Cell 2 Soul: The Humane Health Care Blog

Caregiving's Imperative

Arthur Kleinman's recent Perspective piece in the New England Journal of Medicine deserves a wide audience.  Unfortunately, full access is open to only NEJM subscribers or those affiliated with academic institutions.  If, after reading the following quotes, you want to read the entire article, please email me and I'll send you a copy.

picture from http://kennonsburgumc.com

"Modern medical practice's greatest challenge may be finding a way to keep caregiving central to health care. The moral core of medicine may seem abstract, until you see health professionals passionately struggling to be useful, compassionate, responsive, and responsible while working with the indifference of bureaucratic rules, the cold counting and costing of institutional audits, and hard-to-balance personal demands on their time and concern. 

Looking at medicine [as a caring vocation] reinforced my belief that the structure and demands of medical schools and hospitals create obstacles to caregiving. How to revivify caregiving in medicine became the issue. Teaching about illness experiences remains important. Yet the moral–emotional core of those experiences deserves greater primacy — as does the social suffering that affects everyone, but especially marginalized people already injured by poverty, isolation, and other forms of structural violence."

From Illness as Culture to Caregiving as Moral Experience
Arthur Kleinman, M.D.
N Engl J Med 2013; 368:1376-1377April 11

Dr. Rakesh Biswas alerted us to an article in the Stanford Medical Alumni Magazine about Kleniman and his work -- especially his recent epiphany.  See:  Medicine: A Love Story.  The past few paragraphs are especially important.

Heart Matters: Katherine Treadway, M.D.

Katherine Treadway teaches medical students about the patient-doctor relationship at Harvard.  She will give a free talk in Lenox, MA next week.

Heart Matters:
The Patient-Doctor Relationship
Thursday, October 11, 2012 at 6:00 p.m.
Shalespeare and Company
Founder's Theater
70 Kemble Street, Lenox, MA
Sponsored by BMC

Treadway has written extensively on this topic. "I watch the second-year students file into the Ether Dome for their first day of my “Patient–Doctor 2” course. For me, this course marks their true entry into medical school. Here, they will refine their history-taking skills, building on their knowledge of pathophysiology and disease; they will learn how to perform a physical examination; and they will touch a living stranger's body as clinicians for the first time. For them, right now, these are just skills to be learned. They do not see how they will be transformed by them. They know that these newfound abilities will open the door to clinical medicine. They do not know how utterly changed they will be by crossing that threshold."  Full Article

If you wish to attend, please email Sue Kelly at BMC or call 413-447-2775 by October 9 

Dr. Treaway’s advice to students:
As you acquire more medical knowledge and responsibility, there will be times you will focus more and more on the problem and forget the patient attached to it. As you strive to take a good history, get the facts straight, perform a good physical exam, and put it all together into a comprehensive clinical picture, you will find that with all the anxiety involved in wanting to do it right, the patient becomes further and further away...
While I am busy treating the bodies of my patients, I try to remember to treat the patients as well — to touch them in small ways as well as large.

The Factory as Metaphor

Dr. Jeremy Graham, a Spokane physician, has written a provocative essay comparing the Factory to the modern medical Clinic.  As you read it, think about the role you play as patient, family member, care giver.

Dr. Graham writes: "Industrial throughput and productivity are the watchwords of contemporary US healthcare.  Striving to deliver care, administrators and doctors advocate “lean management,” “best practices,” efficiency, and production. A spirit averse to waste rides high upon the elimination of  “non-value-added” activities.  It seems that with sufficient abstraction, medicine is an industry which can learn to be lean, like any other. Factory and farm, hospital and clinic, are ultimately interchangeable."  To read more  Download The Factory_Graham

Author Bio: Jeremy D Graham MA, DO, FACP writes,  "I am a teaching Internist on the faculty of Internal Medicine Residency Spokane with a clinical emphasis on Inpatient wards and hospital medicine.  With my background and prior training in cultural anthropology, my academic interests include incorporating the social and material costs of illness as relevant outcome considerations of humane medical care. Email:  Jeremy Graham.

Magic Words by Marla Lukofsky

(if you prefer an easier to read pdf: Download MAGIC WORDS

 This essay was inspired by Mary Armstrong's tribute to her hurse practitioner which was published here on February 8th.

Years ago, I had a positive experience with a remarkable Nurse Practitioner at UCLA named Sherry Goldman who was in charge of a special program for breast cancer, a disease which I had. I was struggling with the terrible side effects of my treatments. They were getting the best of my mind and my body.  When I walked into her office for my appointment, she did the physical examination.  She also asked me how I was feeling and remarkably she waited for the answer.  I was open and honest with every detail.  She validated my mind-set and made me feel less alone with my thoughts. Her medical suggestion to improve my status was to take walks every day. “Start small, short distances, a block or two and then make it longer with each day," she suggested.

My response to her was a resounding  “NO!  I don’t want to. I don’t feel well, I don’t look good, and I don’t have the energy.”

Well, Sherry the NP sat quietly for a moment, absorbing my adamant stance and then said to me those magic words, the words that only one could say if they had taken the time to really listen, while having the keen observational skills to sense what the problem was with a simple walk. What were her words? I know you’re waiting for them… Her words were, “ Then don’t walk for you Marla, walk for ME... and I want to hear how much you’ve walked when you come back to see me in two weeks.”

Suddenly my eyes lit up, my back straightened and a fire was in my belly and it wasn’t acid indigestion. That day I went home and started to walk and with each day I walked more and more, longer and further.  Soon, I was walking for hours daily, chomping at the bit to report back to Sherry with pride at my accomplishment. Two weeks later I did just that at my next appointment at UCLA, when I saw her.  I looked like a new person.   I was a new person.

 There is a belief that one shouldn’t do things just to please someone else but rather to do it to please oneself. Well, that is all well and good some of the time but there are other times when it’s imperative to break that rule. If pleasing someone else is the key to getting a person back on track and healthy again then so be it and that’s exactly what happened with me.  Not only did my health and strength improve, but I also took up jogging and now I walk and run FOR ME! and I have not stopped since. I’m entering my first 5K Marathon in March.  I have not had that kind of positive experience with the medical profession since, but I will NEVER forget what that incredibly smart and talented Nurse Practitioner did for me. NEVER!

Author:  Marla  Lukofsky

Marginal Notes: Some things happen for a reason

"It's a Wonderful Life" — Clarence and George

A new used car that is on the blink. An intellectually limited father. Icy roads in the aftermath of a winter storm. A belated telephone call at eventide. Some things happen for a reason.  more»

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for 32 years. His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

Mary Armstrong's Tribute to a Wonderful Nurse Practitioner

NP with Patient

"Long ago, when I was in college, I received health care from the university's student health clinic. This is not a place where you would expect top of the line care, as it was run much like a health department. You rarely had the opportunity to make an appointment with the same doctor twice, and the majority of your visit involved waiting to see a doctor who would speak with you for two minutes before writing you a prescription or sending you off for lab work."

This time "When the patient room door opened, a smiling lady walked in and introduced herself as “Suzy.” She continued by saying that she was a nurse practitioner. 'Great,' I thought to myself, 'this is going to be a waste of time. There's no way she's going to be able to figure out what is wrong. She's just a nurse practitioner.'”  Read on: Download Nurse-guest post

 

Author Bio: Mary Armstrong is a writer and editor for Medical Assistant Colleges.   She enjoys writing articles for other sites on various topics of interest. For privacy reasons, she has decided to keep the health condition mentioned in her writing unidentified.   You may reach her at: EMAIL.

Marginal Notes: Showing my (digital) age

I see my own primary care physician once a year for my annual physical exam. He used to sit and talk to me. Now he sits behind a flat screen monitor and records my answers to his questions with the click of a mouse. All of my salient medical data is duly digitalized, readily available for immediate electronic access. This, I’m told, is progress.  more»

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for 32 years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

My Uncle "Doc"

In Pittsburgh, instead of going to a doctor, my family usually consulted Doc, my mother’s oldest brother who was an internist. After he entered medical school, he was always called “Doc” instead of Abe. Doc Starr was a quiet, serious, modest man, not tall, and with a gray moustache. Late in life he married Helen, who had worked for him as an office assistant and then became his companion. 

Renee Marks Cohen has graciously submitted her moving piece about "Doc."  You will enjoy it:  Download My Uncle Doc – Abraham Starr. You may contact Ms. Cohen at: RMC_Email.

A Patient Request

by Zena David

The night my brother, Steve, a long-time resident of a nursing center, was sent to the emergency ward, I expected him to be admitted to the psyche ward of a Chicago hospital.  It wouldn't have been the first time.  Occasionally, the medication he took to stabilize his schizoaffective behavior didn't hold. Medicare hadn't approved the new medication that might have helped in a timely fashion.   He walked the halls, refused to eat, had difficulty urinating, descended into a deep depression and heard voices.  This time, he would be a patient on the medical floor until his prerenal azotemia (impending kidney failure) and a blockage in the bladder could be treated surgically. He could not, in this state, enter the psyche ward. 

By the time I flew to Chicago from California, I saw my brother pulling out the IV's before being physically restrained. The psyche ward did not have the capability to handle patients with certain medical conditions so even though Steve's  doctors tried to get him into the ward, they were unable to do so. Never having been operated on, confused as to what was happening to him, and often being addressed in the third person, my gentle and gentlemanly brother became uncooperative and at times belligerent, ripping off the bandages protecting the fistula. Two operations later, my brother left the hospital having taught the staff that a smile and a kind word are as crucial to the healing process as the medicines that were injected into his veins.

“Whoever survives a test, whatever it may be, must tell a story.  That is his {her} duty,” said Nobel Peace Prize winner and Holocaust survivor Elie Wiesel.  My brother, Steve, never won a prize, but he is noble. And his story must be shared.  Within his living nightmare, he found his voice sounding it out so that it could make a difference to those who heard him.  I wanted him to know what he went through. I wanted him to know how proud I was of him.  I wanted him to know what he taught me.

 Robert Frost said, “The only way out is in.” Steve orbited in and out of consciousness and sanity and into traumas that frightened me.  Then he surfaced to a place where our words could meet and be understood not only by me but also by the medical staff.  This is our story.  See: Download A Patient Request

My Brother Steve

Author Bio: Zena David, a former public school educator, was awarded several Los Angeles Educational Partnership Grants which enabled her to develop interdisciplinary projects  and publish articles about the programs for middle school students.   She encouraged her English and drama students to share her philosophy, “love what you do and feel that you matter.”  The English Council of Los Angeles honored her for her achievements as outstanding English classroom teacher in 1986.  The next year, she received a Global Teaching Award for her children's Museum exhibit and her production of  The Diary of Anne Frank led to a correspondence and an invitation to visit Miep Gies at her home in Amsterdam. She became an assistant producer for a Dramalogue award winning theater and an associate director for the UCLA extension musical production about the second half of life.  Zena also has also written plays  and acted in several small theater as well as community productions.  She has facilitated a creative writing workshop in a women's prison. Her most recent speaking engagement was this year at the Yom HaShoah Observance and Photo Exhibition, “Through Your Eyes:  Holocaust Memorials Around the World.” As a writer, actress, and director, she is most interested in using the creative arts to integrate issues and heal traumas. Email:  Zena

Confession of a Professional Patient

One of our members, Beth McKim, works as a simulated patient (SP).  Her essay, Confessions of a Professional Patient, gives a rare insight into a SP's mind-set.

"Three young doctors, their necks splotched crimson with fear, come up one at a time, to deliver the same, life-changing news to me. Their hands tremble and voices shake in these encounters as they disclose that my tests indicate I am facing a potentially serious, or even fatal, disease." Read more: Download Professional Patient

A simulated patient (SP), standardized patient or sample patient (also known as a patient instructor), in health care, is an individual who is trained to act as a real patient in order to simulate a set of symptoms or problems. Simulated patients are used in medical education, nursing education, evaluation, and research.

Author Bio: Beth McKim resides in Houston, Texas with her husband, Buddy, and their Labradoodle, Lucy. After working for twenty four years as a Staff and Parent trainer and Director of Volunteers for Child Protective Services, Beth currently enjoys studying Creative Writing and Spanish. A former marathon runner and triathlete, she is now an avid swimmer, Yoga enthusiast, and overall fitness devotee. She feels particularly rewarded by her part- time job as a medical actress. Email Ms. McKim.