Saturday, July 11, 2009

Health care's missing care

Health care's missing care (Globe & Mail Essay)

Caregiving is a lost art, says Arthur Kleinman –let's restore humanities to the same level as diagnosis and treatment

Arthur Kleinman

From Saturday's Globe and Mail

Most physicians, apart from primary-care providers, do little in the way of hands-on caregiving. Hospice doctors are caregivers; physicians who routinely deal with the end of life, such as oncologists and cardiologists and nephrologists and gerontologists, are surrounded by caregiving opportunities, yet few take part in its nitty-gritty – leaving the practical assistance and emotional tasks to nurses, social workers and the patient and his or her network of support.

In medical school, the curriculum in both basic science and the clinical-apprenticeship years places the greatest emphasis on understanding disease processes and high-technology treatments. The illness experience gets less and less pedagogic attention, as the student progresses from classroom to inpatient ward and clinic.

In the broader system of health care, students can all too readily discern that medicine largely leaves caregiving to others. Those others include nurses, whose professional science has made caregiving a central element of knowledge production and training."

Your thoughts?

Wednesday, March 25, 2009

Realistic levels of pain relief

Realistic Levels of Pain Relief
From Medscape Neurology & Neurosurgery, March 13 2009

Question: Is it possible to achieve 100% pain relief in all people all of the time?
Response from Bill H. McCarberg, MD
"...Knowing that complete relief from the pain is rarely possible and understanding that most patients recognize this dilemma, the provider should not promise this outcome. When discussing the continuing treatment of a patient who has been examined, has failed multiple therapies, and returns to the provider with pain levels of 7 or 8 out of 10, the discussion should focus on other aspects of treatment. Statements from a pain provider such as "There is nothing more I can do," "You will need to learn to live with this pain," or "The doctor who deals with this type of pain is a psychiatrist," are all dreaded phrases to the patient with persistent pain. The provider should instead promise continued support and, despite lack of treatment efficacy, should not give up on the patient or stop being creative in providing help. Appropriate statements include "Even though we have not found anything to stop your pain, I am still here for you," and "You and I are going to continue to work on this pain problem to improve your function." For the patient with persistent pain, promise what you can deliver: comfort, compassion, creativity, teamwork, a caring environment, and most of all, yourself.

Patients seek help and wish for a cure but are comforted by our style and manner. We can always deliver compassion and continuity of care, which may not seem like much, but it is greatly valued by our patients."

M: Yes... this is exactly the respect for which I am looking.

Sunday, March 8, 2009


RICHARD ASHER AND THE SEVEN SINS OF MEDICINE (reposted from Dr. Dr Aniruddha Malpani's blog: The Patient's Doctor)

From the article:
This paper was written to introduce the student and recent graduate to Richard Asher - a colleague well worth knowing. His essays are refreshing and thought provoking - they will reward both student and seasoned practitioner.
Richard Asher, who was born in 1912, qualified in medicine in 1934. He spent the most important part of his career at the Central Middlesex Hospital in London. Although Asher's specific clinical interests were endocrinology and clinical hematology, they ranged more widely than these subspecialties. In his capacity as Chief of the Mental Observation Ward at the Central Middlesex Hospital, he described several new syndromes including myxedema madness, and Munchausen's syndrome.
Describing the modern hematologist in 1959, Asher refers to him in a somewhat Chestersonian statement as an individual who "instead of describing in English what he can see, prefers to describe in Greek what he can't." (5)
His terse, crisp language and his humour are seen not only in clinical writing but in special articles dealing with general medical and philosophical issues. Papers such as "Why are medical journals so dull?" (4), "Straight and crooked thinking in medicine" (2), "Talk, tact and treatment" (3), "Clinical sense: the use of the five senses" (7), "The dangers of going to bed" (1), "Six honest serving men for medical writers" (9) are examples of this exceptional talent. A decade after Asher's death, Beaven wrote that the man's "immense vitality, energy and dramatic flair made him a legend in his own lifetime" (12)...

...Many of Asher's papers have a timeless quality - and, like some of our medical classics, deserve rereading from time to time. His lecture "The Seven Sins of Medicine" is as instructive as it is entertaining. First published in The Lancet, on 27 August 1949 and re-published in a collection of his essays (10), his comments are directed to seven sins although he asserts that there are "an unlimited number." His lecture, he said, was given in the hope that "those students who wish to avoid them (the sins) may do so, and those who wish to indulge in them may enlarge their repertoire or refine their technique." The seven sins of medicine are identified as obscurity, cruelty, bad manners, over-specialization, love of the rare, common stupidity and sloth. The lecture, as topical today as it was some 35 years ago, serves as a gentle and humorous reminder of the pitfalls of medical practice.

ME: Some things don't change...

Saturday, February 7, 2009

Testing Treatments for Better Healthcare

Testing Treatments for Better Healthcare, 2006

Authors: Imogen Evans, Hazel Thornton, and Iain Chalmers
131 pdf pages

The foreward sells it:

"This book is good for our health. It shines light on the mysteries of how life and death decisions are made. It shows how those judgements are often badly flawed and it sets a challenge for doctors across the globe to mend their ways.
Yet it accomplishes this without unnecessary scares; and it warmly admires much of what modern medicine has achieved. Its ambitions are
always to improve medical practice, not disparage it.
My own first insight into entrenched sloppiness in medicine came in the 1980s when I was invited to be a lay member of a consensus panel set up to judge best practice in the treatment of breast cancer. I was shocked (and you may be too when you read more about this issue in Chapter 2).
We took evidence from leading researchers and clinicians and discovered
that some of the most eminent consultants worked on hunch or downright
prejudice and that a woman’s chance of survival, and of being surgically
disfigured, greatly depended on who treated her and what those prejudices
were. One surgeon favoured heroic mutilation, another preferred simple
lump removal, a third opted for aggressive radiotherapy, and so on. It was
as though the age of scientific appraisal had passed them by."

A good read...


Monday, February 2, 2009

The See-Through Doctor: Sitting Naked in the Exam Room

The See-Through Doctor: Sitting Naked in the Exam Room Medscape Journal of Medicine, 2008; 10(8): 186
"There once was a time, only dimly remembered today, when doctors still hesitated to ask a patient to disrobe, struggling instead to drop the mouth of a stethoscope down a slightly unbuttoned shirtfront.
While this may sound like history from the horse-and-buggy era, it was commonplace in this country just 50 years ago.[1] Yet in that relatively short time, patient and physician roles have metaphorically begun to reverse. Today, it is the patients who are demanding that reluctant doctors stand naked in the exam room. “Your test results have just come back from Dr. Google,” they begin accusingly, “and I think we should discuss those patient satisfaction scores.”

Includes video.

Interesting changes in the Doctor-Patient Relationship...

Books on Doctors as Patients and a few on the Doctor-Patient Relationship