This month, the literature and medicine group at my hospital met to discuss Arthur Miller's Death of a Salesman. The play, which first opened in 1949 with Lee J. Cobb in the leading role (clip here) and is now playing in Boston at the Lyric Stage Company, concerns Willy Loman, a man in his sixties who hauls a sample case up and down New England with "a shoeshine and a smile." Charm is important in sales and Willy has plenty. He is, as he says repeatedly, "well liked." He is also miserable. His marriage, his relationship with his sons, and his mental health all teeter on collapse.
As health professionals, it was hard for us to talk about Willy Loman without wondering what we would do if he were our patient. For one thing, we agreed, we'd tell him to switch jobs.
I wrote a column this week about the role computers play in the doctor patient relationship, and my concern that screens shift physicians' focus away from their patients. This column is part of a large conversation going on nationally and beyond about what I'd call "distracted doctoring." A Wall Street Journal opinion piece by my colleague Dr. Victoria McEvoy addresses the issue of whether all the digital box checking now required of doctors as part of "quality assurance" is helpful. She asks, "Would you rather your doctor won the 'quality' contest by doing good list management and robust box checking or spent that time listening to you?"
But amid all this talk about distracted doctoring, I've heard less about "distracted patient-ing." An experience I had this other day got me thinking about whether smart phone screens (and sounds) interfere with patients' (and doctors') attentiveness in the exam room.
A patient and I were discussing a symptom that was very frightening to her--she'd passed out--and potentially indicative of a serious medical problem. Every few seconds a sound emitted from her handbag: ping! ping! And every time her purse pinged, the woman turned her head to peek over at her phone, which lay in the open bag. I found it hard to focus, and I can't imagine she found it any easier.
Still, I was a little reluctant to ask the woman to silence her phone--and I've been reluctant to ask many other patients to do the same.
For one thing, I was trying to be mindful of that fact that this was her time and should be conducted as much on her terms as possible. I have an elderly patient who does not have a smart phone but who flips through a magazine during her visits with me. I used to find this annoying, but I came to see it as her way of maintaining a bit of control over a situation in which she feels out of control (it's hard to feel in control when you're in a flimsy gown and the other person in the room is wearing a suit). Maybe my patient kept her phone on during our visit to tell me: my ping, my choice.
Also, it's hard to begrudge a patient their phone when I've got this huge computer monitor on my desk (and a beeper on my belt and a phone on my wall).
Plus, I know well how hard it is to turn off a phone, even for a little while, when you never know when your kid (your plumber, the school nurse...) is trying to reach you urgently.
But the pinging distracted both of us nonetheless.
So I'll say here what I didn't say then: please show me those baby, prom, and wedding pictures, consult the list of questions you've listed digitally, then silence your phone and put it away. I'll put mine away, too. At least there will be two fewer sources of distraction in what's become an increasingly distracting medical office.
Now that medical marijuana is legal in Massachusetts and licenses have been awarded for the first twenty dispensaries across the state, you'd guess that my practice is busily preparing to meet the demands of patients seeking marijuana prescriptions for several debilitating conditions including chemotherapy-related nausea and AIDS-related weight loss.
You'd guess wrong.
Since Massachusetts voters approved legalization of marijuana in 2012 I've received no special training (required for physicians to certify patients as eligible for marijuana treatment), been invited to no seminars or lectures, and have little more information than that which the state has provided to my fellow citizens.
Nothing. Nada. Crickets.FULL ENTRY
The doctor at the summer camp I attended as a kid believed that calamine lotion and time cured just about anything that ailed campers--and he was right. Time still heals most wounds, but patience is a tough sell to people whose visits to my office often involve taking off work or getting a babysitter, fighting traffic, and shelling out for parking and insurance co-pays. After all that, time doesn't seem like a satisfying prescription. Still, an article published in JAMA Internal Medicine in September by researchers at Harvard Medical school and featured this month in Boston Magazine reveals that when it comes to back pain, time is an underused treatment.FULL ENTRY
At first I thought it was kind of dumb, and kind of intrusive, and kind of patronizing. The cafeterias at Mass General, where I work, started labeling every food and drink they sell with a red, yellow, or green dot signifying unhealthy, moderately healthy, and more healthy choices respectively. Say you're on line waiting to order a sandwich. A BLT sounds good, but bacon? Red! Mayo might be nice, but mustard is...green! More and more I found myself considering the "color" of my cravings.FULL ENTRY
The exam room and hospital bedside are usually non-partisan zones. Though there have been exceptions--anti-nuclear activists Dr. Benjamin Spock and Dr. Bernard Lown come to mind--physicians tend not to be particularly political people. And even when they are, their politics don't usually intersect with their clinical work. When President Reagan was shot and joked with surgeons, "I hope you're all Republicans," the response from one doctor (a Democrat) was: "Today Mr. President, we're all Republicans." But sometimes doctors find themselves, or thrust themselves, into the middle of political conflict--such was the case of Dr. Kenneth C. Edelin, who died this week at 74.FULL ENTRY
Last year around this time I mentioned my fondness for the annually appearing Best American Essays and my particular pleasure in noting that, each year, more and more of the essays in this anthology address medical topics. Eight out of twenty-four of the essays selected for inclusion last year dealt with illness or the body. This year's volume, edited by Cheryl Strayed (author of the best-selling memoir Wild) features fourteen medically themed essays--more than half! Mental illness is a particularly common subject, as is pregnancy.FULL ENTRY
Sometime during Thanksgiving, between the first bite of stuffing and the last touchdown or mention of an old grudge, someone will suggest that everyone at the table name something they're grateful for. And some people will roll their eyes. But they shouldn't. It turns out that being grateful and, more specifically, expressing gratitude, is good for your health.FULL ENTRY
November 22nd marks the fiftieth anniversary of the assassination of President John F. Kennedy. I am just barely old enough to remember that terrible day, but I do remember it--vividly. I recall sitting in my mother's brand new '64 Ford Falcon station wagon with the fake wood panel siding, parked in front of my older brothers' school. Mom had picked me up from morning kindergarten and we were waiting for my brothers to be dismissed--they got out early on Fridays-- when the announcement that made my mother gasp came over the radio: The president has been shot in Dallas.
It was only recently that I realized my memory is as inaccurate as it is vivid.FULL ENTRY
For decades now we've been hearing about rising rates of obesity and the health risks associated with excess pounds. But we've also heard that diets often fail, or even make people gain weight and that most diets are either ineffective or downright dangerous. No wonder my patients sometimes ask me: Isn't there any diet you'd recommend?
There is.FULL ENTRY
Until a few days ago, the most unpopular person on the Internet was the woman who posted this:
That woman has now been replaced as Most Hated in Cyberspace by the North Dakota woman who plans to withhold Snickers and Kit Kats from trick or treaters she deems overweight and, instead, hand them this note:FULL ENTRY
I didn't feel that great last week. I was tired, jittery, and had an upset stomach. Several of my patients mentioned they'd had similar symptoms and I concluded we all had a bug that's going around Boston: Red Sox fever.FULL ENTRY
Mark Twain once quipped: "Everyone talks about the weather, but nobody does anything about it." Is the same true of exercise? Despite a growing, multibillion dollar fitness industry, despite an increase in sales of treadmills, weights, and other home exercise equipment, despite public education campaigns like Let's Move, eighty percent of Americans--four out of five of us--do not get the recommended amount of cardiovascular and strength training. 41 million Americans belong to gyms--less than half of those actually go to them regularly.FULL ENTRY
A study by researchers at Brigham and Women's Hospital and Dana Farber Cancer Institute just published in the Journal of Clinical Oncology confirms what primary care doctors already know: marriage is often, but not always, good for your health. The study found that among more than a million people with common cancers such as colon, lung, breast and prostate, those who were married were more likely to be diagnosed early and stick through treatment, and survived longer than their single counterparts. WBUR's Commonhealth report about the study--"Nagging Wives Save Lives"--emphasized this particular finding: marriage benefits men's health more than women's.
The word "doctor" derives from the Latin verb docere: to teach and, as a doctor, I do often offer instruction. But when a woman in her eighties comes in for her annual physical and tells me she's still dancing, mowing her own lawn, and helping out her older neighbors, I have no illusions about which of the two of us should be doing the teaching.FULL ENTRY
In my practice, as in most medical practices, we accommodate patients' particular needs in all kinds of ways: wheelchair accessible rooms and hallways, interpreters of virtually all languages including American Sign Language, gowns and instruments in a wide range of sizes, information sheets and videos suitable for patients with a variety of educational backgrounds.
No one questions the appropriateness of these accommodations.
But what about when the doctor or nurse requires an accommodation?FULL ENTRY
Over 100 years ago, the great physician Sir William Osler said, "He who knows syphilis knows medicine." His point was that syphilis can affect so many parts of the body in so many different ways that its manifestations are a veritable encyclopedia of medicine. In the 1980's the same was said of AIDS.
Lyme disease is also a bit of a shape shifter, as I've been reminded this summer.FULL ENTRY
In the past few years, I've observed an epidemic of sorts: patient after patient suffering from the same condition. The symptoms of this condition include fatigue, irritability, insomnia, anxiety, headaches, heartburn, bowel disturbances, back pain, and weight gain. There are no blood tests or X-rays diagnostic of this condition, and yet it's easy to recognize. The condition is excessive busyness. It's one with which, as a fellow sufferer, I empathize especially.FULL ENTRY
During a recent visit to Dublin I was saw a neon sign in a pharmacy which read:
I was, first, amused by the wording. Dublin, home of George Bernard Shaw and Yeats and Joyce (and storytellers and bards in every pub) is a city with a deep and natural love of language--where even pharmacy signs are poetry.
But, next, I got to thinking. Am I "present" in my practice, even when I am in?FULL ENTRY
I also remember, years ago, the first time I entered an exam room and found the patient waiting for me tapping away furiously at a miniature keyboard with both thumbs. "My Crack-berry," he explained.
Is it appropriate or helpful to consider everything we eat/drink/do/watch/buy/use a lot an addiction?FULL ENTRY
For some reason, in my thirties, I began to feel anxious about flying. It happened--pardon the pun--out of the blue. I'd had no bad experiences and I am not particularly phobic. I know I'm in good company: my patients. One of the most common prescription requests I get is for anti-anxiety medicine for people who are afraid to fly. Fear of flying is very common, affecting 20%-30% of people. What, exactly, are we afraid of? Crashing, of course, and terrorism and then there's claustrophobia (fear of closed spaces) and acrophobia (fear of heights) and agoraphobia (fear of environments over which we have little control).
Now, there's something else to worry about in the air, something not common but much more common than most of the things we're already worrying about: a medical emergency.FULL ENTRY
A few years ago, while I was teaching in the hospital, a medical student presented the case of a man with coronary artery disease, diabetes, hypertension, and hyperlipidemia. When we entered the man's room I was surprised that the student had omitted a certain fact from his presentation: the man weighed well over 400 pounds.
No one argues that diabetes and blocked coronary arteries are diseases. And nobody argues that obesity, at least in part, causes these diseases--or that losing weight helps improve or even reverse them. But the question of whether obesity itself is a disease has been controversial.
The American Medical Association, the nation's leading organization of physicians, has just announced its stand on the question: obesity is a disease.FULL ENTRY
A fascinating op-ed piece by Brigham and Women's physician and Harvard Medical School professor Jerry Avorn appeared on June 11th in The New York Times. It's called "Healing the Overwhelmed Physician." What the 'overwhelmed physician" about whom Dr. Avorn writes is overwhelmed by may surprise you.
It surprised me.FULL ENTRY
In the aftermath of the Boston Marathon bombings, accounts of interactions like the one depicted in this brief video clip, in which a U.S. Marine who lost both legs in combat counsels a new amputee, reminded me of the power patients have to help heal other patients. Patient-to-patient healing occurs in many ways, formal and informal, from group medical visits to impromptu meetings.
In my most recent Boston Globe "In Practice" column, I wrote about patient-to-patient healing, including the story of a conversation between two of my own patients which was helpful in an unexpected way.
Have you experienced patient-to-patient healing?