Category: Patient-Centered Care

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Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

Categories
General Patient-Centered Care The Medical Commencement Archive

“Becoming Healers”: Dr. Jonathan LaPook, 2017 Commencement Address of Quinnipiac University School of Medicine

I am pleased to present this week’s Commencement Archive piece: Dr. Jonathan LaPook’s keynote address at the 2017 Quinnipiac University School of Medicine Commencement.

Dr. Jonathan LaPook is the Chief Medical Correspondent for CBS news and has served in this role since 2006. A board-certified physician in internal medicine and gastroenterology, he is also a Professor of Medicine at NYU Langone Medical Center. He attended medical school at Columbia College of Physicians and Surgeons, and completed an internal medicine residency and a gastroenterology fellowship at the New York-Presbyterian Hospital/Columbia University Medical Center. Dr. LaPook has received two Emmy awards for his work in 2012 and 2013 covering the national drug shortage and Boston Marathon bombings, respectively.

 

While Dr. LaPook is accustomed to speaking in front of crowds and cameras, this particular speech was a first for him.   With great pride and humility, he addressed the very first graduating class of Quinnipiac University School of Medicine. While the event was new to everyone involved, the message Dr. LaPook delivered stems from his diverse experiences as both a physician and journalist.

Dr. LaPook discusses the semipermeable membrane—or as he puts it, an emotional wall—that lies between us (as physicians) and the patient. One must be mindful of the emotional balance that exists, and this, according to Dr. LaPook, is the first and last challenge of the art of healing.

“It starts with a decision about the emotional wall we all build between ourselves and our patients. Constructing it is tricky. You don’t want to make it too thin and porous, because that can be emotionally devastating. But you don’t want to make it too thick and impervious, because then you miss out on all the good stuff, the precious moments when you connect with a patient as a person. I treasure the time an elderly patient showed up for an office visit on a beautiful spring day, and I wheeled her over to the Central Park Zoo to watch the sea lions. No medicine I have ever prescribed has had a more powerful therapeutic response. Everybody has to find a comfort level. For me, erring on the side of “too empathetic” is the way to go. Patients pick up on it, and if they feel you really care, they’re more likely to open up to you.”

 

“When we’re watching a movie and an important moment is about to happen, how do we know?”

Unfortunately, when caring for sick patients, other than a few beeps on the monitor, important moments don’t come with dramatic music or close-ups. There is no camera-pan to direct our attention to informative, meaningful information. We are both privileged and burdened with this responsibility of seeking out and interpreting information in order to make informed decisions.

“Well, in life, there’s no close-up and there’s no change of music. You have to play the soundtrack in your own head. You have to control the zoom button yourself. You must catch that moment when the patient—consciously or unconsciously—tells you what’s the matter. You need to get them to open up to you as one human being to another. And they will not do that unless they know they are talking to a human being!”

As Dr. LaPook continues, he begins to discuss his career in journalism and its implications on his medical practice. In particular, covering global health crises has shaped his ability to communicate oftentimes complex medical information to a broad audience.

“The key is taking complex topics and presenting them in simple, accessible terms. Communicating clearly—and succinctly—is an important skill. Work on it.”

Dr. LaPook summarizes with a single piece of advice.

“Be comfortable with uncertainty. If you’ve been practicing medicine for five years and you think you have all the answers, you’re in the wrong profession.”

Although patients may expect us to have all the answers, we must not burden ourselves with this expectation. Medicine is an art, not a calculation. Physicians consume diverse clinical data not necessarily to find an answer but rather to justify a decision.

Dr. LaPook sends the graduating class out with a final message.

“What’s going to distinguish you as true healers is the way you embrace humility, compassion, and empathy. Turn away from the computer screen and look your patient straight in the eyes. Understand the extraordinary importance of listening. And realize that even when you don’t have the answer for a patient in need, you can still help—with a sympathetic ear, a reassuring touch of the hand, and by sticking by them, through sickness and health.”

Read the full speech in the Commencement Archive: https://www.themspress.org/journal/index.php/commencement/article/view/297/314

Categories
Emotion Empathy General Humanistic Psychology Narrative Patient-Centered Care Psychology Reflection

Immigrant’s Suitcase: Ordinary people with the will to do extraordinary things

A mother separated from her missing husband flees a war-torn country, her homeland, to provide a brighter future for her children. She’s a dentist by training and practiced dentistry back home; but here, here she’s cleaning homes for a living. Why? When she left her home with her four children by her side, headed to a safer place, to America, what was in her suitcase? Alongside the picture of her missing husband and the few possessions that remained after the destruction of her home, in her suitcase, she has hopes and dreams, fears and doubts. She looks to her children for strength, but she’s terrified every time she looks them in their eyes. She is not optimistic, but she is hopeful; she looks the odds straight in the face and proceeds anyway. Because hope is not logical, it is powerful.

She’s cleaning the home of a happy family; the father is an engineer and the mother is a doctor and the children play piano. Their life, their hopes, goals and dreams are dependent on the stability of their country, but they cannot see it. The same hands that used to place crowns to relieve the pain of the suffering are now scrubbing the floor of another woman’s bathroom. But hope is powerful, and she lives through the dreams of her children. Two of her daughters want to be doctors. Her third daughter wants to be an artist. Her son is eight and he loves math. In her suitcase, she brought with her the dream of a better education for her children. “In Syria, we ate grass. In Egypt, we didn’t have food. In Indiana, I love school.” These are the words of her eight-year-old son.

A man runs to catch the bus. He can’t miss the interview; he really needs this job. It is his third interview in as many days. His last job got him enough money to get his family off the streets for a couple weeks. But motels are more expensive than he ever imagined. He’s homeless. His family is homeless. This wasn’t a possibility he considered when he graduated with his MBA. He had a great job, but the hurricane took everything away. And he hasn’t been able to get back on his feet. He catches the bus and pays the $1.75 in quarters. He checks the email that he printed; the interview is in room 4015. He runs up the stairs; he really hates being late. As he enters his interviewer’s room, a bead of sweat runs down his forehead. What’s in that bead of sweat? Desperation and nervousness, humiliation and self-pity, purpose and resilience.

His interviewer gives him the job offer. He smiles and shakes his head. A tear runs down his face. He can’t take the job; he can’t manage the branch that makes most of its revenue through alcohol sales. Another day and another interview, but his family remains homeless. He needs the job, but rejecting the offer was an easy decision. He believes that although alcohol may have small benefits to people and society, the harm it causes is much larger than its benefits, and wants to play no part in its distribution; he will not be a co-creator in the intoxication of his neighbor’s mind.

A young woman sinks into herself on the examination table. Her husband is holding, squeezing her hand. The doctor is still talking. He looks very sympathetic. The young woman just learned that she has a cancer growing inside of her lungs, an aggressive cancer. The doctor thinks ‘we can fight it.’ The young woman’s mind is overwhelmed into quietness. All she can think about is her daughter’s play after school that she doesn’t want to miss, even for this. The doctor brings her back, ‘Do you feel comfortable about our next step? I think that’s the best place for us to start.’ The young woman shrugs. What is in that shrug? Fear and uncertainty, peace and tranquility, ambivalence, a need for normalcy, a desire for time to make meaning.

The young woman is herself a physician, trained and licensed as a radiologist. She knows enough about cancer and the late stage non-small cell lung cancer she has been diagnosed with to know that the longevity of her future has been called into question. And yet this is not the topic of discussion with the doctor. Instead, he discusses treatment options, which is fancy talk for a long list of big words in different orders and combinations. When asked about the next step, she shrugged. She shrugged because there didn’t seem to be room for her in that room. (Insert young woman with terminal cancer here). Although it is more comfortable for the doctor to rattle off treatment options, the patient wants to take time to acknowledge the inexorability of our life cycle. To the doctor, it was the end of a beginning, and they were, together, supposed to begin a new chapter of strength and resilience. While he rattled off treatment options, she just wanted to catch her daughter’s play after school, and she was running late.

In the words of HL Menken, ‘For every human problem, there is a solution that is simple, neat, and wrong.’  Without taking a moment to explore what’s inside the immigrant’s suitcase, the homeless man’s bead of sweat, the sick young woman’s shrug, we stand a sorry chance to witness, help, and learn from ordinary people with the will to do extraordinary things. This is the power of narratives; the power of listening. I call myself to look inside the suitcase, to investigate the bead of sweat, and to ask about the shrug; I call myself to listen.

I find myself in an imperfect world, full of injustice and oppression. I find myself an imperfect man perfectly given the ability to alleviate suffering, on a personal level with a smile or a hug, and on a larger scale by fighting injustice and refusing to stand idly in the face of oppression. Poverty belongs in a history museum. And hunger…we have enough food in the world for every member of the human family to eat a balanced 3000 calorie meal. When we eliminate poverty and hunger, there will be many other injustices for us to face. I want to make facing these injustices my mission. My mission is to be ‘human’ as best I can; to work to establish justice in any capacity that I can, from a generously given smile to an honest political campaign.

Photo Credit: Robot Brainz

Categories
Clinical Emotion Empathy General Patient-Centered Care

Opinions Aren’t Facts

I wanted to discuss an experience I had in the newborn nursery. I was assigned to Baby K—a small baby girl who was delivered by emergent cesarean section because her mother abused cocaine during her pregnancy. Looking through Baby K’s chart, an unsettling feeling came over me. This was one of the first times I directly saw how a mother’s behavior impacted her child. Before this, all my clerkships had dealt with adults who were responsible for their own health. Seeing an innocent newborn enter this world with a disadvantage because of her mother’s actions was disheartening.

With this in mind, I went to talk to Mother K the next morning. The chart stated Baby K was going to be given to her great-grandmother, and I needed to confirm this information. I could immediately tell that Mother K was upset when I asked her to confirm. She said, “Yes, she’s going to her great-grandma, but I’m still going be involved! I’m NOT giving up on her!” I realized that just asking the question caused her emotional pain. Especially since the social worker, the nurse, and probably several others, had also asked this question. She again assured me that she loved Baby K, but that she just needed to get her life together before she could care of her. After talking more to Mother K, I realized she was trying her best.

This experience opened my eyes to my perception of patients. After browsing Mother K’s chart and reading that she continued to abuse cocaine while pregnant and was planning on giving Baby K to another caretaker, I may have made the assumption that she didn’t want anything to do with Baby K at all. This assumption may have been reflected in the way I asked her questions, leading her to become distraught. Many patients, especially those who suffer from substance abuse, have lost complete control over their actions. Their mind is controlled by an addiction, and they need help before they can take care of others. After talking more with her, I learned that Mother K actually planned to enroll herself in a treatment center that has housing. After getting better, she yearned to resume care of Baby K. These are details that were never mentioned in any notes, but if they had been mentioned, may have altered my first impression of Mother K before I met her. I also learned that Mother K continued to use cocaine during her pregnancy because she didn’t realize its impact on Baby K. She used cocaine during her prior pregnancy with her older son, and he remained “normal and healthy.” Even though we, as medical professionals, can understand how abusing cocaine during pregnancy is directly detrimental to the fetus, many individuals may not understand this basic concept of maternal-fetal physiology. We thought Mother K’s use of cocaine was due to her lack of care for Baby K, when in reality it was fueled by her lack of knowledge.

The most important lesson I learned was not to judge patients based on chart review alone. I know this seems like “common sense,” but it can be easy to jump to certain perceptions after reading the tone of some of the notes in a patient’s chart. My goal in the future is to enter every patient’s room with a blank slate. Our duty has always been to provide the same quality of care for all patients, regardless of their actions or beliefs, but sometimes we let our feelings get in the way of this duty. I have struggled with this in pediatrics more than I have in any other specialty. When I talk to parents who are willing to move mountains for the health of their children, I feel endearment towards them. There is nothing stronger or more special than a parent’s love. In contrast, with parents like Mother K, it is easy to become frustrated. After examining Baby K, I kept thinking about her fragile little arms and small shrunken head. Baby K may grow up to have health consequences that could have easily been prevented. All I can do is allow this experience to shape future patient encounters. I’m going to try to place myself in each parent’s situation and ask myself: what information or advice would I find the most helpful right now? At the end of my time with Mother K, I gave her a tight hug—I’m rooting for her. I hope she is able to complete her treatment and be reunited with Baby K soon.

 

Photo credit: Weird Beard

Categories
Clinical Emotion Empathy General Patient-Centered Care

Are you a cheerleader or a fan? Examining motivation in medicine

One of my favorite aspects of medicine is the relationship between health and lifestyle. I think of lifestyle as all of the “stuff” that affects patients outside of the exam room, including diet, exercise, family relationships, and living accommodations. All of these things affect the physical body in ways that are not always immediately apparent. In my most recent rotation, my preceptor and I treated several obese women complaining of low back and hip pain.  Thinking about the relationship about weight and musculoskeletal pain, I was surprised that my preceptor never made suggestions to patients about increasing their activity level or improving their diets. “I’ve realized that I’m not a cheerleader,” he told me, when I questioned him. “Trying to make people change only ends in heartache for me.”

It’s difficult to think about how patients can change their lifestyles without first thinking about their motivation for change. January happens to be the perfect time talk about motivation since this is the time of the year when people are making those pesky New Year’s resolutions.  W.D. Falk, a philosopher, writes about motivation as a direct product of one’s morals, and divides motivation into two subtypes: motivational internalism and motivational externalism. Motivational internalists believe that one’s motivation for doing something is directly linked to how the activity in question relates to one’s morals. In other words, if a patient is convinced that exercise is a good, morally correct thing to do, that moral conviction will be enough to motivate them to exercise. On the contrary, motivational externalists see no link between one’s moral convictions and their motivation. No matter how important or morally correct our patients think something is, their motivation for changing their lives has to come from some external source. A patient may believe that exercise is a morally good activity, but this belief alone is not enough to actually motivate them to exercise.

Acknowledging the existence of these two groups (and of course, many shades of grey in between!) will allow us to understand how we may best help our patients without using a “one size fits all” methodology. Some patients may able to find the impetus for change within themselves. These patients may articulate specific plans to achieve a goal or they may have independently improved their own wellbeing in the past. Other patients may need external motivating factors to make changes necessary to improve their health, most often in the form of a trusted confidant. We need to use our best clinical judgment to decide which approach would work better for each patient.

My preceptor’s comments also helped me recognize that in addition to understanding our patients’ capacities for change, we also need to think of our own capacities for motivating our patients. Some physicians are cheerleaders willing to stand on the front lines with their patients. These practitioners feel energized by helping people make positive changes and are willing to make an emotional investment in their patients’ lives. They help their patients set goals, consistently communicate with patients about their progress, and are willing to act as an emotional support whether or not the goals get met. Other physicians may not see themselves as cheerleaders for change. These physicians still have a responsibility to discuss aspects of their patients’ lifestyles that need improvement; however, their role might take form as a “fan” in the stands, rather than a cheerleader on the sidelines. They can still cheer on their patients and check in with them about their lifestyle changes, but may need to help patients find someone else in their healthcare team who is willing to do the ground work that it takes to help patients set and reach goals. In fact, I believe that it is far better to honestly acknowledge that you are a lousy cheerleader than to try to help your patient, only to become disheartened by their lack of progress and abandon them out of sheer frustration before their goal is met. It’s only through an honest acknowledgement of our own abilities and limitations that we can help our patients change their lifestyles for the better.

 

Photo credit: Jeff Turner

Categories
Clinical General Law Opinion Patient-Centered Care Pharmacology Public Health

Access to Contraception

Contraception is essential to a woman’s health, empowerment, equality, and independence. This belief is championed by the Center for Reproductive Rights, Guttmacher Institute, Planned Parenthood, and others. More importantly, governing bodies of health care overwhelmingly defend access to contraception:

 “Contraception is a pillar in reducing adolescent pregnancy rates.”

  • The American Academy of Pediatrics [1]

 “Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman.”

  • American Academy of Family Physicians [2]

“The American College of Obstetricians and Gynecologists [ACOG] supports access to comprehensive contraceptive care and contraceptive methods as an integral component of women’s health care and is committed to encouraging and upholding policies and actions that ensure the availability of affordable and accessible contraceptive care and contraceptive methods.”

  • American College of Obstetrics and Gynecology [3]

“Access to safe, voluntary family planning is a human right. Family Planning is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty.”

  • United Nations Population Fund [4]

“This policy supports the universal right to contraception access in the United States and internationally.”

  • American Public Health Association [5]

“Family Planning, an integral component of sexual and reproductive health, is a critical pillar for health and development; it is also a human rights issue…When women are denied their right to and choice of family planning methods, they become trapped in a vicious cycle of poverty, poor health outcomes from ill-timed pregnancies and limited capacity to fully realize their potential.”

  • World Health Organization [6]

 

Contraception is regarded by the CDC as one of the 10 greatest public health achievements of the 20th century.[7] Of the many reversible contraceptive options available, implant and intrauterine device are most effect, with less than 1% risk of failure for both perfect and typical use compared to an 18% failure rate for typical male condom use.[8] Of course, condoms are the only available contraceptive method that also protects against transmission of infections, including the human immunodeficiency virus (HIV) and human papilloma virus transmission through certain makes of condoms.

Benefits of contraception include: improved health and well-being, reduced global maternal mortality, pregnancy spacing and subsequent health benefits, increased participation of females in the workforce, and economic independence for women.[9]

In the United States, 70% of women ages 15 to 44 years old are sexually active and do not want to become pregnant. Thus, 70% of reproductive aged women are at risk of unintended pregnancy. The Guttmacher Institute, a leading researcher of reproductive health, reported that consistent and correct use of modern contraception (i.e. condom, hormonal contraception, long-acting method, or permanent method) without any gaps in use during all months a woman is sexually active resulted in 68% of sexually active reproductive age women avoiding an unintended pregnancy.[10] These women accounted for only 5% of unintended pregnancies that occurred in 2008. In comparison, 41% of the 3 million unintended pregnancies were a result of inconsistent modern contraceptive use and 54% resulted from nonuse.[10]

Sadly, in addition to other Catholic-based religious organizations, the United States Conference of Catholic Bishops argues that contraception does not prevent unintended pregnancy nor reduce abortion rates.[11] The USCCB also does not believe that contraception is basic health care.[12] Instead, the USCCB states,

 “Contraception is an elective intervention that stops the healthy functioning of healthy women’s reproductive systems. Medically it is infertility, not fertility, that is generally considered a disorder to be treated.”

Let me be clear. Access to contraception is basic health care. 222 million women globally have an unmet need for modern contraception.[4] This burden is highest in vulnerable populations such as adolescents, those from low socioeconomic households, those with HIV, and internally displaced persons.[4]

The WHO issued guidance and recommendations on “Ensuring human rights in the provision of contraceptive information and services,” in which officials outline nine priority actions policy makers and providers need to take to ensure that human rights are protected in the provision of contraceptive information and services.[13] These steps include:

  1. Non-discrimination in provision of contraceptive information and services
  2. Availability of contraceptive information and services
  3. Accessibility of contraceptive information and services
  4. Acceptability of contraceptive information and services
  5. Quality of contraceptive information and services
  6. Informed decision-making
  7. Privacy and confidentiality
  8. Participation
  9. Accountability [of programs that deliver contraceptive information and services]

In regards to current politics and policy proposals, accessibility of contraceptive options includes affordability.

Under the Affordable Care Act (ACA) healthcare law, preventative women’s health services—including well-woman visits; screening for gestational diabetes; human papilloma virus testing; counseling for sexually transmitted diseases; counseling and screening for HIV; contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence—are covered without any co-payment, co-insurance, or deductible.[14] For reference, if the ACA healthcare law were not in place, the average out-of-pocket cost for birth control would be $78-$185 per year.[14] For myself, my oral contraceptive pills cost $30 per month, totaling $360 per year! This was a financial burden as a student—but essential for my overall health—and so, I budgeted. But not everyone has that capability.

The ACA’s expansion of health care coverage and improved access to care also resulted in reductions in delayed care, as well as improved maternal and newborn outcomes. From 2010 to 2014, the proportion of women who reported delaying or forgoing care due to cost concerns dropped by 3.4%.[15] The health care law also funded the Strong Start for Mothers and Newborns Initiative, a collaboration between the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families. The initiative aims to reduce preterm birth rates and improve maternal and newborn health outcomes. This is key because full-term babies have improved outcomes compared to those born in an early, term elective delivery.

The United States Human Health and Services notes that actuaries, insurers, and economists generally estimate that contraception provisions are at least cost-neutral and may, in some cases, result in cost-savings when taking into account the costs and benefits of unplanned pregnancies.[14] In 2009, the UNPF and Guttmacher Institute published a detailed report explaining how family planning and maternal and newborn health services saves lives and money. Preventing and/or postponing unintended pregnancies results in fewer expenses due to the decreased need for maternal and newborn health care and the management of unsafe abortions.[16] In addition, ensuring standards of maternal and newborn health care reduces the rates of complications and subequently incurred high costs.

Keeping these considerations in mind, our current political climate is of great concern because on January 20, 2017, President Donald Trump issued an executive order to repeal the ACA.[17]

I received an email update this week from ACOG reporting that the AAFP, American College of Physicians, AAP, ACOG, and American Osteopathic Association mailed a joint letter representing over 500,000 physicians asking the White House and Congressional leaders to “stand with us and for America’s women” because “healthy women can better participate in our economy and our workforce, and can reach higher levels of educational attainment.” The letter also identifies four priorities moving forward, one of which is to ensure that women have affordable access to evidence-based care.[18]

ACOG’s committee opinion on access to contraception emphasizes full implementation of the ACA requirement that,

“…new and revised private health insurance plans cover all U.S. Food and Drug administration-approved contraceptives without cost-sharing, including non-equivalent options from within one method category (eg. levonorgestrel as well as copper intrauterine devices).” [3]

Throughout the next few months and years when you are voting or exercising your right to debate the very real challenge we face to reduce health care costs, please remember that investing in family planning and maternal and newborn health care services saves money. And remember that leading healthcare organizations—the very governing bodies who set the standards for evidence-based care—strongly advise that the White House and Congress to write healthcare laws that ensure affordable women’s health care and access to contraception. I urge readers to fight for access to contraception, a necessary and significant human right.

For more information about available contraceptive options, please see the “Birth Control (Contraception): Resource  Overview” published by ACOG, available at http://www.acog.org/Womens-Health/Birth-Control-Contraception#Patient.

References

  1. Committee on Adolescence. Policy Statement: Contraception for Adolescents. Pediatrics. 2014
  2. Klein DA, Arnold JJ, and Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician. 2015;91(9): 625-633.
  3. American College of Obstetricians and Gynecologists. Access to contraception. Committee Opinion No. 615. Obstet Gyneco.l 2015;125:250-5.
  4. United Nations Population Fund and Center for Reproductive Rights. Family Planning. Available at: http://www.unfpa.org/family-planning. Accessed November 29, 2015.
  5. American Public Health Association. Universal Access to Contraception; Policy 20153. November 2015. http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/17/09/14/universal-access-to-contraception. Accessed: November 28, 2016.
  6. World Health Organization. Family Planning Summit, 11 July 2012: WHO’s Commitment. Available at: http://www.who.int/reproductivehealth/topics/family_planning/WHO_commitment_fp.pdf?ua=1. Accessed: November 30, 2016.
  7. Sonfield A, Hasstedt K, Kayanaugh MI, Anderson R. The social and economic benefits of women’s ability to determine whether and when to have children. New York (NY) Guttmacher Institute; 2013. Available at: http://www.guttmacher.org/pubs/social-economic-benefits.pdf. Accessed: November 29, 2016.
  8. Guttmacher Institute. Contraceptive Use in the United States. September 2016. Available at: https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states. Accessed: November 29, 2015.
  9. Starbird E, Norton M, and Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016;4(2):191-210.
  10. Guttmacher Institute. Infographic: Contraception is highly effective. July 2013. Available at: https://www.guttmacher.org/article/2013/06/infographic-contraception-highly-effective. Accessed: November 28, 2016.
  11. Emergency Contraception Fails to Reduce Unintended Pregnancy and Abortion. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/emergency-contraception-fails-to-reduce-unintended-pregnancy-abortion.cfm Accessed: February 2, 2017.
  12. Fact Sheet: Contraceptive Mandates. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/contraceptive-mandates.cfm Accessed: February 2, 2017.
  13. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations; 2016. Available at: http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1. Accessed: November 28,2016.
  14. S. Department of Health & Human Services. Fact Sheets: Women and the Affordable Care Act. Available at: https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/women-and-aca/index.html. Accessed: November 28, 2016.
  15. Simmons A, Taylor J, Finegold K, Yabroff R, Gee E, and Chappel A. The Affordable Care Act: Promoting Better Health for Women. ASPE Issue Brief;2016:1-10.
  16. UNFPA and Guttmacher Institute. Adding it Up 2014: The Costs and Benefits of Investing in Sexual and Reproductive Health. UNFPA, Guttmacher Institute. 2016;1-56.
  17. The White House Office of Press Secretary. Executive order minimizing the economic burden of the patient protection and affordable care act pending repeal. Available at: https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and. Accessed: January 2, 2017.
  18. Healio Family Medicine. AAFP, ACP, others join forces in new effort to protect women’s health. Available at: http://www.healio.com/family-medicine/womens-health/news/online/%7B1b88e282-cd33-402c-a97a-bea5ef45238f%7D/aafp-acp-others-join-forces-in-new-effort-to-protect-womens-health . Accessed: January 2, 2017.

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Blue coat photos

Categories
General Narrative Patient-Centered Care

Lunch Chats

It’s 6:30 AM. I have one hour to see four patients before morning rounds. This seems like ample time, and it is—it just isn’t the best time. My patients are still sleepy. They aren’t in the mood to listen to me talk about meal planning or exercise regimens (at the crack of dawn, I wouldn’t be either). Each morning, I wake my patients up, ask them pertinent questions, and perform a focused physical exam. Then, I let them get back to sleep. Yes, I would see them again during morning rounds, but no, seeing them twice is not enough. I realized early in my clinical education that if I really want to make a difference, I need to visit my patients after lunch.

I was motivated to visit my patients in the afternoon after hearing the following wise words from one of my attendings: “the patient you see at 7:00 AM is very different from the one you see at noon.”

In the morning, sometimes as early as 6:00 AM, patients are sleepy. It’s much harder to engage them in conversation. In the middle of the day, after they’ve eaten lunch, they are often looking for an engaging visitor.

When I started third year, I wanted to heal every issue on my patients’ problem lists. Inpatient medicine is driven by a patient’s “chief complaint,” and the management of long-term health issues is left for follow-up with a primary care provider. This is a practical system, but it is still unsettling. I was never convinced that Ms. B, who came in with a toe ulcer, would continue to manage her diabetes with a “low carbohydrate diet” and regular glucose checks.

When Ms. B was on my team’s service a few months ago, our daily visits to her room generally entailed checking the status of her toe. She received accuchecks every four hours, and her blood sugars were generally well-controlled, but would she really continue to eat this healthy at home? I wanted to find out. After I started visiting Ms. B multiple times a day, I learned so much more about her health obstacles. I learned that she often starved herself the entire day and binged on one “feast” at night. She thought she was being healthy by only eating one meal! I explained that her eating pattern was messing with her body’s metabolism, and I gave her a presentation I had made a few years ago about affordable healthy food choices available at the local supermarket.

Attendings and residents work extremely hard, and they don’t often have enough time to sit with every patient and discuss life choices. As a medical student, I have this time. I’ll never know if Ms. B implemented my suggestions, but I do know she left the hospital with more than a healed toe. Since then, I’ve been visiting my patients after lunch…I’m always surprised by how much I learn.

 

Photo courtesy of Am Kaiser

Categories
Empathy Humanistic Psychology Patient-Centered Care Psychology Reflection

Applying Humanistic Psychology to Medical Practice

“People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, ‘Soften the orange a bit on the right hand corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.” –Carl Rogers1

We as human beings love categories. We enjoy dividing the body into its constituents, from the bones to the muscles to the skin, from the heart to the vessels to the blood cells. The more we can break something down, the more we can dissect it, understand it and build from it. It can be argued that this method of reductionism is what has led to many of the insights of the present day. It is by becoming so specialized within one area that one is able to build upon one’s expertise and develop novel ideas.

This method of classification, however, cannot be used to explain everything around us. While insightful in some areas, it can be destructive in others; namely, the human mind.

Look back at the history of Psychology and we see ourselves jumping through the same hoops of categorization, attempting to reduce our inner worlds into hierarchies and models. From the psychodynamic theories of Freud to the behavioristic perspectives popularized by Pavlov and Skinner, we are led to believe that if we can merely slice apart the human mind into chunk-sized pieces, perhaps we can gain insights into humanity itself.

But unlike the heart or the lungs, the way we choose to see a particular human mind can have profound effects upon that person. Tell someone that they are a mess of electrical impulses and chemicals, and they may see themselves and the world around them far differently than a person who believes that it is they themselves who have control over their lives.

There is a reason Psychology and Psychiatry garner so much criticism from the general public in a way that no other specialty does.  There is a reason that an anti-psychiatry movement exists, but there are no anti-surgery or anti-cardiology movements. It is because these theories, these categories, have an impact on how we see ourselves. They touch upon what it means to be human.

The argument I wish to propound is to urge us all to go beyond these categorizations, be they biomedical, psychological or social, and to take a more holistic approach, which I believe can best be viewed through the lens of Humanistic Psychology.

What is Humanistic Psychology?

Humanistic Psychology arose in response to the more mechanistic views of human behaviour that were gaining popularity in the 1950s2. Rather than focusing on one aspect of a person, be it our childhoods or our innate animalistic needs, Humanistic Psychology proposes that what is important is how the person themselves experiences the world around them. The human being is central. It is not the objective measurement of chemicals, electrophysiology or set questionnaires that lies at the heart of humanity, but how we think and feel.3

There are many contributors to the Humanistic canon, but I wish to focus on just one aspect of it: Carl Rodgers’ person-centered therapy. Although the word “therapy” implies a form of treatment for those with mental health problems, I wish to apply these principles to the arena of healthcare as a whole. I believe the therapeutic relationship between therapist and client can teach us much about our own relationships with patients within hospitals, emergency rooms and clinics.

Person-centered therapy is built upon three principles4:

  1. Congruency
  2. Unconditional Positive Regard
  3. Empathy

I will go through each of these in turn and focus on how they can transform our relationships with our patients.

Congruency

Congruency refers to genuineness, that is, displaying ‘your actual self’4 when dealing with a patient. This involves letting go of one’s mask and revealing one’s true feelings as they come and go. It requires a level of self-awareness, which allows us to fully experience the moment instead of remaining walled-off from our true inner state.

Do not think of yourself just as a doctor, a medical student or a healthcare professional. Undoubtedly there are professional boundaries that must always be maintained, and a profession that you represent every day. But be careful that you do not let this professional façade get in the way of your relationship with your patients. Remember that you are only human and the last thing a sick patient needs is a robot. By displaying an open and trusting character, you give your patient the opportunity to relax, to feel at ease and to be open about what is truly troubling them.

Congruency takes us back to our humanity, reminding us that there is little difference between ourselves and the patient sitting opposite. If we can come to terms with our own thoughts and emotions as we deal with the chaos that occurs in the world of healthcare, then we will be able to display a level of respect and understanding that will allow our patients to appreciate that they are speaking to a human being and not just a title.

Unconditional Positive Regard

Unconditional Positive Regard refers to the belief that people should be accepted as they are. For the professional, it involves displaying a non-judgmental attitude that is provided unconditionally, i.e. without limitations or expectations.

Although this is a concept well known to most of us, it can be difficult to put into practice. We all have our prejudices and our own rigid lines that we draw across our horizons. The expectation is not to get rid of all prejudice, but to be aware of how they impact our behaviour towards others.

Do we at times place blame on our patients?
Does our heart sink when we go to speak to certain people?
Do we have certain beliefs about people based on their clothing, their lifestyle, or their occupation?

Of course we do. Think back to a time when any of these thoughts have come to your mind and think about their effects. It may not necessarily mean that you throw everything in the air and scream your prejudices out loud. But it does mean that the way you regard your patient may be subtly altered; you may show less enthusiasm towards certain patients or display less sympathy than you would for someone else. It is by being aware of these little discrepancies that will make us all better clinicians.

Undoubtedly, healthcare places us all into positions where we come face-to-face with lifestyles that we disagree with and behaviours that we feel uncomfortable around. The idea is to go beyond these actions and see the human being lying beneath the layers. We must accept them as they are, and may be surprised to find that the patient responds with gratefulness at being treated as an equal.

Empathy

Perhaps the term most popular out of the three, empathy refers to the ability to understand what the other person is feeling. It involves having an understanding of the other person’s beliefs and values, and being cognizant of why they care about the issues that are important to them – in other words, it involves fully stepping inside another person’s private world.

Within healthcare, it is important that we do not go through a list of tick boxes and forget that our versions of events are not the same as theirs. All too often we may accept simple words such as ‘I’m frightened’ with a mere nod of the head and a simple smile on our faces without digging deeper and asking, ‘What is it you are frightened of?’ Our job does not merely consist of diagnosis and treatment, but of going further into our patients’ lives and understanding what their illnesses mean to them. What it means for them to be in hospital, to be a patient, to lose their role as a parent or a provider. Without this aspect, we may well cure a disease with our drugs and our technology, but we will never get to the heart of the matter.

What does it all mean?

These are all terms that most of us are familiar with. They are words we may write time and again upon reflection, sayings that we repeat year after year during our interviews. But the idea is to put this into practice, which can only happen if we first take a step back and think about the times when perhaps these three concepts were not fulfilled. Those times when the relationship broke down, when the patient closed up, when we walked out of the consulting room thinking that could have gone better.

Remember that patients do not always come to us with a collapsed lung or a broken rib. They come to us as a whole. The idea behind Humanistic Psychology is to go beyond the reductionist theories that focused on one aspect of a person’s being, and to appreciate the totality of human experience.

Why do I think these three concepts are important? Because I believe these are concepts that make all of us much better clinicians, and ultimately much better people. I believe that almost all of the problems we face within healthcare, and indeed outside of it, revolve around our ability to relate to others. How differently would we act if we could truly see through the eyes of the person sitting next to us, feel their pain and suffering, think their thoughts as they swirl between their children, their loved ones, their aims and their worries? These concepts, although integral to person-centered therapy, transcend the therapist’s room and can be practiced in every dialogue across every hospital and by every person, including you and I.

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl Rogers6

References

  1. Culture of Empathy. Carl Rogers Empathy Quotes. [Accessed: 28th May 2016]. Available from: http://cultureofempathy.com/references/Experts/Carl-Rogers-Quotes.htm [Accessed: 27th May 2016]
  2. com. Humanistic Approach in Psychology: Definition & History. [Accessed: 29th May 2016]. Available from: http://study.com/academy/lesson/humanistic-approach-in-psychology-definition-lesson-quiz.html
  3. McLeod, S. Humanism; 2007. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/humanistic.html
  4. McLeod, S. Person Centered Therapy [Online]; 2008. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/client-centred-therapy.html
  5. Gillon, E. A Person-Centred Theory of Psychological Therapy. In: Person-Centred Counselling Psychology: An Introduction. SAGE Publications Ltd; 2007. p.43-67.
  6. BrainyQuote. Carl Rogers Quotes. [Accessed: 28th May 2016]. Available from:                          http://www.brainyquote.com/quotes/quotes/c/carlrogers202206.html

Featured image:
Genetic inheritance by Patrik Nygren