THE REAL BEDSIDE MANNER

A May 12 Toronto Star article by Lorianna De Giorgio says,

“Bad bedside manner—when a health-care practitioner fails to see the patient as human—can make or break an already complex relationship. Patients crave a deep relationship, full of empathy and trust, with their doctor or nurse. Such a relationship, however, is sometimes lacking in the medical field. Patients complain that doctors or nurses sometimes talk down to them, forgetting they have a family, feelings and concerns. What is the psychology behind a bad bedside manner? And is it a conscious or subconscious decision by the doctor?”

Ms. De Giorgio has hit on a central issue. When I hear complaints from patients, they’re almost never about healthcare’s admittedly awesome technology, but about its lowest-tech aspect, communication. Bedside manner is more than not talking down to patients, though. We’ve all but forgotten what it actually is because it’s been parked in the shadow of the MRI machine for so long. Here’s what bedside manner is: helping others to feel better with one’s presence alone.

Some people are born with this quality. For the rest of us, though, it’s a skill, meaning it improves with practice. We begin to learn it when we recognize sick people aren’t just diagnosis-labeled organisms, but suffering souls as well. We’re talking about compassion here, literally “suffering with.”

No way around it: compassion hurts. Those of us who work daily with suffering must develop some strategy for addressing our own consequent pain. Traditionally, doctors are trained implicitly to repress the pain inherent in practice. As logical as that may seem, it doesn’t work. Buried pain is always buried alive. Look up doctors’ rates of divorce, drug dependence, alcoholism, and other sorrows. Male doctors have a forty percent higher rate of suicide than the general population, and female doctors an alarming one hundred thirty percent higher.

We docs can do better. We can behave like normal people, choosing to feel the pain already resident within us, express it, and even let it affect the way we practice. Of course, doing so might slow the great wheels of medical commerce, but so what? At least we’ll find ourselves healing our patients—and ourselves—along with treating them.

A NECESSARY DOSE OF HUMILITY

The United States Preventive Services Task Force, having studied the potential risks and benefits of the prostate-specific antigen blood test, or “PSA,” has concluded that hazards attending the test outweigh potential benefits. The task force found that at best, one man in every thousand tested may avoid death as a result of the screening, while another man for every three thousand tested will die prematurely as a result of complications from prostate cancer treatment, and dozens more will be seriously harmed.

As you might expect, this finding hasn’t been met with universal hallelujahs. Some prostate cancer advocacy groups as well as the American Urological Association take issue with the published recommendation. In response, Dr. Michael LeFevre, the co-vice chairman of the task force and professor of family and community medicine at the University of Missouri, said, “Change is hard. It’s hard for all of us, both within and outside the medical profession, to accept that not all cancers need to be detected or treated, and that there are harms associated with screening, and not just benefits.”

The broader issue here is the nature of medicine itself. We popularly believe science to be a yes-or-no proposition. We put much stock in its pronouncements since it is, after all, an elegant method for gaining knowledge. But the answers the universe reveals respond only to the questions we ask, and what we ask is necessarily limited since as mere humans we can’t see the Whole Picture. We ask, “Does a heightened PSA level indicate cancer?”, and the response is, “It often does.” That is, it sometimes doesn’t. In addition, cancer doesn't necessarily elevate the PSA. Further testing and treatment can be tangibly harmful, possibly even more than prostate cancer itself.

Of coure, we love when medical science seems to produce a miracle. Take diethylstilbestrol, or DES, a hormone that prevented miscarriages in women between 1940 and 1971. This seemed a terrific advance until it was learned that the children of these women suffered huge rates of genital cancer. Who knew, in 1940, to ask about cancer in these women’s children?

Every few years the argument resurfaces about whether mammograms cause more breast cancer than they detect. Today the weight of evidence leans toward the more benign, yet experts nevertheless recommend ever more judicious use of mammograms.

And so it goes with a multitude of tests and treatments. I raise this issue as a reminder to take medical science with a dose of humility. That we docs are doing the best we can is both the good news and the bad news. Keep in mind the apocryphal story of the medical school dean who, addressing his graduating class, said, “I’m sorry, but about a third of what we’ve taught you is untrue…we just don’t know which third.”

DOC GAVE ME THREE YEARS

“I can’t take any more numbers” said a man in our cancer support group. “This chemo has a forty percent chance of working. Two out of three chances you’ll live five years. Five percent mortality. It drives me crazy. The only numbers I’m interested in these days are a hundred percent and zero. Either I’m here or I’m not.”

“How much time do I have, Doc?” is arguably the question oncologists hear most often. It’s understandable that we want to know, but the answer, of course, is that no can know. So the doc offers us statistics, maybe saying something like, “Well, eighty percent of people with your diagnosis survive two years.”

There are three problems with our use of statistics. One is that by definition they cannot describe characteristics of an individual, only of a group. If you’re informed that of one hundred people in your situation, twenty will be gone in two years, what does that mean to you? You might be among those twenty, you might not. In my mind, the number doesn’t illuminate much. As our group member put it, you’ll be one hundred percent here or zero here.

Another problem is that people unfamiliar with statistics misinterpret them, and almost uniformly toward the negative. You’re told, for example, that median survival time for this particular illness at this particular stage is three years. You go home and tell the family, “Doc gave me three years.” Nope. Three years was the median, meaning that half the group will die before three years and half beyond that time—in fact, some will die decades beyond that time.

A third problem is that we tend to see statistics not as descriptive, but prescriptive, actually a self-fulfilling prophecy. Believing the doc gave you three years, you can unconsciously store the figure in the back of your mind, where it continues to reiterate the message, diminishing your optimism until voila!, you die right on time.

For all these reasons, I know an increasing number of physicians who are reluctant to offer any statistics at all. Yet when knowledgeable about statistics, you can use them to your advantage. We traditionally describe survival rates with a mathematical model called a “bell curve,” which looks like this:

The curve says a small number of patients die relatively soon, a similar number survive a long time (the lower sides of the bell), and the majority fall in between. When you hear a statistic involving you, all you know for sure is that you’re somewhere in that curve. (In fact, even if you’re not sick, you, being as mortal as ever, are somewhere in that curve.) You also know that you want to be as far to the right in the curve as possible.

Bell curves are usually built from data that take just a few categories into account: type and stage of cancer, maybe age of patient, and maybe gender, for example. Within those categories are people with poor nutrition, no support, toxic habits, and who feel helpless and hopeless, along with those who take excellent care of themselves—people who eat well, manage stress skillfully, enjoy high quality relationships, and so on. But those latter practices, being difficult to quantify, aren’t often taken into account. So if you’re leading a healthy life, the bell curve that ostensibly includes you is actually inaccurate. All else equal, you’re already to the right of its median, and by continuing to adopt healthy habits, you’ll extend your life expectancy even further. So here’s my prescription for statistics: take them with a grain of salt.

CALMING THE DRUNKEN MONKEY

A recent study at the University of Rochester Medical Center (to be published in the June issue of Academic Medicine) found that training doctors in mindfulness meditation helped them to listen better and not be as judgmental.

How could it not help? When I saw patients many years ago, before my exposure to meditation, my mind was ajumble. As they related their histories to me, I cogitated about diagnosis, what tests to request, what to say to them, and how to plan management, not to mention worrying about my own performance. Patients might not have suspected they were addressing a man whose mind was a six-ring circus. Attending entirely to my own agenda, I was with them in body only.

These contacts didn’t exemplify a healing relationship. Sure, plenty got done in terms of physical diagnosis and treatment—and commerce, by the way—but little health or comfort were added to the world.

I had no idea that I could have been fully, calmly receptive to this other person. I knew neither how tumultuous my mind was nor that silence was even possible. All my experience and training suggested that my mental extravaganza was normal.

Most medical visits these days are for disorders that stem either from normal aging or pathogenic behaviors like overeating, poor stress management, and sedentary style. We docs can offer these patients some symptomatic relief, but—contrary to the expectations they’ve absorbed from pop culture—we’ll be unable to cure almost any of them. We can help them substantially, though, by guiding them in living with their conditions and in altering habits. This requires authentic relationship, meaning enacting heart-to-heart contact, learning deeply who they are, and earning their trust. This is impossible when your mind is, as the Hindus put it, a “drunken monkey,” but quite achievable when you listen skillfully.

Mindfulness meditation is an effective practice, but not the only one available. Almost everyone can find a meditative form with which they’re comfortable. As a matter of fact, just about any activity can be meditative, including yoga, tai chi, running, and even just plain sitting still. The trick is to do it mindfully—that is, with full attention. If you’re interested, I have two suggestions. First, Google “mindful,” and you’ll be taken to dozens of useful websites. Second, please keep in mind that Buddha got enlightened without paying a single dollar. 

KNOW-HOW ŰBER ALLES

The April 30 edition of the New Yorker features an article about Stanford University’s brilliant success in its support of technological innovation, a strategy that’s earned it $1.3 billion in royalties. Stanford and/or its graduates had a hand in developing almost every household-word e-success, including Hewlett-Packard, Yahoo, Cisco Systems, Sun Microsystems, eBay, Netflix, Intuit, Fairchild Semiconductor, Agilent Technologies, Silicon Graphics, LinkedIn, and Facebook.

It’d be hard to argue that this hasn’t contributed significantly to our culture, yet it has its detractors, however polite and circumspect. In obliquely criticising Stanford’s outsized focus on technology, one of its ex-presidents described the United States as having two types of college education that are in conflict with each other: the classic liberal-arts model and explicit job preparation.

The classic approach is designed to explore the human condition. We’ll navigate more wisely, effectively and kindly through our lives, its rationale goes, if we know something about history, psychology, anthropology, music, and art. High-level job preparation, on the other hand, aims toward lush Silicone Valley employment, or, on the east coast, Wall Street.

During the past generation, the latter model has predominated, not only at Stanford, but in American education in general, from high school up. We’ve heeded the pundits who warned relentlessly that unless we prioritize science in our schools, China or the Eurozone or even India will leave us in the financial dust. We've followed that advice successfully, but at significant cost. A friend from Mumbai commented, "You Americans excel at know-how. What you're not so good at is know-why."

Thus a New Yorker cover in October, 2010, depicted kids trick-or-treating while their chaperoning parents uniformly stared at their cell phones. Our gadget prowess now dwarfs the community skills—nuanced communication, civics, esthetics, sense of place, humility—that we might have learned in humanities courses.

Healthcare exhibits exactly this shift. We apply costly, hi-tech, often invasive and hazardous technologies where compassionate counseling would often suffice. This approach would work if the bulk of medical visits were for strictly physical derangements, but they’re not. Most current illness, from obesity to type two diabetes to hypertension to much of heart disease and cancer results from pathogenic behavior, including toxic exposure. We physicians, able to transplant organs and tweak genes but uneducated in the human condition, can only respond with our routine hi-tech hammers.

Medical educators saw this coming decades ago. When I trained in the mid-1960s, we were offered humanities tidbits, like the opportunity to discuss Tolstoy’s Death of Ivan Illich, or a course in Spanish. It was a decent try, but amounted to water off the backs of ducks anxious to get onto the wards and perform spinal taps. We simply didn’t see the relevancy, nor did the faculty provide a convincing explanation.

Today there are numerous experiments around the country designed to implement humanities more meaningfully in the medical curriculum. They’re up against a culture that continues to value know-how over know-why, but thanks to elucidations such as the New Yorker’s provided, we can afford optimism.

GLORIOUS FOOD

Ah, food, my second favorite fantasy subject. We’re talking about it more these days, possibly because we know more about the association between food and health, especially in the face of endemic obesity and type two diabetes.

Yet doctors get minimal to zero training in nutrition. So Dr. David Eisenberg, an associate professor at the Harvard Medical School and the Harvard School of Public Health, is teaching it to his colleagues—not in some dry, windowless classroom, but at the Culinary Institute of America (the other CIA), in Napa Valley, Calfornia. Read about it at http://www.nytimes.com/2012/04/11/dining/doctors-learn-to-cook-healthy-crave-able-foods.html?_r=1&pagewanted=all&utm_source=mQ+Health+Weekly&utm_campaign=5cd4035972-Health+Apr+13+2012&utm_medium=email.

He offers hands-on experience, teaching them how to cook. Many, having spent their entire adult lives in either intensive trainings or rushed practices, have existed on vending machine cuisine or take-out, and have never hefted a whisk. The idea, of course, is that when they converse with patients about nutrition, they’ll have experiential access to flavors, aromas, and texture in addition to data about protein, cholesterol, and sodium.

After cooking, these docs dine and wine together. Said one chef-instructor of his medical pupils, “Many doctors treat food as a clinical procedure rather than the sensual act it ought to be.” They’re learning what we could all use as a refresher, the opportunity to eat well, which is more than filling the mouth. It means leaving care and responsibility temporarily, communing with friends, and enjoying the world of the senses. One doesn’t have to pay for a Napa Valley workshop to do this. You can do it anywhere, with just about anyone. My mantra is rapidly becoming, “The best medicine is living well.”

IT'S NOT ONLY DEFENSIVE MEDICINE

It's plausible and popular to conclude that unnecessary testing and treatment comes largely from "defensive medicine," but that's not the whole story. Much of it comes from physicians' almost exclusive loyalty to medical science.

This came home to me recently when a friend told me her story. She'd been caring for her frail and aged mom, two hours from her own home, for weeks. At last things settled down. Driving home, she noticed pain in her back. She realized she might have expected something like that, "…as I'd been carrying a heavy burden." By the time she reached home, the pain was severe enough that she called her physician and requested strong pain medication. He suggested he see her first.

He examined her, agreed that her pain was probably secondary to stress, but--just to be sure--recommended a CT scan. When she took the order slip to radiology, the receptionist said, "Fine, but are you aware this will cost you about a thousand dollars?" My friend hit the ceiling. She tore up the note, called her physician, and said, "We both know I don't need a scan. How about just giving me a prescription?" The doc said, "Fine."

Okay, we can say that was an example of defensive medicine. When I related it to another doctor friend, though, he had a different take. "How old is she?" he asked. "Has she had a bone density test? How do we know this isn't a pathologic fracture, or a bony cancer metastasis?"

"My God," I answered, "those are such zebras." That's actually a medical term, deriving from a time-honored axiom in this biz, "When you hear hoofbeats outside, think of a horse before a zebra."

"Sure," my friend said, "but zebras do show up sometimes."

Thinking about that, I realized that's a standard medical rejoinder. Mention zebras and horses to doctors, and they'll focus on zebras because pulling the strange and rare diagnosis out of the hat is one of medicine's holy grails. We all want to be the diagnostic hero. With no connection to the woman with back pain, my doctor friend wasn't practicing defensive medicine. He was on rounds, demonstrating his allegiance to exhaustive science.

The doc who finally wrote the painkiller prescription (the pain, by the way, is now history) was jarred from his scientific perch by his patient simply reminding him of common sense. Of course, both approaches are valid, and precise circumstances ought to dictate the eventual strategy. That must depend, then, on a full conversation between doctor and patient. I'm gratified that an increasing number of studies are concluding that this crucial relationship--which our obsession with high-tech interventions has steadily eroded--seems to be reviving.