No easy answers

“Life is just too complicated, too unpredictable, too hard and too fascinating…to dole out obvious, easily assimilated lessons.”

So writes A. O. Scott in his cinematic review of The Secret of the Grain, the story of a Tunisian family and their struggles as immigrants in their adopted country of France. It is a tale of commitment and hard work, frustration and ambition, with little to show for it all in the end.

For some reason, reading this review on the morning of Christmas Eve resonated with me. For among other things, The Secret of the Grain is about extended family relationships, culminating in a “lavish, hectic dinner, complete with music and belly dancing.” The secret of the film is found in “the close, tireless, enthusiastic attention it pays to the most mundane daily tasks, especially those involving food.”

This morning I am off to the market to procure the myriad items necessary to assemble our annual Christmas Eve dinner, my gift to my family. Today there will be visits to the grocer, the winery and the fish market. When all is done, the table will be set with a variety of special seafood and pasta dishes for everyone to enjoy. Undoubtedly, the meal will be punctuated with passionate discussions as the evening progresses. Eventually everyone will retire for the night, anticipating the opening of the presents on Christmas morning.

Yesterday at the office I evaluated a two-year-old girl for well child care. I had not laid eyes on her for the past nine months. I had the chance to observe this girl as she explored the exam room while I engaged her mother in an extended conversation. In the end it was the mother who broached the diagnosis. “I think my husband and I don’t want to face it,” she said. I had to tell her that I shared her concerns: it appeared to me that her beautiful two-year-old child was indeed autistic.

Christmas is nearly upon us; I can feel the strain of the season, the pains of incessant labor that leave me exhausted and spent. Yet today I will make an honest attempt to rally myself; for, in Mr. Scott’s words, “cares are so tightly woven into our lives that the only practical alternative to despair is an unruly, militant joy.”

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Snow on snow

One Christmas was so much like another, in those years around the sea-town corner now and out of all sound except the distant speaking of the voices I sometimes hear a moment before sleep, that I can never remember whether it snowed for six days and six nights when I was twelve or whether it snowed for twelve days and twelve nights when I was six.

—Dylan Thomas

In the early morning light, tiny snowflakes fall to earth, adding a fresh blanket to the snows of yesterday and the day before.

Snow sticks to the bare branches of the maples in our back yard; snow coats the scalloped fence pickets; snow dusts the boughs of the distant pines like confectionary sugar.

In the corner of the kitchen stands a pair of winter boots recently purchased at the second-hand shop for the sum of one dollar—size 12, the size of my 8-year-old granddaughter’s feet. The boots are blue with Velcro straps, lined with white wool. They will keep her toes warm when she’s outside playing in the new powdery snow.

Snow boots are not a necessity in Florida, where my granddaughter lives. There she walks the sand beaches barefoot in winter and plays tag with the tiny waves. Here in New England winter boots and snow pants will become the order of the day.

Instead of footprints in the sand, there will be tracks in the new-fallen snow for her to find and explore: morning evidence of nocturnal visitors beneath the birdfeeders. There will be a new puppy to romp with as she slides down the small hill or lies down in the winter whiteness to make snow angels.

Yesterday, as I finished brushing the snow off the car, a gaggle of Canada geese passed overhead just above the tops of the tall pines, honking in the morning light. I was glad to see them. Though fleeting, their presence reassured me that for the moment, everything was as it should be.

My granddaughter arrives today on an early afternoon flight. There will be hugs and kisses and smiles all round, then a drive home over snow-covered country roads to a warm bright kitchen, where in a corner by the puppy’s dish new snow boots stand, waiting.

Psychiatrists Revise the Book of Human Woes

A recent piece of New York Times investigative reporting—Psychiatrists Revising the Book of Human Troubles—discloses private meetings of panels composed of psychiatrists convened for the express purpose of revising the Diagnostic and Statistical Manual of Mental Disorders—the book that contains criteria for classifying and diagnosing psychiatric illness.

At issue is that all participants were mandated to sign nondisclosure agreements forbidding them to “make deals to write casebooks or engage in other projects based on the deliberations without working through the (American Psychiatric) association.” In short, they have been forbidden to disclose deliberations while the DSM-V revision is being drafted. Participants also had to agree “to limit their income from drug makers and other sources to $10,000 a year for the duration of the job.”

Judging from comments appended to the article, the outcry against these proceedings has been sharply critical. Special interest groups have a stake in the wording of specific diagnoses, and their representatives heatedly debate whether some disorders actually merit classification as mental illness. It seems that everyone—from individual patients to pharmaceutical firms to mental health professionals to third-party payers—has a stake in the final wording of the DSM-V.

As a practicing clinician, I find it particularly disturbing to read that the list of psychiatric diagnoses has almost tripled since publication of the first DSM in 1952. Undoubtedly, formulation of some of the latest diagnoses has been driven by the pharmaceutical industry, which seeks to market more recently developed psychotropic medications to treat perceived ailments and disorders. Yet other diagnoses—such as schizophrenia, bipolar disorder and autism—appear to be valid in that they provide labels for clinical syndromes that medical practitioners have documented for decades in daily practice.

More and more, modern medical practice is evidence-based, relying on scientific research. Any scientist worth his salt knows that the first step in solving a problem—in this case effectively treating a mental disorder—is to define it. Applying a diagnostic label paves the way for the patient to receive treatment, whether that treatment is pharmacologic or psychotherapeutic. The same label also allows clinicians to be reimbursed for their services by third-party payers.

Problems arise when everyone enters the fray to voice an opinion. At core we are all driven by special interests. In the healthcare arena, suffering patients seek a cure; clinicians expect remuneration for their services; pharmaceutical companies desire to market their drugs; third-party payers want to maximize profits by paying out on as few claims as possible.

As one who has spent his professional career evaluating and treating patients—mostly children and adolescents, many of whom exhibit problematic behaviors—my first priority has always been to search for ways to help better their lives. Sometimes that has meant behavioral intervention, sometimes counseling or psychotherapy, sometimes medication. Obviously, in order to be able to continue to serve my patients, I need to be reimbursed for my services. And while I think that certain categories of mental illness are over-diagnosed in our modern psychiatric paradigm, I applaud the comment of tntgraham, who writes that “there are many dedicated men and women neuroscientists, clinicians and researchers who are continuing to try to better understand disorders of mental life and trying to improve the lives of people who suffer from mental illness.”

Humane Medicine: using your heart and your head

“As I began to listen to my patients’ stories, something else happened—many of them began to experience a sense of healing. Here I’m not talking so much about cure from disease, but rather healing in the Old English sense of the word: wholeness. Heal, whole, health—each stems from the former; health is rooted in wholeness.”

The second installment of the Humane Medicine column, The art of medicine: using your heart and your head, has been published in the December 2008 issue of JAAPA, the official journal of the American Academy of Physician Assistants.

Readers may access a PDF document of the essay here.

Incidental findings: unintended consequences

Over the past three decades one major technological breakthrough in diagnostic medicine has been the ability to image human anatomy through CT and MRI scans. These non-invasive procedures allow clinicians to visualize bone, blood, organ and soft tissue detail inside the human body. Like most technological advances, these scans have produced some unintended consequences—both blessings and curses for practitioner and patient alike.

No one doubts that when obtained under appropriate clinical circumstances, these scans can pinpoint life-threatening diagnoses such as intracranial bleeds, tumors in lung or liver and acute appendicitis. Potential problems arise when such studies delineate anomalies that might not be clinically significant. Clinicians are then faced with the ethical dilemma of whether or not they should inform the patient of every incidental finding in the study, regardless of relevance to the patient’s complaint.

Two recent news articles speak to these issues. Patient photos aid docs reading faceless CT scans, posted on the Cell2Soul blog, describes a study in which photographs of patients’ faces were appended to their CT scans. Radiologists who interpreted these scans demonstrated a propensity toward heightened empathy with the patients. Further, they were more inclined to report incidental findings on the studies, even if they were considered unlikely to affect the patient’s outcome. The rationale for doing so was that these were findings that patients would want to know about or that could affect their future health. At face value, a good thing.

But in a New York Times piece, The Evidence Gap: The Pain May Be Real, but the Scan Is Deceiving, some physicians voice concern that incidental findings might have detrimental effects on patients. One issue is that both the physician and patient might conclude that an incidental finding is the cause of the patient’s problem, which may or may not be the case. This might lead to an unnecessary intervention—surgery, for example. It might also lead to the pursuit of further studies, adding needless expense to the diagnostic workup.

Knowledge of incidental findings could also make patients feel worse about their state of health. I remember the case of a little boy whose pediatrician ordered an MRI because the child had a large head. The scan demonstrated no increased intracranial pressure, but it did show the incidental finding of a benign pineal cyst. Despite the pediatrician’s attempts at reassurance, the report of this finding triggered heightened anxiety in the parents. I recently saw this patient, now 21 years of age, for an unrelated medical problem. During the course of our conversation, he informed me that he had a brain cyst. He wanted to make sure I knew in case it might have some bearing on his present complaint.

The Times piece references a 1998 article in The Lancet where medical researchers suggest that one way to deal with these sensitive issues might to put such findings into epidemiologic perspective. For example, if an incidental finding is known to be common in the general population, this fact could be noted by the radiologist on the report. The clinician would still be faced with the ethical dilemma of disclosure to the patient.

Patient photographs aside, perhaps that would be the most empathetic way of dealing with the issue for radiologist, clinician and patient.

Pupil and Teacher

The new student, obviously nervous, arrived at the clinic that Monday morning. He had had some previous medical experience during his years of military service. As a hospital corpsman, he had shouldered several independent duty assignments. Although he knew something about medicine, he was acutely aware of how much he didn’t know.

The doctor at the inner city clinic had only recently taken the position. He was relatively young himself, having completed his own medical training within the previous five years. After fulfilling his two-year military obligation, this doctor joined a fledgling private practice, only to find the night call overwhelming. Clinic patients were serviced through the local emergency room after hours. This arrangement suited the young doctor much better.

It didn’t take long for the doctor to determine the student’s level of competency. He gave the student free range to evaluate patients in the clinic. They discussed each patient afterwards; the doctor co-signed every chart.

Under the doctor’s tutelage, the student learned office gynecology, pediatrics, psychiatry and adult medicine. Beneath the doctor’s watchful eye, the student performed minor surgical procedures. Every Tuesday morning the two clinicians—doctor and student—would drive to the local hospital for the weekly grand rounds presentation and have lunch together afterwards in the cafeteria.

During one of these weekly sojourns, the doctor, whose hobby was photography, pointed out two wayward youths lounging against a large granite headstone in the local cemetery. “If I had my camera,” he said, “I’d capture that photo — and call it Waiting.” They both laughed at this remark as they drove to the hospital.

One day the student developed an abscess on his arm. The doctor lanced it, drained the infection, and gave the student a short course of antibiotics gleaned from samples provided by a pharmaceutical representative. Some time later the doctor asked the student to remove a small skin growth from his side; the surgical procedure went well.

The student was there the day that the doctor discovered a mass in his own neck. At the doctor’s request, the student felt the lump and gave his opinion. The student was also there when the biopsy results came back showing Reed-Sternberg cells, the sine qua non of Hodgkin’s lymphoma.

Over the following months the student shouldered more responsibility for care of the clinic patients while the doctor underwent radiation treatments for the cancer. Other doctors were contracted to cover his hours and to supervise the student.

Eventually, the cancer went into remission and the doctor was able to return to work. When the student graduated from his program, the doctor took a voluntary reduction in salary to enable the clinic to hire the student as an employee. The former student continued to work with the doctor for the next two years before moving on to pursue further training in a postgraduate program in another state.

The two colleagues managed to keep in touch over the years. They published a series of pieces in an online journal devoted to the medical humanities. The former student provided the text; the doctor contributed complementary photographs. Together they made a good match.

Then one day the doctor’s lymphoma recurred.

Not long ago the same student, now a seasoned clinician, opened a plain white business envelope to find an obituary clipping that bore a black and white photograph of the doctor who had mentored him into medicine three decades before.

Quietly, the former student read through the text. Afterwards, as he stared out through the window in his office to the stately pines silhouetted against the late-afternoon sky, he recalled the words of the great Canadian physician and humanitarian teacher Sir William Osler:

“The pupil and the teacher working together on the same lines, one a little ahead of the other.”