Revelations in a Wheelchair

In late 2001, I heard Daniel Gottlieb, a psychologist and best selling author, talk about an experience he had while waiting in the hallway to give a keynote lecture at a prestigious conference. Gottlieb had been in a serious accident years before and was left quadriplegic. He was sitting in his chair outside of the lecture hall, a coffee cup resting on briefcase on his lap, looking down at his notes. A woman walked by, eyes averted and thinking that he was begging, put a dollar in his mug.
 

Nolan Ryan Trowe tells a similar story in an Op-Ed piece in the Sunday, November 25, New York Times entitled: “Revelations in a Wheelchair: A recently disabled New York City photographer gets an education in the discrimination that people like him must face.”  You may find it worth reading.

An Introduction to Trauma-Informed Care

Two short Perspective pieces in the November 20, 2018 NEJM are excellent introductions to this subject.  They discuss how we, as health care providers, can serve our patients better.  Significant numbers of our patients were victims of violence that informs their general health.  This is a huge, underappreciated subject that we do not think enough about in our rush to get through our busy clinics.

1. Trauma-Informed Care - Reflections of a Primary Care Doctor in the Week of the Kavanaugh Hearing. by Eve Rittenberg. N Engl J Med. 2018 Oct 10.  Free Article

2.  Sit Back and Listen — The Relevance of Patients’ Stories to Trauma-Informed Care.  by Dorothy Novick. N Engl J Med 2018; 379:2093-2094 Free Article

Excerpts:

Rittenberg:

“I am a primary care internist, practicing in a women’s health group. My patients’ experiences reflect the prevalence of trauma in our country: more than one third of U.S. women have been the victim of contact sexual violence at some time in their lives. Sexual assault often starts early — 40% of women who have been raped were first raped before 18 years of age.  In my work, I have the privilege of being present for women who share with me their fears, their hurt, their shame — and trust that I will stay with them and listen

“Health care providers have an opportunity and responsibility to dig deep into ourselves and commit to actively resisting retraumatization, to develop the resources to support survivors, and to support each other as we do this work.”

Novick:

“If there is one thing I have learned over 22 years of practicing pediatrics in an under-resourced urban environment, it is that patients reveal their most personal and painful life experiences when we build trusting relationships and encourage open dialogue. The more we understand about the long-term effects of toxic stress due to adverse childhood experiences, the more important it becomes for us to absorb these stories. They form the crux of trauma-informed care.”

There is also an informative eleven minute online interview with Eva Rittenberg on providing patient-centered and compassionate care for people who have experienced trauma that can be accessed at either of the above links.

Sexual trauma is just one of the Adverse Childhood Experiences and Traumatic Events that result in victims' poor health and shortened longevity.  The ACE Pyramid is a useful summary.

Are You Well Controlled?

by Judith Hendley, BMJ, 11.23.18
Language can convey meaning and shape understanding. It can stigmatize and label or it can empower and affirm.  Therefore, Ms. Hendley would like to be identified as a person first and not as a “diabetic patient.“

As healthcare professionals. it is important to think about the language we use when referring to or writing about people with long term conditions such as diabetes.  We must consider if they would find the language we use in referring to them empowering or disempowering?

This brief but spectacular essay is applicable to many conditions or situations that we encounter in the persons who consult us as physicians.  See: "Are You Well Controlled?"

Doctor Sahib

by Saruabh Jha

New England Journal of Medicine 11.22.18

There was a time when doctors knew their patients and their patients’ families. Medicine, then, was not a team sport: the buck ended with the GP. Saurabh Jha’s  essay about his father in the New England Journal of Medicine is brilliant reminder of a time that has, to a large extent, disappeared.

His physician father in England understood his Pakistani patient “not just because he was fluent in Urdu: as a migrant himself, he understood that most people from the Indian subcontinent  - Muslims, Hindus and Sikhs alike -  don’t see doctors unless they are  ill and don’t take their medications unless they have symptoms."

His father’s “patient trusted him because he believed my father genuinely cared about him.”

This is a moving piece that many of you will appreciate.  Link to Doctor Sahib.

Save the Germs

In the century that has passed, the use of antibiotics made many diseases disappear from the modern world. But now drug-resistant forms of some horrible bug have appeared — and we have little and sometimes nothing in our medicine chest with which to fight them. Enamored of the antibiotics’ power, medicine has over-prescribed them, making new pandemics possibles when resistant strains of bacteria have been selected.

A group of infectious disease specialists and  microbiologists have proposed the formation of a resource of the world's bacteria be established to "save the bugs."*  This Op-Ed piece in the NY Times serves as a good introduction to this topic.

See Save the Germs by Sarah Schenck (11.19.18)

Ms. Schenck is co-director and co-producer of a documentary being made about the critical role of microbes in human health. 

* Preserving microbial diversity. Bello MGD, Knight R, Gilbert JA, Blaser MJ. Science. 2018 Oct 5;362(6410):33-34

Placebo Power

The placebo is a powerful medical treatment that is ignored by doctors at their patients’ peril. It is especially important for patients with chronic stress-related conditions, such as depression, back pain, chemotherapy-related malaise, migraine, posttraumatic stress disorder, irritable bowel syndrome and other functional disorders. Many people with medically unexplained symptoms are in the group that can benefit from placebo therapy.

Gary Greenberg, a NY Times reporter, has written a useful, lucid introduction to this topic.  We have synopsized and discussed it on OJCPCD.

Dr. Leanna Wen

A few years ago, I was privileged to hear Dr. Wen, then the health commissioner of Baltimore, speak at a conference.  She is now the president of Planned Parenthood.  The NY Times had a brief interview with her in the Sunday Magazine of November 11, 2018.

About her profession as public health practitioner she says, There is a saying, “Public health saved your life today, you just don’t know it.” The work of public health works best when we are invisible. The problem is that, when we’re invisible, we are the first on the chopping block.

See NY Times article:  Leana Wen Dislikes the Politicization of Health Care

The Upgrade, by Atul Gawande

In the November 12, 2018 issue of The New Yorker, Atul Gawande has a long article about the complex relationship physicians have with computers and the electronic medical record (EMR).  As a precis, we have placed excerpts from the article with some personal observations on The Online Journal of Community and Person-Centered Dermatology.  Today, almost all health care professionals will, perforce, have to use an EMR.  Gawande's article is a useful introduction to this topic.

Digitization promises to make medical care easier and more efficient. 

But are screens coming between doctors and patients?

Image from NY Times article

On CME Programs

How Physicians Keep Up

In most states, physicians are mandated to attend C.M.E. sessions for continued licensing.  Sadly, many of these programs are just marketing opportunities for PhRMA and device makers.

In a 1905 article in the Boston Medical and Surgical Journal, Drs. RC Cabot and EA Locke wrote:

“Learning medicine is not fundamentally different from learning anything else. If one had 100 hours in which to learn to ride a horse or to speak in public, one might profitably spend perhaps an hour (in divided doses) in being told how to do it, four hours in watching a teacher do it, and the remaining 95 hours in practice, at first with close supervision, later under general oversight.”

‘nuff said,

Reference:

Cabot RC, Locke EA. The organization of a department of clinical medicine. Boston Med Surg J. 1905;153:461-5