse.

Today, Terri Schiavo's brother Bobby Schindler said they knew all along that Terri was profoundly brain damaged but they just wanted to bring her home and take care of her.

And the “right to life” groups are putting pressure on several state houses to write laws to prevent physicians from removing nutrition and hydration from patients.
No, the chapter is not closed.

And I think, neither is an ethical discussion of the Terri Schiavo case a closed chapter. In previous postings, I have brought out the concept of “best interest” in the treatment decisions of patients and have remarked on the issue of “in whose best interest” is a decision being made. This is particularly of note in end-of-life or persistent vegetative state patients. Doctors are taught that their primary interest and fiduciary responsibility is for their patient. And most doctors practice their medicine that way. Of course, they are also taught to consider the psycho-social impact of their patient’s disability on the patient’s family. But it is their patient, whose needs and the attempt to meet the patient’s goals which usually trump all else. The question I want to bring up now and perhaps as a “devils advocate” is whether we should begin to consider seriously changing of the paradigm when the patient is terminally ill or in a permanent vegetative state. Should we, at that point in the patient’s medical course, look seriously at the needs of the family? Should we begin to consider requests and decisions that now might be in the best interest of the family since the patient’s interest as a cognitive person is virtually gone or now gone forever? Would it have been in the best interest of the Schindler family to have allowed them to take home and nurse their heart beating “doll”. For Terri as a person, this would have been irrelevant. Of course, and this is where best interest for the family may not be a simple consideration, Mr. Schiavo may have found that his best interest was to follow what he understood was his wife’s request.

Physicians practice their profession at the desire of society. If society comes to a consensus that they want more consideration of the family’s best interest and their views including medically extra-ordinary treatment or even “right to life” decisions in the terminally ill or persistent vegetative state patients can physicians ignore this request?

..Maurice.

Humor as Used in the Doctor-Patient Relationship: Constructive and Destructive(2)

I wondered whether humor in psychiatric practice was a useful tool in the psychiatrist-patient relationship or whether there were special concerns with its use as compared with the use in general medical practice.

Psychiatrist Shrinkette covers this issue on her blog and has responses from some visitors on how they look at humor in psychiatric consultations. In addition, Shrinkette wrote me e-mail stating, in part, her view:

"...what's different about psychiatry is that the relationship between psychiatrist and patient becomes fodder for understanding the patient's life and symptoms. People respond to us as they've responded to other important figures in their past (it's called transference). So humor becomes one more variable to interpret.

Another difference is that sometimes patient's symptoms can include
extreme humor (manic patients, for example). We're supposed to model
appropriate behavior, and that means not cracking up at their stream of
manic jokes (if the whole session consists of the patient joking and me
laughing, that's not therapy!) But sometimes we can soften an
important message to a patient with a little joking (at least we hope
so)."

Thanks Shrinkette. ..Maurice.

Parental Medical Decision Making: In Whose Best Interest?

I indicated in my last post that the in evaluating the ethics of the parental medical decision-making scenarios I presented, the goal would be in terms of the best interest with regard to the child patient. However, this goal may not be the most realistic and most just in this situation.

A 1985 article in the Journal of Medical Philosophy (vol. 10, nr 1, pages 45-61 ) titled ”Parental discretion and children's rights: background and implications for medical decision-making.” by F. Schoeman raises the issue of in whose best interest should parental decision making for their children be considered appropriate by law and society—only that of the child involved or of the child, parents and the family as a whole. The abstract of the paper is as follows:

”This paper argues that liberal tenets that justify intervention to promote the welfare of an incompetent do not suffice as a basis for analyzing parent-child relationships, and that this inadequacy is the basis for many of the problems that arise when thinking about the state's role in resolving family conflicts, particularly when monitoring parental discretion in medical decision-making on behalf of a child. The state may be limited by the best interest criterion when dealing with children, but parents are not. The state's relation with the child is formal while the parental relation is intimate, having its own goals and purposes. While the liberal canons insist on the incompetent one's best interest, parents are permitted to compromise the child's interest for ends related to these familial goals and purposes. Parents decisions should be supervened, in general, only if it can be shown that no responsible mode of thinking warrants such treatment of a child.”

Do you agree that parents who make medical decisions for their child also have the responsibility to consider the decision in terms of their entire family and not solely in what is in their sick child's best interest? How should possible conflicts of interest in this situation be evaluated and handled? ..Maurice.

Now Its Time to Take Ethics Quiz I

From Associated Press today: “CORPUS CHRISTI, Texas -- Child welfare officials seized a 12-year-old cancer patient from her parents, saying they were blocking radiation treatment that doctors say she needs.” With this story in the background to show how society can affect parental medical decision-making, let’s all take an ethics quiz using 3 variations of a different scenario.

Scenario 1- Both parents of a 12 year old son, who has already received two courses of very symptomatic chemotherapy treatments for a fatal cancer condition without improvement, are informed by the boy’s physicians that another treatment is “medically indicated” but the chance of response and improvement is only one in ten and may be much less. The physicians insist on attempting one more course, however both parents feel the toxicity to their child will be too profound and refuse to approve the therapy. The physicians want the court to take custody of the child if the parents refuse.

Scenario 2- Same as Scenario 1 but the son when informed by the physicians that he may die without another course of chemotherapy does not give assent to the treatment.
He explains that he doesn't want to experience the terrible symptoms he had with the previous treatments.

Scenario 3- Same as Scenario 1 but there is parental disagreement: mother approves another course and the father refuses. The son when informed that he might die without another course of chemotherapy does not give assent for the same reason as in Scenario 2.

Write me your comments about what you think is the most ethical resolution of each of the three scenarios if the goal of the decision-making is to provide care in the best interest of the 12 year old patient. ..Maurice.

Humor as Used in the Doctor-Patient Relationship: Constructive and Destructive

As a followup on my previous post presenting doctor jokes and their meanings, I would like to extend the thread to an excellent paper titled “Humor in the Physician-Patient Encounter” by Jeffrey T. Berger, MD; Jack Coulehan, MD, MPH; Catherine Belling, PhD published in the Archives of Internal Medicine 164: 825-830:April 26,2004. The therapeutic but also the possible negative effects of humor in doctor-patient relationships is discussed. Empathetic humor is advised: “Humor in medicine, however, may also be grounded on a recognition of the human condition that is shared by patient and provider. Such humor relies on empathy and compassion rather than on irony and avoidance. It embraces rather than excludes.” Examples of constructive but also destructive humor to the relationship by both the physician but also by the patient is presented. An excerpt of a concluding guideline to humor in clinical practice follows:

Useful parameters for humor in the therapeutic relationship include the following:

• The physician should be assiduously
conservative in selecting the
content and manner of humor, because
patients are often intrinsically
power disadvantaged and may feel too
inhibited to express their disapproval.
Encounters based on empathy,
respect, and authenticity diminish
the perception of power imbalance
and facilitate a deliberative model of
the physician-patient relationship.
While humor may assist in this process,
poorly selected quips or comments
may also distance the physician
and serve as a barrier.
• Gently self-deprecating humoror
externally focused humor(eg,
weather or parking) carries the least
risk, in terms of miscommunication,
especially when the physician’s
relationship with the patient is
not well developed. In such situations,
a joking comment humanizes
the physician and is unlikely to offend
the patient.
• To minimize the impression
of flippancy, the physician should not
rely exclusively on humor as a mode
of communication during a physician-
patient encounter.
• Physician-generated humor
should be grounded in empathy; ie,
the physician should have a relatively
accurate understanding of the
patient’s values, limits, predispositions,
and receptivity.
• The physician should be
receptive and respond in kind to
the patient’s attempts at constructive
humor.
• To clarify the patient’s
meaning and to help resolve anger,
confusion, or other barriers to trust
and continued communication, the
physician should directly confront
inappropriate or destructive
patient-generated humor.

I hope you all have a chance to read the entire article. I can tell you that I am going to make this article reading and discussion fodder for my first and second year medical students as they learn how to relate to patients. Where I teach, humor, as an element of patient interaction, has not been a point of discussion for these student groups in the past. Do any of the physician visitors to my blog recall this topic in early medical school teaching? Also how do you use humor in your practice? ..Maurice.

Note: Thanks to primary author Jeffrey Berger, M.D. for making me aware of the article and permitting this posting.

Doctor Jokes and Their Meaning

Many doctor jokes have a meaning or reality as their basis. That is why they are worth reading and chuckling over since that reality is what makes them funny and something we can learn from them.

Here are a few and you can read a whole lot more if you go to globalfamilydoctor.com Each joke is followed by my own "thoughtful" comment. By the way, if you think of a better astute comment than I posted, let me know. I hope you find the jokes as funny as I did. ..Maurice.
***

A young GP notices that all the doctors in the surgery are relatively bright first thing in the morning, but all, except one, look frazzled by evening. The one exception is an older GP who always appears fresh and happy. The younger doctor is keen to know if it is his attitude, life outside medicine, certain skills in handling people, a different range of patients and problems, would it be worthwhile sitting in with him during consultations etc. During these thoughts, he notices the other doctor in the car park and decides to seek advice.
"I get worn out from listening to people's worries and concerns and sad stories all day. What is your secret for remaining so fresh?"
The older GP smiles and says: "I never listen!"
(My comment: The difference between a technician and a physician.)
***

Margie received a bill from the hospital for her recent surgery, and was astonished to see a $900 fee for the anaesthetist. She called his office to demand an explanation.
"Is this some kind of mistake?" Margie asked when she got the doctor on the phone.
"No, not at all," the doctor said calmly.
"Well," said Margie, "that's awfully costly for knocking someone out."
"Not at all," replied the doctor. "I knock you out for free. The 900 dollars is for bringing you back around."
(My comment: Patient’s aren’t always aware of what physicians do.)
***

Waiter to GP at a modern pharmaceutical company sponsored educational meeting: "How did you find your steak, Sir?"
GP: "I looked under a mushroom …. and there it was."
(My comment: The companies are learning.. but wasn’t that mushroom a black truffle?)
***

Three GPs were on their way to a convention when their car got a flat. They got out and examined the tyre.
The fist doctor said, "I think it's flat."
The second doctor examined it closely and agreed. "It sure looks flat."
The third doctor felt the tire. "Mmm, yes. It feels like it's flat."
All three nodded their heads in agreement. "We'd better run some tests."
(My comment: In medicine uncertainty trumps observation.)
***

George went to his doctor complaining that he was no longer able to do all the things around the house that he used to do.

His doctor took more history, performed a thorough examination and ran a gamut of tests. When he returned for follow-up, George said, "Now, Doc, give it to me straight. I can take it. Just tell me, in plain English, what is wrong with me."

"Well, in plain English," his doctor replied, "you're just plain lazy."

George paused. "Okay," he said, "Now give me the medical term so I can tell my wife."
(My comment: Sometimes plain English is better understood.)
***

A college professor was explaining a particularly complicated concept to his class when a pre-med student interrupted him.

"Why do we have to learn this stuff?" the frustrated student blurted out.

"To save lives," the professor responded before continuing the lecture.

A few minutes later the student spoke up again. "So how does physics save lives?"

The professor stared at the student without saying a word. "Physics saves lives," he continued, "because it keeps the idiots out of medical school."
(My comment: Maybe there is a better way.)
***

The psychiatrist said to his nurse: "Just say we're very busy. Don't keep saying 'It's a madhouse.'"
(My comment: All those in healthcare have to think before they speak.)
***

The GP met Fred back in the consulting room following further history, review of investigations and specialists letters and further examination and said, "Fred, I have some good news and some bad news."
"Oh, no. Give me the good news first, I guess," Fred replied.
"I'm going to name a disease after you."
(My comment: ..and the bad news is more importantly “there is no treatment”.)
***

GP interviewing potential new associate: "For a doctor with little experience in general practice, you are certainly asking for a high salary."
Applicant: "Well, the work is much harder when you don't know what you're doing!"
(My comment: Honesty is the best policy.)
***

A GP asked a medical student, as they discussed a patient's management:
"What would you do if you were in my shoes?"
"Polish them!"
(My comment: Patients pay attention to the whole doctor.)

Ready for more? Just go to the link above.

Need to Determine Medical Decision-Making Capacity: Surrogates as well as Patients

There is more work for the physician to do when attempting to establish a medical decision for a patient who is incapacitated to make decisions but who has a surrogate, designated or not. The physician must now determine whether the surrogate has the capacity to make a medical decision for the patient. Specifically this means whether the surrogate is cognitively, medically and emotionally able to make a decision as honest substituted judgment or in the true best interest of the patient, free of self-interest or other various conflicts of interest. [A substituted judgment is the act of making a decision based on knowledge of the values and preferences of the patient and not what the surrogate would have wanted if they were in the patient’s position. If these are not known, then the surrogate must make a decision in the patient’s best interests, that is, a decision that would most likely contribute maximally to the patient’s benefit or what an average, reasonable person might decide.]


K.A. Bramstedt writing an article in Internal Medicine Journal 2003; 33: 257–259 titled “Questioning the decision-making capacity of surrogates” gives an example of her own experience and discusses the approaches to deal with this responsibility. Interestingly, she points out, in the following excerpt, the weakness of substituted judgment by the surrogate. (Her resource references are deleted in this excerpt. Read the original article for details.)

“Research has shown that the presence of documented patient health-care preferences such as an AdvanceDirective, or even prior verbal discussions between the surrogate and patient do not automatically facilitate substituted judgment by an appointed surrogate. Frequently, surrogates project their own values and health-care preferences into their decision-making for the patients for whom they are decisionally responsible. Friends and family functioning as surrogates tend to overestimate, while physicians tend to underestimate, the amount of medical intervention the patient would want. However, studies have also shown that patients believe that their appointed surrogates will
indeed act according to their written or spoken wishes. Whether patient, physician or surrogate, people tend to believe that others are likely to behave as they do; thus their decisions for others are frequently projections of their own values and preferences Substituted judgment is thus difficult for surrogates to perform and therefore unlikely to be realized, despite the wishes of patients.

However, in her conclusion, she does not feel that substituted judgement is “fatally flawed” but is useful and “might be aided by descriptively written advance care plans, and by research generating methods to better convey the descriptive information to surrogates for their substituted judgment activities.”

In previous postings, I have mentioned this responsibility of the physician to evaluate the surrogate as part of considering the surrogate’s request. The physician, of course, has neither the time nor resources to turn into a private detective with regard to the surrogate’s motives for the decision. However, taking a little time to communicate with the surrogate and evaluate the surrogate’s responses to questions dealing with the basis or rationale for the decision or request may be sufficient for either physician confidence or concern about the surrogate. If there is concern about the capacity of the surrogate, the physician has the duty to take this into consideration before writing orders. It may require the physician to look to another surrogate, have the assistance of an ethics committee or even involve the courts. Any questions? ..Maurice.

An Ethical Response by Physicians?: “When Patients Refuse Assessment of Decision-Making Capacity”

Most times the patient is quite willing and even eager to listen to the physician who is attempting to get informed consent for a procedure or treatment that the physician advises and will make their own decision known followed with an explanation.. The informed consent process is not a one-way communication with the doctor talking to the patient. It requires that the patient communicate his or her understanding of the information to the doctor so that the consent or dissent is validated. But what if the patient wants to be left alone or refuses to communicate and the procedure or treatment is beneficial for the patient’s health? If the patient refuses to explain this behavior or request in spite of the apparent benefit offered, how can the physician evaluate the patient with regard to capacity to make personal medical decisions? What should be the response of the physician? What should happen next? Should the physician assume that the capacity is absent and simply go ahead with the procedure or treatment?

This dilemma of clinical medicine is discussed in an interesting article titled “When Patients Refuse Assessment of Decision-Making Capacity: How Should Clinicians Respond?” by Samia A. Hurst, M.D. in the Archives of Internal Medicine 2004;164:1757-1760. The author concludes the paper with:

“Patients who refuse to explain the reasons for their choice make assessment of their decision-making capacity impossible. I have argued that if a patient who refuses beneficial treatment also refuses to explain why, clinicians should first do their best to engage in a dialogue with the patient, and to try to find others with whom the patient would agree to discuss the reasons. If this is unsuccessful, clinicians should assess the risk to the patient if the patient's wishes are followed. If this risk is significant, they should choose a course of action as if the patient were incompetent. The reasons for choosing this course of action should be explained to the patient as if the patient were competent. This approach neither sacrifices respect for the patient's choices nor care for the patient's best interest. It permits satisfactory resolution of difficult situations with the least possible harm. By outlining a framework for decision making in defined situations, this approach could help prevent decision making from being frozen by the impossibility to assess capacity. More important, it gives clinicians who face such situations the possibility of persisting in their efforts to establish a conversation with their patients.”

You must read the entire article to fully understand the rationale for the conclusion. However, do you think that this approach to the dilemma is ethical, not paternalistic and if not representing patient autonomy it does represent beneficence towards the patient? ..Maurice.