Sunday, August 28, 2005

The Great Divides in Medical Practice

Today, my father-in-law and I put up a fence.  It's a solar-powered electric fence, that divides our paddock in two.  Why?  Because it is time for Champie to be weaned.  

After we put up the fence, we tested it.  135 volts.  Champie can be a bit insouciant, as the picture shows, but I think 135 volts might get his attention.  He won't like being separated from his mother, but sometimes you just have to do these unpleasant things.

Later, I found the picture below.  For some reason, it stuck in my head.  It was a little tickle of intuition: the picture symbolized something important.  

Photo in the News: Grand Canyon to Get Glass Bridge

This is a depiction of a planned glass bridge that juts out over the Grand Canyon.  You can see across, but you can't get across.  Sort of like the electric fence.  Plus, both involve a certain kind of danger.  Both bring you close to a distinctly unpleasant sensation.  

In response to my request for thoughts about the ideas of empathy, and racial and gender disparities, in health care, I did get some email.  One pointed to this, a collection of letters written in response to a newspaper article (In the Hospital, a Degrading Shift From Person to Patient).  Here is one of the letters:
To the Editor:

While I was hospitalized after surgery for peritonitis, one thing really struck me: doctors and other medical staff members are human beings. And in order to perform grueling tasks like surgery or intubations, they have no choice but to do away with human feelings.

That shift from person to patient may be perceived as degrading, but it is also a vital to medical staff, because there are things you can do to a patient that you wouldn't dream of doing to a person.

Bruno Dupont
Johannesburg, Aug. 18, 2005
I should think that someone named Dupont who lives in Johannesburg could tell us quite a lot about disparities, and someone hospitalized for peritonitis ought to have something to say about empathy.  (A couple of assumptions, granted.) He makes a good point: "there are things you can do to a patient that you wouldn't dream of doing to a person."  

The practice of Medicine is rife with Great Divides.  

There are the divisions between doctor, and patient; between the doctor's thoughts, and the accompanying feelings; between the doctor's assumptions about the patient, and the reality; and, of course, there are racial, socioeconomic, and gender divisions.  All of these deserve considerable introspective thought.

So far, only one horse out of the five has touched the electric fence (October, the poor thing!).  The rest saw him jump back, and now they won't go near it...

As physicians, we learn by watching our colleagues.  If one of them jumps away from something, we are likely to stay away, too.  That becomes habitual.  Doctors may think they are smarter than farm animals, but sometimes I'm not so sure of that: we all are influenced by instincts.

...After a few days, we could turn off the fence, and the horses would still shy away from it.  

During the course of medical training, how many times does a medical student see an attending shut off his or her feelings, shy away from confronting unjust disparities, or fail to challenge an unfounded assumption about a patient?

We assume that people have supportive families at home, when they may not.  We assume that if they say they understand something, that they do understand it.  We assume that a patient who looks cheerful could not be depressed or suicidal.

Then there are the assumptions that we are trained to make.  We assume that if they deny substance abuse, that they could be lying.  We assume that a young woman might be pregnant, even if she says it would be impossible.   We assume that patients with bipolar disorder might have unprotected sex with strangers, even if they live in a convent.  

Sometimes we offend patients with these assumptions.  Sometimes the assumptions are justified, and the patient is upset even though you are being scrupulous with your assumptions  This can be distinctly unpleasant.  Sometimes the assumptions are not justified, and we are too proud to endure a distinctly unpleasant confession.  

We may be able to see across the divide, but we can't get across.

Consider the "fact" that "there are things you can do to a patient that you wouldn't dream of doing to a person."  

Is this really true, or is it just an attitude we have learned?  Consider another of the letters:
To the Editor:

I spent all of January 2005 and six weeks in the spring on the transplant floor at Memorial Sloan Kettering having chemotherapy related to my acute myelogenous leukemia.

I determined to make my room a "nest," and the doctors and nurses responded to me as a person, asking questions about a photo or pointing out something of interest to a new resident.

The cleaning staff members are also important to one's well-being. At first I was a bed to clean around. As I engaged people in conversations about themselves, they began to smile when they entered my room.

I refused to see myself as a patient even though my day consisted of infusions and transfusions. I asked that hospital's alternative medicine staff members visit me. They provided soft touch, visualization techniques, meditation and music. They helped me feel alive.

The positive energy surrounding me helped me survive some very desperate days.

Janice Jeffrey
Brooklyn, Aug. 18, 2005
We may be able to see across the divide, but we can't get across.  

But maybe, we can get across.  Maybe we just think we can't, because we've been jolted a couple of times, or because we've seen our mentors shy away.  As I mentioned before, all of these deserve considerable introspective thought.
UPDATE (8/28/2005)

I posted on this topic previously, here; and subsequently, here.  As it happens, when Yvonne and I came home from grocery shopping today, we saw that Champie had jumped over the electric fence!  He's not quite five months old, and never has been trained for jumping, yet he jumped right over it.  Maybe horses actually are smarter than doctors; certainly, they are more courageous.

Categories: medicine, armchair musings
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