“Dermanities”—Spring, 2007

The spring 2007 issue of Dermanities is now online.

For those readers not famililar with this publication, Dermanities is an open-access web-based journal dedicated to melding the medical humanities and the practice of dermatology.

Articles are written by and for the benefit of patients and practitioners alike.

You can read my article “Beauty’s Only Skin Deep” or browse the table of contents here.

Hummers, Bugs and Health Care

You’d have to be living in the backwoods of Appalachia these days not to know that the price of gasoline at the pump has reached an all-time high—and this is just the start of the summer driving season, when gasoline prices continue to climb. Refineries produce only so much gasoline for public consumption. Like any limited resource, the more you use, the less there is left for the next guy in line.

While waiting at the traffic light yesterday morning, I noticed an oncoming vehicle as it slowed down and coasted smoothly around the corner—a large shiny white Hummer. Hummers populate the streets of Baghdad these days, and lately our streets at home seem to be following that trend.

During the Arab oil embargo in the ’70s, people waited in lines at service stations. The price of petrol escalated as folks scrambled to replace their gas guzzlers with lighter fuel-efficient vehicles. At the time I drove a Volkswagen bug—the “people’s car.” I don’t remember how many miles to the gallon it got, but I ran it on the cheap and it got me where I needed to go.

In some respects our healthcare system is similarly structured. Like gasoline, there is only so much health care (measured in dollars, doctors and facilities) to go around. In theory, the less the availability, the more expensive the service—but even with improved access, the price doesn’t necessarily drop.

Now, just this morning, new light has been shed on our twisted system of healthcare costs. An article in today’s New York Times (14 June 2007) divulges a little-known fact: there is not necessarily a direct correlation between the cost of health care and the quality of that care. Published data show a wide discrepancy in the cost of coronary artery bypass graft surgery performed at Pennsylvania hospitals in the Philadelphia area. Moreover, they demonstrate little correlation between the cost of the procedure and patient outcome. Hospitals that delivered the best care, as evidenced by low mortality rates and shorter stays, received less payment for their services—in some instances less than half.

Although a Hummer will cost you considerably more at the dealer as well as at the pump, a reliable VW bug would get you where you needed to go—at considerably less expense all round.

Too bad the original VW bug has become obsolete.

Teaching and Thinking

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education. —Sir William Osler

Today’s New York Times (13 June 2007) carries an op-ed piece about a conflict of interest that those of us who practice medicine face daily, namely the overwhelming influence that the pharmaceutical industry brings to bear on our prescribing habits.

This comes on the heels of two other recent articles exposing the huge profit some oncologists make by routinely prescribing chemotherapy to some patients despite documented lack of effectiveness.

Much more than mere pillow talk these days, drug companies actually underwrite the cost of much of our continuing medical education. In the past they wined and dined doctors to influence prescribing habits. Nowadays, they underwrite the research that supports the use of their particular drugs, then buy contracted physicians to peddle their influence through continuing medical education materials and seminars.

If that were not egregious enough, the pharmaceutical industry has taken things one step further: they actually define illnesses or disease states to market their drugs more effectively. No where has this been more blatant lately than in the realm of psychotropic drugs. For example, what we used to call shyness is now labeled social phobia, in large part because there is a drug with an indication to treat it: Paxil.

It has come to the point that drug companies dictate so much of a physician’s education from the outset that they have doctors in their back pocket as loyal prescribers for the duration of their careers.

This flies in the face of Sir William Osler’s late 19th century admonition to physicians to be wary in dealing with powders and potions:

“Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs.…the desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor’s visit is not thought to be complete without the prescription.…the temptation is to use medicine on every occasion, and I fear we may return to that state of polypharmacy, the emancipation from which has been the sole gift of Hahnemann and his followers to the race. As the public becomes more enlightened, as we get more sense, dosing will be recognized as a very minor function in the practice of medicine.…” (“Teaching and Thinking,” in Aequanimitas, p. 125)

Again Sir William admonishes us: “The battle against polypharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish.” (“Medicine in the 19th Century,” Ibid., p. 255) Indeed not—the fight continues. Our ranks have been infiltrated, and we have sold our license to practice medicine for a price.

Osler’s talks and essays eventually appeared in a single volume, Aequanimitas. In the early decades of the last century, this book was given as a gift to many graduates of medical schools in the United States by none other than—who would have guessed it?—the pharmaceutical giant, Eli Lilly.

Pauline W. Chen, M.D.

A good friend and former faculty member invited me to the private prep school where he had taught for thirty-five years to hear one of his former students speak. Now forty-two years old, practicing as a transplant surgeon, Pauline Chen had recently released her first book, Final Exam.

In her opening remarks Dr. Chen stated that she would address a question that she has been asked time and again—can you do a good job as a doctor and still interact on an emotional level with the patient?

Dr. Chen opened with a story—a tale about a young man who developed a type of cancer of the bile duct system. Dr. Chen was part of the team that cared for him. This man eventually succumbed to his disease after several rounds of chemotherapy. He spent his last weeks in the ICU. Although his physicians felt that they had given him the best of care, none of them ventured to visit him during his final days. Dr. Chen was no exception. When a trusted nurse pleaded with her to get involved with his care, Dr. Chen always found an excuse: there were other matters more pressing. (At the time, this patient was no longer on Dr. Chen’s service.)

Dr. Chen spoke about the concept of “aequanimitas” (equanimity) as advocated by the 19th century Canadian physician and humanist Sir William Osler: doctors need to learn to distance themselves emotionally from those patients under their care. Maintaining equanimity allows the physician to make objective decisions in caring for the patient, decisions unclouded by emotions that may arise in the physician himself.

Dr. Chen shared her discovery of John Keats’ concept of “negative capability,” that of learning to accept uncertainty in medical practice, to maintain an attitude of openmindedness in dealing with the patient. Although best known as the English poet who succumbed to tuberculosis at a young age, Keats had trained as an apothecary and surgeon before opting for a life of literature. Dr. Chen suggested that Keats’ concept of negative capability trumped that of Osler’s equanimity.

In closing, Dr. Chen shared another story. This too was the tale of a man who succumbed to a similar form of biliary cancer. But this time, instead of distancing herself, Dr. Chen continued to visit her patient twice a day, taking time to listen to his concerns and to speak with his family. In the end it was the family who gave Dr. Chen permission to grieve at the bedside after her patient slipped away.

Afterwards there were several questions and comments from the audience. One man, a retired physician, complimented Dr. Chen on her touching tales. He suggested that she look upon these as part of a learning curve. “Eventually,” he said, “you will be forced to adopt a position of equanimity with your patients if you hope to survive as a practicing surgeon.”

Although we who practice medicine may wish otherwise, we will experience those deep emotions that surface in our daily dealings with patients. Practicing with equanimity will only get us so far. Unless we choose to face our feelings and deal with them in a constructive way, eventually many of us will find ourselves emotional cripples, unable to relate to others in our broken humanness.

“Notes from a Healer”—Sunday Morning Requiem

A summer Sunday morning, bright with promise; then, tragedy strikes—

Intrigued readers can peruse my latest “Notes from a Healer” column—Sunday Morning Requiem—in the Yale Journal for Humanities in Medicine.

Sunday Morning Requiem is an excerpt from my newest book, Village Voices. You can read a description of the book, comb through a preview and purchase a copy here.

The Yale Journal for Humanities in Medicine acts as an online clearinghouse for manuscripts dealing with humanities in medicine.