Did Medicine Lose The Narrative?

Gene Beresin MD, Harvard Medical School faculty, wants to bring back the narrative to medical education. He made the point yesterday that coherent narratives help both patients understand themselves, and medical trainees understand their field. Narratives, he argued, creates attachment, and attachment creates security and comfort-crucial elements of a healing process. I am sorry, Dr. Beresin, as much as I fully support your mission, I am afraid that despite all of the advantages of electronic medical records, the major downside is the loss of the narrative. The stories are becoming much less important, replaced by symptom checklists and automated responses. I am not saying that medical care will get worse without the narrative, but I am saying that without the narrative, the practice of medicine changes its lure. Some folks,  like myself, are drawn to narratives. We love stories, be that in our patients, in books, in film or in theatre. The stories create a richness of life’s experiences which deepen one’s sense of oneself, as one begins to see a wider perspective of the world. So, maybe if I were coming of age today, I would be drawn to Eastern medicine, where the narrative still matters. Dr. Beresin, a man, I would guess, in his sixties, holds the old torch, making me nostalgic. He volunteered that he is also a musician, a man of the arts. That’s cool. Yet, despite his Ivy League credentials, I am afraid no mover or shaker in our health care system is going to listen. The value of the narrative is slipping away from the health sciences. It is too bad, but it is our future.

Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

Women Doctors

Last night I had the privilege of speaking to a group of women physicians, mostly psychiatrists, leading to the inevitable topic of how quickly the field of medicine is changing in that it is unrecognizable from our field twenty years ago. We were middle-aged women who remember when it was a big deal for a woman to become a physician; gender atypical, one might say. Now, over half of most medical students are women. As a group, our daughters, not our sons, are entering medical training. “What does this mean?” one woman asked. “Women will earn the money and men will take care of the household,” one woman answered. “Or women will do both, like they have been doing for generations,” another woman said. “Women are twice as likely to get depressed as men,” I say, adding in a well-established psychiatric statistic. “Is this related?” I ask out loud. “Yes, but women are twice as likely to get depressed from menarche to menopause, so that makes it seem hormonal,” one knowledgeable woman answered. “Yes, but those are also the years where women have to juggle a lot of competing responsibilities,” another well-informed woman chimed in. “Men are more likely to be alcoholics,” another woman said, implying that maybe men deal with their psychological issues through substances and not through talking about their mental state. As usual, we had no answers, but many questions. Our worlds,  the world of knowing a “woman’s role” and the world of medical practice, is confusing to us. We want to help people, but how best to do this, is not completely clear. We want to be role models to our younger colleagues, but we do not understand their world and they do not understand ours. All in all, it was nice to be together to chat about common concerns. My job was to keep the conversation going. They did not need me for that. The passion for this topic generated the energy in the room.

SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

Going Global

Education is global, like all other industries these days. Medical schools are having training programs around the world. Exchanging information, exchanging students, a long-time practice of college education is now expanding to graduate schools and post-graduate education. UCLA Medical School are now setting up guidelines for their world-wide electives. Cornell Medical School has started a “branch” in Qatar. Two UCLA Child Psychiatry fellows are off to India to explore child mental health in a rural area. Some UCLA Family Medicine Residents ventured off to Haiti after the earthquake to help with the pressing medical needs of the distraught population. This, strikes me, as a new and exciting expansion of medical education. In my day, it was the rare soul who ventured out of the country to explore how medical care is administered in different health care systems. Sure, we were allowed, maybe even encouraged to do electives at other US medical schools, but we were never supported to go beyond our borders. I suspect that this relatively new development goes along with our increase in connectivity and thereby the increase in cross-fertilization. It is wonderful to think that our next generation of physicians will have a broader world view. It is also wonderful, selfishly speaking, to think that there might be opportunities for teaching around the world. Teaching and learning always go together. Global teaching and learning seems so rich and vibrant with new ways of thinking about how to help people. For example, European physicians write prescriptions for spa treatments as a way to help those in mental distress. I think that is brilliant. Trite but true-the world has so much to offer.

 

See also….http://shirahvollmermd.wordpress.com/2012/08/21/calling-my-266-german-friends/

‘Nonessential Medications:” Another Rant

Teaching Primary Care Residents, I learn so much. I also get frustrated, angry, and fantasize about going on the rooftops to let others know of my unhappiness. “Sometimes, when a patient comes in the hospital, and we are not sure what is going on, we stop the SSRIs and all the nonessential medications to see what is going on with the patient,” an excellent, smart, hard-working resident says to me. “Who says the SSRI is nonessential?” I ask, thinking that no one is checking in with the patient to see if he feels their SSRI is “nonessential”. “Well, you know, it is not life and death,” he says, understanding my discontent. “No, it is usually not life or death, but it is quality of life, and this can determine if the patient is motivated to help himself get better,” I say, knowing that the resident does not need an education about the importance of SSRIs, but that he is reflecting back to me the feelings of the team-the medicine team, composed of interns, residents and attendings. “I am sorry,” I say, “but I think that behavior suggests a dismissiveness to mental health. I think that the team is believing that SSRIs are relatively trivial medications and so they can be stopped, similar to vitamins.” He agrees, but looks at me with some sense of regret for bringing this to my attention because he can see my upset. I wonder how to push through this arrogance, sometimes seen in primary care, where they believe that physical health trumps mental health, every time, as if they are not closely linked. Medicine, as a field, has a lot of room for growth. Openness, as with all growth, has to be the first step. For now, I am stuck.

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

        ”The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

Health Care Disparities

Rant alert-I am angry! In teaching my Family Medicine Residents about the delicate and complex role of benzodiazepines in the treatment of anxiety, one of my students informed me that at the low-income clinic where many of my students work, they have eliminated this class of drugs from their formulary. I could hardly contain my rage. In fact, I did not contain it and I began to try to turn my rage into an important teaching point. That is, regardless of income level, patients are entitled to have access to medication which can make their lives significantly better. Instead, this policy has made it so getting treated for anxiety is now a middle to upper middle class possibility, but lower-income folks have to find other means of dealing with anxiety. The unfairness of this discrepancy is hard to understand. The medications are cheap. There is no cost barrier.

  I do see how prescribing benzodiazepines are time intensive and therefore costly in that way. The medications need to be monitored. As with prescribing any medication, there is a risk of liability. Yet, it is a clinic, and the mission of the clinic is to help low-income people receive health care. Treating anxiety with available medications is part of that mission-I would think. Second, and terribly obvious, how are my residents supposed to learn how to prescribe these anti-anxiety agents if where they work does not allow them to use these agents? Yes, they do get experience with the likes of Xanax, Klonopin and Ativan on their other rotations, but they should also be able to learn to see how these medications impact people who are struggling with unemployment, foreclosures, and high intensity exposure to violence and substance abuse. Helping someone with anxiety, whether with medication and/or behavioral techniques, enables the patient to cope with what might otherwise feel like impossible situations. Further, anxiety causes medical problems to get worse, so if the doctors can’t treat their anxiety with psychotropics then they will be treating their medical problems, such as their increased blood pressure, their increased sugars, and their irritable bowel disorder. Treating the mind, helps the body, and treating the body helps the mind. Why is that not clear to policy makers?

Teaching Teachers

    Marcia Goin MD said that when psychiatric supervisors get together and talk about their teaching experiences, their student evaluations improve. Michael Balint MD found that when primary care physicians meet regularly to talk about their difficult patients, physicians experience more enjoyment in their work. The Soldiers Project, a volunteer therapy organization, works by having the therapists meet on a regular basis to share experience. Twelve-step programs help people heal by forming a fellowship where individuals can share their stories, without shame or judgment. The thread is clear. People do better when they can confess their sins; when they can talk about how they messed up. Carrying around guilt and shame leads to defenses which students, patients, and individuals have to spend a great deal of negative energy in order to cope with these bad feelings. Feelings shared are often feelings released. Releasing feelings frees the person to do the job that they are good at doing. Removing negative self-statements removes some of the obstacles to good performance. Further, belonging to a fellowship inspires folks to do the best job they can; the fellowship creates a greater sense of their impact on the world, a greater bang for their buck. Groups, when formed with consistency and meaning, are agents of change. Like children on the playground, sometimes it is just more fun to make a circle and hold hands, and not play alone.

See also….http://shirahvollmermd.wordpress.com/2010/03/10/belonging and http://shirahvollmermd.wordpress.com/2010/10/06/weight-watchers/ .

Medical Education

This blog will begin my series on medical education.

Medical education is a complex business. How do you take young, energetic, hard working, bright people and transform them into caring physicians? Do you teach them five days a week, eight hours a day? Do you give them time for independent study? Do you have grades? What about class ranking? Do you teach compassion? Do you charge tuition or should the government fund it since society needs physicians? Do you tell them what specialty to pick or should they choose themselves?

I went to medical school from 1982-1986. I went to class forty hours a week. I had homework and examinations. We were graded and we were ranked. I was happy. I did not know any other model of education. The state medical school was inexpensive and the prospective income was sizeable but not enormous. Today, there are much fewer lectures. There is a lot of time for independent study. There are no grades. There is no class ranking. The most important assessment tool is part I of the medical boards. The typical medical student has enormous debt, and  they could choose a specialty with enormous income potential. The variation in incomes among specialties has increased substantially. The pressures have changed. The impact of these changes are not clear-at least not to me.

Yesterday, I gave a lecture on eating disorders to five fourth year medical students who are part of the Primary Care College. The Primary Care College is for those who are interested in Family Medicine, Internal Medicine, Pediatrics or Psychiatry. I do not know why Psychiatry is part of the Primary Care College and neither did the students. In fact, the students told me that most people interested in primary care are not in the Primary Care College. We shared feeling confused. I spoke about how understanding eating disorders helps us to understand the mind/body connection. They seemed to listen. They asked good questions. At the end, we chatted about the changes in medical education and the changes in the practice of medicine. We spoke about health care reform and the need for more primary care doctors. They shared that most of their class will not be going into primary care. Most, want to specialize. No one says they want to specialize in order to make more money, but together we speculated that that was part of the motivation.

I left feeling puzzled. I left feeling old. I wondered how did medical education change so much. I wondered how to think about these changes. I did not know. I do know that this next generation of doctors will take care of me as I age. I hope they will be there for me when I need them, but the uncertainty of it all is sometimes frightening. Watching young adults become physicians with life and death responsibilities is endlessly fascinating. At the same time, watching their development makes me realize that we not only depend on these people to take care of us and our loved ones, we also depend on the system of medical education to transform them into smart, intuitive and responsible doctors. I hope the system works.