Category Archives: Health and Wellness

An Appalling and Alarming Devaluation of Life

I received an email earlier this fall from someone very close to me – a psychiatrist, in her mid-60s, extremely intelligent, level-headed, non-reactionary, balanced, rational, and even. She tends to be somewhat progressive and mildly left-of-center on social issues. She sent me the link to Ezekiel Emanuel’s article in the Atlantic, “Why I Hope to Die at 75”, and she expressed significant concern.

I also tend to be somewhat progressive and left-of-center on social matters, reasonably level-headed, and non-reactionary. I found the article to be chilling.

I provide the brief background on our personalities and social-issue political leanings very deliberately. You need to know who is alarmed here, because my article is about to sound like it was written by a right-wing pundit with paranoid tendencies. It was not.

The piece in The Atlantic invokes fears far beyond those of death panels (which, as unacceptable as such a concept is, at least imply that there are some decisions to be made as far as who might merit the resources to have life-saving treatment). Dr. Emanuel’s article sets the stage for an expectation that people’s health is not something for which society should pay at all once they have reached a specified age (the specific age he chose is 75). No need for a death panel – you just need access to a person’s date of birth. He repeatedly uses the term, “American Immortal,” to imply that the idea of living healthily into old age is unrealistic, selfish, and greedy. He steps so far over the line with his stated “personal” preferences that the rest of us won’t be able to help but view the government as magnanimous when it generously allows Medicare to cover an antibiotic for a 76-year-old. I am afraid that Dr. Emanuel aims to be so outrageous in his arguments that a slight step back will be viewed as reasonable.

His points of persuasion reminded me of an Onion article from the late 1990s, when Dr. Kevorkian was frequently making headlines (“‘Vehicular Manslaughter Doctor’ Assists in 23rd Doctor-Assisted Vehicular Manslaughter”). The Onion writers are able to make anything funny – even a subject such as assisted suicide. Their satire in this particular article goes over the top in its farcical quotes depicting the suffering of people (for example, having to put on a special pair of glasses just to read) whom they are putting out of their misery by running over with a car. Dr. Emanuel’s depictions of the infirmities of those 75 and older are frequently as preposterous as those of The Onion (for example, one of his instances of something horrible to be enshrined in the memories of someone’s children or grandchildren is that person’s having to ask what someone else said – seriously, he implies that it’s better for a person not to have a memory of a grandparent who has some hearing loss). To be fair, Dr. Emanuel does not advocate direct homicide of those 75 and older, but he most certainly promotes shoving them out of the healthcare world onto a proverbial ice floe. And rather than being funny, the seriousness of his dissertation is simply horrifying.

His position is coldly utilitarian. He establishes any loss of functionality, productivity, or creativity as making the world smaller, of being no way to live or to be remembered. So he recommends that people die first, before losing any functionality, productivity, or creativity. I certainly would not want to be the in-any-way-less-than-perfect family member of this guy.

Dr. Emanuel puts forth that those 75 and older already have grandkids or even great-grandkids, and their continued existence overshadows the next generation down. I would put forth that a little therapy would go a long way towards resolving such psychological issues for someone who feels he is not able to achieve his rightful position as patriarch, and I would put forth that such therapy would be significantly preferable to killing off one’s parents.

Speaking of killing people off, it also shocked me that a physician would take the medically unsound (from a population/public health standpoint) stance that after a certain age he would refuse a flu vaccine. Is this so he can pass influenza along to infants, other elderly people, and those with weakened immune systems, so as to efficiently thin the herd and more quickly reduce their financial burden on society? There are creepy parallels to both The Giver and Children of the Corn.

On Ezekiel Emanuel’s website, there is a big quote screaming from the homepage (www.ezekielemanuel.com): “Zeke Emanuel is a force of nature. Author, ethicist, cook, medic, policymaker: he makes other over-achievers look lazy and inadequate. There are very few policy experts – in health care or any other field – with Zeke’s smarts, political antenna and persuasive powers.” This man is a member of the academic and political elite. One of the architects of the Affordable Care Act (ACA or “Obamacare”), he is in the healthcare policy inner circle. His words do not die on the page. People in positions of power are listening to this man.

He sets up a false choice of being a sickly immortal-wannabe or forgoing all medical care at a predetermined age. He puts forth what is either his own fear of not being at his peak or what is his politically calculated and expedient depiction of old age as a universal “succumbing to that slow constriction of activities and aspirations,” and thereby devalues any life that is not at his defined “peak.”

This man is an ethicist. His ethics are unnerving.

I asked my youngest son to read the article and tell me what he thought about it. He is still two months shy of turning 14. I’ll stipulate that he is a smart 13-year-old (he has two smart older brothers to learn from), but still – he’s 13. Here’s his response:

“There’s a lot of wrong stuff in that article. He makes it sound like getting old is bad and that life is less worth living when you’re old. He’s wrong. As you get older, you know more and more about life, so you live it more clearly. You’re wiser. So what if you slow down a little? And what’s wrong with listening to books and doing puzzles? He said it was bad for people to have memories of someone older or weaker. He sounds like he just wants to shove old people out on an ice floe.” So I wasn’t the only one who had that ice floe image. “And that thing he said about older people overshadowing younger ones – that’s just messed up.”

I then asked my son if it sounded like the author was just stating his own personal opinion. He answered, “Actually, it sounds like he’s trying to convince other people of what he’s saying under the guise of it’s being his own opinion.” Out of the mouths of babes. He’s a high school freshman and he wasn’t fooled.

My son asked who this author is. I told him that he’s a very influential doctor involved in healthcare policy. He replied, “that’s scary.”

Listen to the kid.

Because Ezekiel Emanuel is a member of the political elite, he will have the prerogative to “change his mind” and access healthcare when he’s older than 75. But when his words have been enacted into policy, the rest of us won’t have that option. This man’s words and his position of influence combine to seriously threaten our right to life, liberty, and pursuit of happiness. Do not let him force anyone to go gentle into that good night before they’re damn good and ready.

I cannot dismiss his article as the musings of a madman. His words appear to be the cold, calculated attempt at the social engineering required to decrease our country’s medical bills in a deeply disturbing manner. They are a set-up to “well, if Ezekiel Emanuel is totally healthy and strong and climbing mountains in his late 50’s and declares that he should be dead in less than 20 years and not using up money for healthcare, then who is someone with (arthritis, diabetes, any ailment of any kind) to demand care? Why should we give a new hip to a 70-year-old? Why should we treat cancer in someone in their 60s?” I hope every member of the AARP (and every one of their family members, and anyone who is in or someday plans to be in that demographic) reads Dr. Ezekiel’s article. And I hope they read mine.

Do not let this man have the last word. Do not let him smile sweetly and innocently as he sets the stage for a “there will be no coverage for chemotherapy (or dialysis, or ICU care, or hip-replacement surgery, or medications other than painkillers…) after age (whatever seems like a number likely not to cause a huge outcry)” policy enactment. Let the outcry be heard now. Let it be huge. Keep your eyes and ears open. Follow what policy makers and policy influencers are saying and know who your elected officials are listening to. Keep reading what Ezekiel Emanuel writes. Keep up the outcry as necessary and keep it loud. Do not underestimate the power and influence of his words, or the power and influence of your own.

 

Exponential Ire

I was invited to a “networking party.” I went. I was horrified by what transpired there. And disgusted. And felt blindsided. And angry. And blown away by the prevalence of what I couldn’t decide was greed, ignorance, or an unseemly combination of the two. And what magnified the intensity of my repulsion was the fact that a large proportion of the people involved have the title, “doctor” (although none of them were MDs, DOs, or PhDs). I felt mortified.

The evening began like any other business networking event. We walked around, munching on some hors d’oeuvres and shmoozing informally. Then we all gathered for the formal part of the evening, where we all took turns introducing ourselves to the group with a brief “elevator pitch” (quick spiel) of what we did for a living, and if we were a visitor we told the group whose guest we were that evening. And then, the presenter began. And I almost fell over.

This was not a networking thing. This was a pyramid scheme.

The presenter had a board with little velcro hearts and rainbow-colored umbrellas arranged in a triangle shape with the apex at the bottom. There were four layers, so above the one cute little velcro item on the bottom there were two on the layer on top of it, four in the next layer, and six (with two empty spaces) at the top. The presenter then explained how each little symbol represented a person in this wonderful system, and how each new member was added to the top layer when they paid a “gift” of $1,000 to the person at the bottom. She added two symbols to the top to complete the row of eight and to then demonstrate that when the person on the bottom had received her $8,000 in “gifts,” having originally only payed in a gift of $1,000, thereby netting $7,000, the pyramid above split into two, and each of the people who had been in that next layer above the recipient would now be the recipient of the $1,000 from each new member in the next layer of people who joined, with this pattern repeating so that each person would end up netting $7,000.

There were multiple assurances from the presenter and confirming enthusiastic shouts from people in the room that this was all perfectly legal, since it was all in the form of “gifts,” and that it was not at all a “pyramid scheme.” A pyramid scheme is a model in which members make money solely by recruiting new members to pay into a program, and new members pay in with the expectation that they will have a turn as a money recipient. This was absolutely a pyramid scheme.

Pyramid schemes are unsustainable. They implode. The people who start them and get in on them early will make money off the many people who will lose their money when they join later.

In the room that evening, people bragged that they were on their second time through. They spoke of how wonderful it was to be able to “help” the person on the bottom who only invested $1,000 but now was on her way to receiving many times that amount. And they spoke of how noble it was to help the people in this group, who each had reasons for needing to grow their money – tuition for their children’s college, seed money for starting their own businesses, etc.

What they neglected to discuss was the basic math involved. The concept of exponential or geometric growth. The one person who started the program needed to recruit 14 other people to fill in that first triangle cycle with the top layer of people each paying in $1,000. For each of those 8 payers to receive their $8,000 and split the triangle in two for the people in the next layer up, they needed to recruit one hundred and twelve people (sixteen to pay the two people in the original second layer, thirty-two to pay the four people in the original third layer, and sixty-four for those eight people in the original 4th layer). For those sixty-four who paid in to the original fourth layer of eight people to receive their own payout requires recruiting eight hundred and ninety-six more people. This is because each layer of people must double three times for the payout to be complete. Within about 9 of these complete cycles you’ve covered the population of the United States, and in less than two more full cycles after that you’ve covered the population of Earth.

Obviously this contrivance collapses fairly quickly. A lot of people will lose their money, since the number of people buying into the game plan is finite. The system is designed to have a lot of people lose their money. This particular scheme tries to make it ok by describing the buy-in as a “gift,” thereby trying to excuse themselves from being obligated to each person buying in.

How scuzzy. How unethical. Or, if giving some of the people involved the benefit of the doubt, how ignorant.

And as I mentioned above, several of the people who were a part of this scheme (not people who were brought in as guests to this “networking party”) were members of professions in which they have patients and people call them “doctor.” They are not MDs or DOs, but they refer to themselves as “primary care doctors.” They are practitioners of “alternative medicine.” And here at this event they were actively taking part in a scheme that showed they either lacked a basic understanding of high school math or they understood it quite well and were willing (and hoping) to exploit the ignorance of others for their own financial gain. Either possibility is frightening in members of professions that purport to care for the health and physical well-being of others.

Members of these particular professions frequently speak against conventional medicine. They speak of “toxins” in vaccines. They promote homeopathic “remedies” and “preventions.” Do practitioners in these fields not understand the math involved when each person with measles in an un-immunized population infects 12 to 18 others, how quickly that number explodes, and how 2 out of every thousand people infected will die (significantly more, up to 10%, in areas where people are malnourished and don’t have access to adequate medical care) and how many will suffer blindness, encephalitis, or pneumonia secondary to a measles infection? Do they not understand the comparison of those numbers to the one person in a million who will suffer a severe allergic reaction to the vaccine? Do they not understand that a homeopathic remedy, which is created when an herb or a poison (yes, a poison) is diluted multiple times (so that there is exponentially less of the substance with each step), leads to a solution in which there is no detectable active ingredient (which is actually a good thing in the case of the poisons) – the opposite of exponential growth? Or do they understand these concepts well enough but are willing to exploit the ignorance of others for their own financial gain, even if that exploitation is not just financial but is at the expense of the health and well-being of those whom they purport to “heal?”

I do not presume that every alternative medicine practitioner participates in predatory Ponzi schemes. But each of us, especially when we make a point of announcing our profession and describing what we do, is a representative of our profession. If there had been a group of financial planners taking part in that pyramid racket, what would you think of that profession? What if there had been a large contingent of lawyers? Or teachers? What would that do to your trust of that profession as a whole? I know that there are chiropractors who treat back pain and don’t talk their patients out of vaccinations or into useless remedies or out of appropriate medical care. But I have to try harder now to remind myself of that. And I find it easier to understand when the general public complains that “doctors” are just looking to make money when I find “naturopaths” who call themselves “doctor” trying to recruit people into a pyramid financial arrangement that will find their recruits each out a thousand dollars as their “gift system” collapses.

It’s been almost two months since the “networking party.” Rather than continuing to fume, I am stepping back, taking a deep breath, and trying to transform my indigestion and raised blood pressure into helpful words. Think about what you do. Think about what you promote. Think about the consequences of what you do and promote, both to yourself and to others. Ask yourself if you are acting out of greed only, with a disregard for the well-being of others, or out of a sincere desire to make the world a better place. When someone is handing you a line, figure out if they are doing it out of greed (and a disregard for the well-being of others). Go back to basic math, to basic science, and to basic ethics. And when you are making a decision about your health or the health of someone you love, work with a doctor who understands and respects these basics.

Housecleaning and Doctor Visits

I spent this past week worrying that my in-laws were going to divorce me. For sure. No getting out of it this time.

I do not keep a neat house. There are piles everywhere. Piles of books. Piles of papers. Piles of clean-but-unfolded laundry. Piles of mail. Piles of music. Piles (believe it or not) of instruments. Piles of shoes. Piles of coats (it’s cold these days, but varying degrees of cold). There’s a drum set in the living room (because that’s where the piano is). Did I mention the books?

My parents-in-law keep an immaculate house. I don’t think I’ve ever seen a pile of anything in it. Ever. And they’re arriving this afternoon for a weekend visit.

They get that we’re busy. They get that we suck at housekeeping. They have never, in twenty-one years of marriage or the dating years prior to that, criticized us. They focus on our strengths rather than weaknesses. But we all have our limits.

Normally, it’s possible to move the piles around a bit, tidy up around them, and keep a reasonable level of cleanliness in between the occasional deep-clean. But it’s been quite some time since the last deep-clean, and there’s only so much you can do with the touch-ups.

My house epitomizes the problem with the state of medicine today. Stay with me on this.

We’re busy in my family. You should see our Google calendar – so many overlapping color-coded blocks that it actually looks beautiful if you step back and let your eyes go a little fuzzy. So aside from regularly taking out the trash and recycling, cleaning the toilets, and doing dishes and food clean-up, other stuff gets relegated to an as-needed basis. When something gets really gross, we clean it. When something breaks, we fix it. When the toothpaste spatter around the sink reaches a critical radius, we wipe it. But when that goes on for too long without a no-one’s-going-anywhere-until-this-entire-place-is-company-ready cleaning frenzy, it can get really bad.

Bad enough that a visit from your parents-in-law, whom you love deeply, actually frightens you.

A similar phenomenon has been happening in medicine. And, like my house, it’s been getting worse. There’s no time to spend with patients. There’s more and more on the schedule. There are more billing issues to focus on. More regulations. More pressure to see a greater number of patients. More hoops to jump through to maintain board certification. Doctors have time to swab a throat here, adjust a blood pressure medication there, give a quick reminder that someone’s due for a colonoscopy, tell a patient that it would be in his best health interest to lose a little weight. It’s like cleaning around the piles. It can sort of work for a short while, but the dirt builds up.

Every so often, a doctor’s got to sit with her patient and do the equivalent of a deep housecleaning. Find out what’s going on in the patient’s life. Listen to the fact that her son’s been out of work for a year. Maybe that’ll give you the clue that perhaps the reason you’ve had to increase her insulin prescription so much recently is that she’s been giving half of it to her son, who also has diabetes.

My husband and I have spent 8-and-a-half hours so far today straightening and cleaning. We’ve got a little over an hour to finish whatever we’re able before his parents arrive.

It’ll be ok. The bathrooms with which they’ll have contact are thoroughly clean. There is no dust and there are no piles of clothing in the room where they’ll be sleeping. And much of the rest of the house is a heck of a lot better than it was. We’ve done a pretty good job. Not the ideal, whole-house deep clean, but targeted deep clean with broad adequate cleaning. Kind of like a doctor’s visit that focuses on diabetes, high blood pressure, smoking cessation, headaches, ways to reduce stress, healthy eating advice, and ways to fit exercise into a daily routine, The next visit will address the need for a screening colonoscopy, and will describe the preparation for it.

That prep would be the equivalent of our cleaning out our basement. Maybe I’ll wait until I’m 50.

 

Ebola Politics

There’s much in the news this week of a nurse who is refusing to stay in quarantine after her return from caring for patients with Ebola in West Africa. So many issues here. Hard to know where to begin.

First, the nurse is correct in her statements that there is no scientific evidence that she should be in quarantine. She has twice tested negative for the virus. She has no symptoms (a forehead temperature registered high at the airport when she first arrived in the United States, but follow-up temperature readings have been normal). The disease is not contagious until people are symptomatic. And again, she has tested negative twice so far.

The fact that she has valid scientific points does not mean that her manner of spurning authority is the most useful strategy or the wisest thing to do in this particular case.

The fear surrounding this particular disease is intense. The vitriol directed toward those who contract the disease when caring for the people afflicted by it is mind-boggling. There is a lack of logic and common sense regarding this disease which is maddening. So adopting a tone that appears belligerent is not necessarily the best way to calm fears, educate people, and work with the scientific community and government officials in a cooperative, productive and helpful way.

Thousands of people have died in West Africa due to this Ebola outbreak – about 5 thousand at this point, out of about 13.5 thousand total cases, in countries whose populations total about 22 million. The medical infrastructure is not present to adequately treat the people there and control the disease. We need more facilities and healthcare personnel to contain the outbreak. The bigger the outbreak becomes, the higher the likelihood that people with the disease will end up in the United States, so even if some people don’t have deaths of people in another area of the world high on their personal radars, the outbreak will have some effect here – it is a global issue. We need people to work together in a smart way.

Ebola is spread through contact with bodily fluids of a person who is actively sick. Casual contact with someone who does not yet show signs of disease has not been shown to transmit the virus. Monitoring people who have come in close contact with actively ill Ebola patients (i.e., healthcare workers, people who are cleaning the bodily fluids of those who are ill, etc.) through the potential incubation period (the time it takes from exposure to disease development, in the case of Ebola 2 to 21 days) is fairly easy to do when there is a small number of people to monitor. When we send large numbers of military personnel to help with the crisis overseas, it will be more difficult to monitor everyone individually on their return, and so a three week quarantine from time of last exposure makes logistical sense.

We are not quarantining every doctor, nurse, lab technician, or custodial worker involved in the care of Ebola patients and their environments. We are monitoring. We are using common sense. We are looking at the data – this is not a new disease, and we have observed the patterns of transmission.

The nurse who is fighting her quarantine has brought in lawyers. She is figuratively kicking and screaming about her rights being violated. The general public is looking at her reaction and saying, “How selfish! What a spoiled brat! How dare she put me at risk?! Three weeks is no big deal. She should err on the side of caution and be done with it!” Her belligerence invokes anger, not understanding or alliance. Her dismissal of people’s fears does not promote an environment of respect and teamwork.

The nurse’s lawyers and the state of Maine’s lawyers are currently trying to work out a compromise. This is beyond ridiculous. Why are lawyers negotiating a public health issue? The state’s public health department has authority here. The federal government, through the CDC (Centers for Disease Control and Prevention), has authority. If the state’s public health department has said “quarantine,” then the quarantine should be respected. If the state has its information wrong, the CDC can step in.

The nurse in this case is well within her rights to cry “foul” to a policy that is grounded in fear rather than scientific reality. But the crying should be done smarter.

She should have called Doctors Without Borders, with whom she’d been volunteering. She should have called WHO (the World Health Organization). She should have called the CDC. After speaking with these organizations and getting official confirmation of appropriate protocols, she should have spoken with the state authorities with whom she disagreed. If they didn’t listen to the advice from WHO and the CDC, the nurse then should have gone to the newspapers and TV networks.

I understand and agree with the stance of not blindly going along with inappropriate policy. When reality/facts/science are ignored, bad things happen. People are ostracized. People are vilified. Already, a child was kept out of school in Connecticut because she had visited Nigeria (not an epicenter of this disease, and she had not come in contact with any sick people) for a family wedding.

The school defended its decision by saying “some of the other parents were scared.” This makes about as much sense as keeping a kid out of school in the Midwest because he had visited his family in Texas, and someone in Texas had Ebola. That school ignored facts and made poor decisions based on ill-informed fears. The nurse in our story is trying to prevent such poor decisions.

If she had just said, “whatever,” and stayed inside for three weeks (or in her original quarantine tent for three weeks) she would have not suffered any long-term negative effects, but she would have been complicit in the propagation of such ridiculous events as transpired in the Connecticut school. She would have been complicit in allowing fear-generated policies to stay in place that would discourage anyone from helping those in desperate need of medical help. She, a healthcare professional, would have been complicit in bad medicine.

But by simply showing defiance and going straight to the lawyers, she, a healthcare professional, says that it’s ok for people to defy public health authorities.

So here’s an alternate unfolding of events:

Nurse gets off plane. She discloses her work with patients with Ebola. Forehead temperature scan reads high. She denies any symptoms. Because of the high temperature reading and an abundance of caution, she goes to the hospital for temporary observation. All subsequent temperature readings are normal and the nurse remains free of symptoms. Lab tests for Ebola are negative. Nurse calls Doctors Without Borders and gets contact information of their infection control experts. Nurse calls CDC and WHO and gets contact information for their Ebola gurus.

Infectious disease team at hospital talks to Ebola gurus from CDC, WHO, and Doctors Without Borders. They reach consensus. They make recommendation to local health department. Local health department makes decision based on evidence, expert consensus, and known data, rather than on TV news sound bites of the fears of random citizens with no science or health background or training. In the meantime, the nurse waits for the appropriate people to deal with the issue. And she abides by the answer.

The media circus was unnecessary. The lawyers were unnecessary. What was needed was communication among all the experts – those on the front lines, those with the epidemiology background, those with the infectious disease expertise. And the government entities needed to listen to those with the knowledge. And a healthcare professional should have recognized the need for this type of communication facilitation, and should have respected the public health entities by working appropriately through the correct channels.

Lastly, keep in mind that tens of thousands of people in the U.S. die from complications of influenza every year. Get a flu vaccine. Measles is one of the world’s most contagious diseases, and it’s contagious from four days before a rash shows up. Get your kids vaccinated. These are issues the media should be headlining in this country right now.

 

Shared Experience, or the Lack Thereof, and Understanding

I just recently attended a meeting where there was a panel discussion on caring for Holocaust survivors. The person who opened the meeting spoke about how she felt inadequate when dealing with this population because she had no personal place of reference – she had no family members who died during the Holocaust, and so she couldn’t truly understand what the survivors went through.

I have a different thought.

Although every experience each of us has helps us to put ourselves in the shoes of others, helps us to empathize, helps us to imagine what others may be going through, each shared experience also puts a potential block between us and the person we are trying to understand.

There’s an old joke: “When two people are having a conversation, one person is talking and the other person is waiting.” We know what we want to say. We are ready with our next speech. We listen to enough of what the other person is saying to tie it in and segue nicely into our “response” to what the other has said. Frequently it’s not truly a response to what the other has said – it’s our response and reaction to the thought as it was first introduced.

If we think we understand someone else, we may fail to listen enough. If we think we don’t understand them, we may listen more carefully. If we think that we cannot understand someone, then we may stop listening altogether. It’s a balance.

I am frequently struck by how differently two people can experience the same event. And I am frequently struck by how similarly two people can respond to disparate events. So alignment of thought, emotion, reaction, and experience is not completely predictable. We need not to presume that we understand someone else. We need to listen and remain open to the possibility that we might not “get” someone that we think we do, or that we might completely “get” someone to whom we had thought we couldn’t relate.

While in many cases having a fundamental experience in common can strongly connect people, the durability of that connection ultimately depends on factors other than that common experience. A genuine caring for the other person, a willingness to hear what that other person has to say (rather than just assuming knowledge of the other person’s story), and the ability to accept differences in the other person enables the relationship to grow and strengthen. When those other factors are present, that shared experience is not necessarily crucial to the interpersonal bond.

Support groups can be very helpful for many people. They pull together individuals who are sharing a specific struggle. The people in these groups can learn from one another, sympathize with one another, gain insights from one another, and support one another. But generally the people who participate in support groups are people who want the support, want to support others, want to connect. There are guidelines in place to protect members’ anonymity (if so desired), and to allow each member the opportunity to tell his or her own story, thus encouraging other members to listen. It’s not simply the shared experience that makes the groups work – it goes far beyond that.

Because I must work very hard to maintain a healthy weight, I can sympathize and empathize with people who struggle with their weight. But if I assume that their experiences and reactions are the same as mine, the counseling and advice I give could very easily not work for them. When I listen, when I get people to tell me their stories, I can combine their situation with what I know from the medical literature, what I know from my own experiences, and what I know from having listened to others’ narratives, to synthesize and formulate a plan with them.

I am not a smoker. I have never felt an overpowering urge for a cigarette. Yet I have been able to help many people quit tobacco use. My lack of sharing in the experience forced me early on in my medical career to take the time to really listen to what my patients had to say about why they smoked, why they wanted or didn’t want to quit, what made it difficult for them to quit, and what seemed to help them and what didn’t. I didn’t come at it with a preconceived notion, with an “oh, I’ve been there, I know what to do” approach – I let my patients teach me.

So while a shared experience certainly can help people understand one another, it is not necessarily so, and a lack of experience-sharing can in some instances lead to better understanding through true listening unhindered by expectations and preconceptions. The key is the willingness to listen. To stop waiting for our turn to talk, and to really listen.  Of course this means that the conversation will take longer, since we need to take the time to formulate a response after fully listening to and hearing what the other person has to say, but the communication that actually takes place during that interaction will be far more fruitful.

The person at the meeting who felt inadequate in counselling a certain population because she hadn’t experienced their trauma still has plenty to offer. If she says “I will never know what you went through, but I care about you and want to understand you. If you will teach me, if you will tell me your story, I will do my best to listen and to learn,” then she will have potentially opened a door to a connection, to trust, to a potentially therapeutic relationship, and ultimately to an understanding that can possibly help her to help the next person whose story she listens to and hears.

 

 

 

What Football and Infectious Disease Control Have in Common

Communication. Such a simple concept. And yet so many ways in which it can fail.

Two examples of communication failures hit the news this past week, both of which have potentially severe medical repercussions, albeit on very different scales.

The first occurred this past Saturday at a Big Ten football game. The quarterback took a hard hit, and his head slammed backwards onto the ground. When he got up, he was so shaken and off-balance that he stumbled and collapsed into his teammate. So obviously, he would be pulled from the game and given medical attention, right? Nope. The coach put him back in for another play, as the crowd booed its displeasure and indignation. No one could believe the coach would show such blatant disregard for his player’s well-being, and there are strict regulations in place regarding head injuries in sports and protecting the athletes when there is any suspicion they have suffered a concussion.

But the coach didn’t pull the player out for a neurological check because he (the coach) hadn’t seen the player’s hit, his head-slam, or his resultant signs of head injury. The coach knew the quarterback was playing on an injured ankle (which had been medically cleared for play), and when he saw him limp back to the sideline, he assumed it was an ankle issue, stuck him in for another play, then had medical personnel check his ankle, and put him in again. Thousands of people in the stadium saw what happened. Millions of people saw on TV. Everyone assumed the coaches saw. But they didn’t – they were monitoring so many different things, planning, talking to people, and assuming important information would get to them. But the information didn’t get to the right people.

The university where this occurred is taking steps to ensure such an event doesn’t happen again. For example, they’re placing medical personnel in the press box for future games and giving them direct communication lines to the coaches. Systems approaches are good. They help. I’m glad they’re putting in extra safety layers to protect their student athletes, and I hope other schools and teams follow this lead. But systems measures can only go so far. We also need individual safety layers, and I cannot overstate the importance of personal advocacy (both self-advocacy and advocacy of others).

If the quarterback had said, “Hey, Coach, I hit my head and don’t feel right,” or, if he was too dazed to speak for himself, if his teammates had told the coach about the injury and their concern, or if anyone who had seen the incident had spoken up and relayed the information to the coach, then the athlete would have been given prompt medical attention and not sent back out on the field to be head slammed again. People need to speak up. And they need to speak up to the people in authority – the decision makers – and not just grumble quietly or complain amongst themselves.

Earlier this week, the news hit that the first person in the U.S. had been diagnosed with the Ebola virus. Ebola requires close contact with someone who is symptomatic with the disease in order to spread. We have good infection control measures in U.S. hospitals. We have quick dissemination of news. We have the CDC (Centers for Disease Control and Prevention). We have state and local health departments. We have a lot of good systems in place. The patient had recently come from Liberia, where there is a current outbreak of Ebola. He developed symptoms, he went to the hospital, and he told some of the medical personnel that he had just recently returned from Liberia. And he was sent home with a prescription for antibiotics. And he continued to be symptomatic, exposing other people for days, until he returned to the hospital and received the correct diagnosis, appropriate medical care, and concomitant infection control measures.

In this case, the patient actually had communicated the important information, but it didn’t get to the correct people. A systems issue, to be sure. But more individual advocacy and strong communication would go a long way here, too.

I was not on the sidelines with the football team, and I was not in the emergency room where the patient first presented, but I have some pretty good ideas as to some of what may have been going on.

Both the sidelines of a football game and an emergency department can be bustling with action. Things are going on in different areas. Different teams (offense, defense, trauma, radiology….) and their respective coordinators (offensive and defensive coaches, head coaches, triage nurses, nurse practitioners, attending doctors, etc.) are functioning within a larger whole, trying to attain their overarching goal (winning a game, getting all the patients taken care of) while trying to maintain the well-being of each individual (the athletes, the patients). With so much going on, communication frequently suffers. And when people are nervous about speaking up, communication suffers.

Players may have been afraid to “argue” with a coach. They may have assumed the coach knew all the facts. The patient or his family or the nurse he originally spoke to may have assumed the ER doctor or Physician’s Assistant or Nurse Practitioner who discharged the patient had read the travel history and considered the possibility of an Ebola infection. Both situations just needed someone, anyone, to say to the decision maker, “Hey, wait a minute. Do you know that (I hit my head and can’t walk straight/the quarterback looks like he has a concussion/this patient was just in a country with an Ebola outbreak/I just flew in on a plane from Liberia)?”

Systems approaches. Individual back-ups. Individual care. Systems back-ups. All necessary to minimize the holes in the information sieve. Don’t skimp on the systems. But also never be afraid to plug the holes in the systems yourself.

 

The Restaurant With the “Unhealthiest Meal” Does a Lot of Things Right – Go, Red Robin!

In general, mine is a family of food snobs.  My eldest son crossed a school off his college list because “Really, Mom, how can I be in a town for four years that doesn’t even have Indian food?” And those of you who know me (or are at least familiar with me through my writing) know my propensity to push healthy food choices. So it may seem somewhat strange that I’m about to extol the virtues of a burger joint. But it’s actually totally consistent.

As far as general food snobbery, most people like a good burger now and then, and Red Robin makes a good burger.

As far as the healthy food choice thing goes, Red Robin makes it a lot easier than many other places to make nutritionally sound picks.

This past summer, one particular combination of items at Red Robin was called out for adding up to 3540 calories. It included a bacon cheeseburger (with lots of other stuff on it, like battered, fried onions and creamy sauces) with an extra meat patty, “bottomless” fries, and a large milkshake (with an extra refill glass). Anyone could tell you that a meal like that will pack a lot of calories. And fat. And refined carbs.

I am not defending that meal. But I am defending the restaurant.

Red Robin has a full array of meal options, has multiple ways to make your lunch or dinner healthier, and tends not to be financially punitive for healthier choices. Rather than ordering a huge milkshake with a refill included, you may order an unsweetened iced tea. As far as the burgers go, you can substitute a ground turkey burger, a veggie burger, or a grilled chicken breast for no extra charge. You can choose a whole grain bun or even a lettuce wrap for the sandwich (which they do quite well, I must say). If you choose not to have their “bottomless” fries, they do not charge you extra to substitute (also “bottomless”) salad, steamed broccoli, or cut-up fruit. And they have many other meal options, all of which they readily tailor to your specific dietary requests.

I cannot tell you how annoyed I become when a restaurant “punishes” me for trying to choose a healthier modification to their meal. A local trendy breakfast place, when I wanted to skip the large pile of fried potatoes that came with my eggs, charged me $2.50 to instead serve me two completely anemic tomato slices. This was several years ago, and I have not gone back there.

So when a major restaurant chain provides me with choices that include vegetables, fruit, and lower fat proteins, and when they don’t up-charge the healthier options, I say, “Bravo!”

I’m fine with the milkshakes remaining on the menu. It is my choice to avoid them most of the time, and I discourage my kids from indulging regularly in them. But every once in a while, it’s ok if we split a mint chocolate shake. Especially if our preceding dinner had sides of broccoli rather than fries.

The person doing the ordering has the power to determine what they will ingest. Use common sense. Eat veggies. Use olive oil. Drink water or unsweetened iced tea. Save the indulgences for rare occasions, and share them so that there is reasonable portion control. And give props to the establishments that make it easy to do so.

 

A Flood of Problems

Wow.  When it rains, it pours!  Yesterday, our area got between 4 and 6 inches of rain in a very short time, which maxed out our local drain system capacity.  With no room for the torrentially downpouring water to go, the drain system (which combines storm run-off with sewer drainage) backed up into most homes in our city and several surrounding ones. Freeways and surface streets were flooded, cars were stranded, people were stranded, and there was and is a lot of general yuckiness.

I have, sadly, heard of one fatality, but so far most of the consequences of the storm are related to stuff, and not to lives.

However, the “stuff yuckiness,” i.e. sewage-contaminated basement flooding, has the potential to cause more people-harm.  So here are some resources:

The Oakland County Health Department has some great information: http://www.oakgov.com/health/Pages/Flood_Safety.aspx, as does the Red Cross: http://www.redcross.org/prepare/disaster/flood.

Beware of electrical hazards. contact your local public safety and public works departments for guidance.  Contact licensed flood/disaster recovery companies.  If local companies are swamped (no pun intended), call companies from other cities a few hours away – they may be willing to travel, especially if you and several neighbors get together and offer them a bunch of customers.

Even if the flood water looks clean, it has a high likelihood of sewage contamination, so everything should be treated as if it is raw sewage (since it likely is, although it may be somewhat diluted raw sewage).  Bleach is an excellent disinfectant, but it can be fatally dangerous if mixed with other chemicals. If you have a little bleach left in a bottle, and a little Lysol, for example, in another bottle, do NOT use them together in the same area – the chemicals can combine to form highly toxic gases.

Wear gloves and protective clothing.  Don’t track the water through your house.  Make sure you and your family have had Hepatitis immunizations.

I know it’s an awful experience to deal with a flood.  Even if people are ok and it’s “only stuff,” the stuff that needs to be thrown away is a flood of memories, and the costs of repair and recovery can lead to an outpouring of money from your bank account.

Let the air flow and remember to breathe.  Let the love flow – help your neighbors and let them help you.  And buy a sump pump or two….

Step on a Crack…

I recently went to an “admitted student day” with my eldest son at the university he plans to attend in the fall.  On our campus tour, our guide pointed out a block on the ground in the center of campus (which incorporates a symbol of the university) that no one steps on because “stepping on it will cause you to fail your first exam.”  In the winter, it is the first spot to be shoveled out after it snows so that no one inadvertently steps on it.

There is no evidence whatsoever that there is any element of truth to the story.  Of course, it’s difficult to do a double-blind, placebo-controlled study, but perhaps it could be done with blindfolded students in thick, rubber-soled shoes, taken in zig-zag-y paths either around or on top of the block, prior to their first exams.  But I would think that only those disinclined to believe such stories in the first place would participate in the study, since no one would want to fail an exam if they stepped where they believe they shouldn’t step.  The not-stepping-on-the-square is different than protecting the symbol from spray paint or other vandalism by rival colleges.  And people wear this symbol on their socks (which get stepped on, obviously) and on the seats of pajama pants (which get sat on), so the not-stepping-on-it isn’t really out of respect for the symbol.  It honestly stems from fear and discomfort arising from a superstitious story.

A remarkable number of otherwise critically-thinking individuals choose to participate in this superstitious behavior.  Many who do so say that even though they don’t really believe the story, “it couldn’t hurt.”

But that kind of thinking and behavior can hurt.  It ingrains a habit of following superstition and kowtowing to irrational fears  Of ignoring fact.  Of ignoring evidence.  Of ignoring science.  And then people make excuses for the superstitious behavior and try to rationalize it: “I just felt like I shouldn’t step on it,” or “I did it out of respect to people who believed it.”

Full disclosure: I hold an undergraduate degree from this particular institution of higher learning.  And I remember walking on the block.  On purpose.  Before my first exam.  Because I did not want to have to worry about having to focus on where I stepped, and I knew that if I gave in to the story at the beginning, then I would end up becoming a slave to the superstitious behavior.  And I did not fail my exam.  But I remember feeling uncomfortable each time I stepped there (which I did frequently over my years in attendance, purposefully).

I want to explore that discomfort.  Again, I really don’t think it’s a “respect for the symbol” issue, as I and my school-mates never had any problem stepping on, sitting on, or eating over any other versions of that symbol.  I have no doubt that if the story were “step on it and you’ll get an ‘A’ on your next exam,” that it would be the most trampled upon spot on campus.  Or that if the “don’t step on” spot were 3 feet to the northeast of the block, that the northeast nondescript area would be avoided.  My unease really was a bit of a sense of fear.  That I was doing something “wrong” that somehow tempted fate.

Never mind the fact that I understood very well that attending classes, doing the reading, doing the problem sets, asking questions when I didn’t understand something, and studying were the factors which would determine my grades on my exams.  These factors have a proven, cause-and-effect correlation with exam performance.  I know that.  And I knew that then.  And yet the unease…

I think some of this unease has to do with a sense of control (or lack thereof).  I can control whether I do the reading, the homework problems, the studying.  But I cannot control what the professor will choose to ask on the test, whether it will focus predominately on subject matter I understand or on subject matter that’s more difficult for me, or how well others do (which affects the grading curve).  Believing a superstitious story (or acting on it) is an acknowledgement that some things are beyond my control, and it’s an action to try to take a bit of control over the uncontrollable.

And yet this lack of ability to control everything is precisely the reason it is dangerous to fall into the superstitious behaviors.  They have the ability to make us feel like we have control when we don’t, and to make us neglect the factors over which we really do have a lot of power.  The superstitious behaviors can indicate that we’re giving up on the provable, the scientific, the rational behaviors.  And we need to remind ourselves not to do that.  We need to make sure that the fear doesn’t take away our power of rational thought and behavior.  We need to remember that although the rational behaviors do not produce infallible results, they are still supremely more reliable than the superstitious, especially when they are not simply “rational,” but also studied and scientifically/factually verified.  We need not to allow a tiny amount of uncertainty or discomfort to outweigh a preponderance of evidence.

Doctors need to remember that their patients frequently feel a lack of control.  And that patients experience fear.  We need to understand the tendency of many people to feel superstitious.  We need to understand the feelings that drive people to seemingly irrational behavior.  We need to remember that once a seed of fear is planted, it can sprout roots and gain hold.  We need not to roll our eyes when people express fears about vaccines, but we need to acknowledge the sense of unease that a human has when he or she feels as if he or she has incomplete control in a situation, and the fear that person has when someone has planted a seed of doubt and suspicion.  The more we understand our patients, the better we can communicate with our patients, the better we can relate to our patients (and our patients to us), and the more likely we are to be heard and our advice followed.

And all of us need to think about what we are afraid of and why.  When there is overwhelming evidence, for example, of the safety of immunizations and the science behind them, we need to think about why we would be afraid of a a repeatedly dis-proven risk, why we would allow the roots of that seed to take hold once we have figured out that it’s a weed, not a flower.  We need to think about why we feel compelled to buy special water with a “memory” of a magic herb and grow suspicious of “western ” or “traditional” medicine.  Or why we are afraid to step on a specific square on the ground.  And we need to force ourselves to step on that square, so that we reinforce our resolve not to become slaves to irrational thinking and behaviors.  The fact that we do not have 100% control does not mean that we should throw up our hands and disregard a preponderance of evidence.

It’s scary not to have complete control.  But every human is faced with such reality.  It is incumbent upon us not to allow that fear to assume de facto control.

 

 

A Little Privacy, Please

Our privacy is eroding. Some of this erosion is our own fault – we post to Facebook, Twitter, and other social media with reckless abandon. Some is the nature of modern communication – electronic trails are just as easy to find as paper trails (if not easier). Some of the privacy erosion really doesn’t bother me so much – if Target knows that I buy a lot of Cheerios, I’m happy to accept their General Mills coupon for $1.50 off my next breakfast cereal purchase. But there are some places where I expect and demand privacy.

Like in a doctor’s office. Or hospital. Or pharmacy.

But business has so inserted itself into so many aspects of life, including medicine, that my expectation of health-related privacy is being slammed into the wall. Although I really couldn’t care less if Target knows my cereal-buying habits, I certainly do care if they share the information when I purchase a pregnancy test. Or athlete’s foot spray, for that matter. Of course the store has no idea if I’m purchasing health-related items for my own family or for someone else, so it’s unlikely that this information will be used for anything other than targeted coupon offers, but it still really bugs me that people look at this information. And yes, I am aware that I can simply use cash when purchasing over-the-counter wart remover if I want complete privacy on that issue. But the fact that I have to consider it really bothers me.

What price convenience? And what price financial savings? I have a Target Red Card. It gives me 5% off the price of everything I buy at Target. It allows me to return items even if I’ve lost a receipt. It gives me coupons for things I buy. But I read an article a couple years ago that talked about a man finding out that his teenage daughter was pregnant because she started receiving store coupons in the mail for diapers and infant formula after she had purchased a pregnancy test and vitamins. This is a breach of privacy. And it could also cause harm aside from breach-of-privacy with its presumptions. For example, while some couples who purchased a pregnancy kit and then started purchasing vitamins may in fact be delightedly experiencing a pregnancy and happy to receive a coupon for a stroller, a couple experiencing fertility difficulty (or who experienced a miscarriage) might not appreciate receiving constant flyers for baby item sales. It’s one thing if someone actively opts-in or signs up to receive notification of promotions of certain types of items, but quite a different thing to have the automaticity and presumptuousness, and it’s a problem.

There are other financial “incentives” that erode our medical privacy. One that bothers me quite a bit is the extra charge for health insurance that many companies currently impose unless you have a yearly health screening and fill out an online, detailed, personal questionnaire about health-and-safety-related issues. Strange that this bothers me, considering what I do for a living. And considering that I am all about people taking responsibility for their health. And considering that I am all about educating people on health-and-safety-related issues and healthy lifestyles. And that I like when there are resources to help people. And that I understand deeply how addressing certain issues can significantly improve a person’s overall health and well-being (and in so doing, how it can have a positive financial impact as well).

But I figured out what it is that bugs me so much. I actually would have no problem with it if there were the same requirement for a yearly check-up with one’s own physician and if the questionnaire were between each individual and that person’s physician. My problem is with the online, one-size-fits-all survey/questionnaire with detailed, personal questions (many of which have nothing to do with modifiable risk factors) that goes to some random computer algorithm and perhaps some random person (who is not a doctor). Seriously, the lifestyle health coaching company does not need to know when someone’s first menstrual period was – they can simply ask if a woman has discussed breast exams and mammograms with her physician. My issue with the current system of monetarily penalizing those who don’t comply with this invasive questioning is the presumptuousness and the intrusion of someone else into my doctor-patient relationship. There are too many people in the exam room.

By all means, the companies should feel free to offer their support services as an option to those who decide they would like to use them, or to those whose doctors feel they would benefit. But if you are not my patient and you were not invited in by my patient, then get out of my office. And if I did not invite you, then get out of my doctor’s office.