Thursday, July 20, 2017

Self-Disclosure in the Clinic and the Classroom

As I mentioned in a recent post, I'm in Vermont while my wife teaches at the Middlebury College Bread Loaf School of English, a program in which the students are primarily high school and middle school English teachers.

Tomorrow I'll be leading a second workshop on "Making Ethics Part of High School and Middle School English Class."At the workshop on June 30th the teacher/students identified a topic they wanted to come back to: should they bring their own moral and political selves into the classroom, and if the answer is "yes," how should they do it?

I've never taught in high school or middle school and can't claim any direct expertise on how to deal with the question the teachers raised. But I've given a lot of thought to what is typically called "self-disclosure" in medical care and have written about it (see here). In contrasting the issue as it comes up in the clinic and the classroom, I see self-disclosure as a vastly tougher question for high school and middle school teachers than it is for physicians and other clinicians.

In the clinic, self-disclosure occurs largely in a 1:1 setting - the patient and the doctor. The major question for the physician is whether self disclosure will further the clinical objectives. Research suggests that the impulse behind self-disclosure is often fulfillment for the doctor more than benefit for the patient. The commonest risk is that the patient will feel less listened to and less rapport. The most serious risk is that physician self-disclosure will lead to a slippery slope of increasingly intimate interactions. Many situations that end with doctor-patient sex began with physician self-disclosure.

When we physicians contemplate self-disclosure we should ask ourselves three relatively straightforward questions. First, a bit of introspection: do we tend to talk about ourselves too much? If so, we should be especially on guard. Second, is there anything special about our relationship with this patient - such as a wish to impress the patient or to be his friend  - that draws us towards self-disclosure? Finally, what is the rationale for anticipating that self-disclosure will help the patient?

In high school and middle school, the teacher is an adult dealing with a classroom with 15 - 30 youngsters. Student reactions, of course, are likely to vary, so there's no way to guage the potential impact on every student in advance.  But the most challenging aspect is the school setting itself. Even if the patient-physician dyad occurs in an organizational setting like a clinic or group practice, it's primarily a two person relationship. By contrast, English class is just one piece of the student's relationship with the school. And in the background, the students' families properly regard themselves as having a central role in their child's education.

To prepare for the workshop I tried to imagine myself as a new high school or middle school teacher thinking about self-disclosure in the classroom. I pictured a series of steps to help me develop an approach:
  1. Talk with my experienced colleagues. How have they handled self-disclosure in their classes? What guidance can they give me?
  2. Talk with my department chair and perhaps the principal. They are responsible for and most knowledgeable about the school's relationship with its community. Are there issues of particular sensitivity to be aware of?
  3. Consider the environment the students come from. What is the cultural starting point for the class likely to be? How will this influence how the students hear me?
  4. Examine my own skills. Am I someone who students can feel comfortable questioning or challenging? Can I model a stance of curiosity and mutual respect?
I'm looking forward to learning from the teachers who will participate in the workshop. What a privilege it is to be able to explore ethics in the classroom with a group of experienced and devoted teachers!

Saturday, July 8, 2017

Psychiatrist-Patient Sex - plus a detective

When I was looking for audio books for my drive to Vermont, how could I resist Shrink  Rap, especially since the author was the wonderful Robert B. Parker of "Spenser" fame. Here's the blurb from the jacket:
Boston P.I. [private investigator] Sunny Randall is working as a bodyguard for popular romance writer Melanie Hall, who is being stalked by her psychiatrist ex-husband. Melanie was a patient before becoming his wife, but now she is absolutely terrified by him. To find out why, Sunny puts on a disguise and goes to the shrink for therapy.
The most-read posts on this blog are those under the tab of "doctor-patient sex," and I was eager to see Parker's take on the topic.

Melanie Joan Hall is a wildly successful chick lit writer and, like her heroines, a romantic soul. She falls in love with her psychiatrist (Dr. Melvin) whose practice is entirely composed of needy female souls like herself. Dr. Melvin allows an erotic transference to form, but then instead of using it as an opportunity to minister to Melanie Joan, he exploits it for sex and control. 

Melvin has sex with many patients, but he singles Melanie Joan out for marriage. Although he's a thoroughly evil character, Melanie Joan only catches on when he invites two of his friends to participate in what the narrative calls a "gang bang." Until the "gang bang" moment Melanie Joan has been entranced by what she calls the "master/slave" relationship. But when the potential "gang bang" shocks her into recognizing Dr. Melvin's evilness, she flees. Melvin goes off the deep end and stalks her. Enter private eye Sunny Randall.

Sunny seeks out Dr. Max Copeland, a skillful and ethical psychiatrist, to help her strategize about Melvin. Sunny tells herself she's seeing Copeland for advice, not therapy, but Copeland engages her in self-reflection as well. He's a superb therapist - respectful, insightful, and entirely focused on helping his detective-patient. He obviously likes and admires Sunny, who is brave, honest, funny, and emotionally open, but unlike Melvin he is scrupulous in using his interaction with her to develop a therapeutic alliance.

Parker has excellent insight into the ways patients may idealize a therapist who listens to them attentively. Sunny herself feels the pull when she becomes a "patient" in Melvin's practice. I won't give away how she cracks the case - it's scary and humorous. But when she expresses her puzzlement at how in the early phase of their "therapy" Melvin was actually helpful to her, Copeland responds as I have to comments on earlier posts - physicians who exploit patients A, B and C may also have skills that allow them to practice very competently with patients D, E, and F.

Shrink Rap brought to mind Dressed to Kill. a Brian DePalma film I saw in 1980. I'd not heard of the film until a young woman patient brought it up in a therapy session. She said it reminded her of her treatment. When she went on to mention that the psychiatrist in the film murdered his patient, I remember feeling horrified. Alas, I can't remember what I said to my patient, but I resolved to see the film. I won't give away DePalma's Hitchcockian plot in case you decide to see it, but my patient got the film story right. The psychiatrists really does murder his patient.

Parker and DePalma render the dark side of our fantasies about psychiatrists. The cultural figures who - in our upbeat moods - we see as wise and powerful healers, turn into monsters when they choose to use their power for evil aims. It's the same dynamic as the wolf in Little Red Riding Hood - a loving grandmother on the outside but ravenous wolf within.

Sadly, the stories Parker and DePalma tell so well aren't restricted to myth. The reason my posts on doctor-patient sex have garnered so much readership is that the myth plays itself out in life. The problem isn't new. 2500 years ago Hippocrates asked physicians to pledge fidelity to their patients' well-being, and to eschew sexual exploitation. Hippocrates understood that just as the wolf gives in to temptation when he sees Little Red Riding Hood and her basket of food as tempting morsels, physicians of his day, and ours, are exposed to temptation as they practice their art.

The reason the Hippocratic oath has survived for 2500 years is that Hippocrates saw medicine as a sacred calling that requires an impeccable standard of ethics. Parker and DePalma's engaging stories show what can happen when the oath is ignored.

Sunday, July 2, 2017

Teaching Ethics in High School and Middle School

I'm again in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of 4-5 summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

For the past five summers I've been doing a workshop on "Making Ethics Part of High School and Middle School English Class." The idea for the workshop came from recognizing that my underlying goals for teaching medical ethics were similar to the teachers' goals for their students in English class. Working with the teacher-students at Bread Loaf is a pleasure and a privilege. Their commitment to fostering development in their students is similar to the commitment to fostering health and well-being I see in the medical students and residents I work with.

This year the topic we chose to focus on was an experience several of the teachers had (a) teaching courses that explicitly included "justice" or "ethics" in the course objectives and finding (b) that the courses didn't work well. We asked: what was the problem and what could be done about it?

The group identified three main reasons the "justice"/"ethics" courses fell flat:
  1. Adolescent cognitive development. Kids of every age show great variation, but teen age thinking tends to be black/white, with the result that for many the idea that thoughtful people may reasonably differ is a foreign notion. Discussions of ethical and political dilemmas may seem to them like a "politically correct waste of time." I'm still embarrassed at a piece of my own black/white thinking from when I was 17. My parents, born in 1905 & 1907, were from a martini-drinking generation, and the practice they and their friends had of drinking several martinis after work and forgetting that there was a child in the home (me), led me to a very moralistic view of alcohol. So when my friends proposed going out for beer when I was a first year college student, I replied "If we're going out for alcohol, why stop there? Why don't we go directly to heroin?"
  2. The school environment. Kids recurrently encounter high stakes tests. Many feel that their future depends on getting good grades, which means "getting the right answer." Their anticipation of being judged inhibits curiosity and limits the pleasure they might take in deliberating about moral dilemmas. Some years ago when medical ethics was an elective at Harvard Medical School (now it's part of the required curriculum) I had designed a session on "personal mission in medicine." I thought it was a great plan, so when the class completely bombed I was puzzled and asked the students to help me figure out what the problem was. The students told me what I'd missed: "This is our first semester in medical school. Our mission is not to flunk out. We have no interest in speculating about what our mission  should be 5-10 years from now!"
  3. Culture of narcissism. Several teachers commented on a culture of narcissism symbolized by the popularity of "selfies." This isn't a new idea. Christopher Lasch popularized it in his prescient 1979 book subtitled "American Life in an Age of Diminishing Expectations." The teachers felt that social media reinforced the longstanding cultural pattern. I was especially struck by the observations of two teachers who also coached high school sports teams. Both commented on the decline of "teamness" and the tendency for young athletes to be preoccupied with their own goals and achievements.
The participants exchanged tips on what teachers can do to bring moral reflection to life for their high school and middle school students:
  1. Careful planning. It's important to find works of literature that entice teenagers into moral reflection. Two teachers mentioned The Ones Who Walk Away from Omelas, a short story by Ursula Le Guin I'd never heard of, no less read. It's a moral fable that can be seen as challenging capitalism and the division between the rich and the poor. (The story is just 4 pages - I encourage you to follow the link.) Other teachers emphasized the value of "warm-up exercises" like improv to get the students loosened up and readier to experience curiosity about themselves and others.
  2. Role modeling. It's important for teachers to demonstrate open mindedness, readiness to be questioned & challenged, and interest in the views of others in their interactions with the class.
  3. Drawing on established frameworks. One of the teachers leads a course called "Theory of Knowledge," which is part of the International Baccalaureate curriculum. The course focuses on what it means to claim to "know" something and what forms of evidence apply in different realms of activity. It encourages students to examine their own presuppositions and to recognize their biases. Another teacher uses the Harkness approach - a discussion method developed at Phillips Exeter Academy. Since a central goal in ethics teaching is to cultivate the habit of thoughtful inquiry into the basis of views held by self and others, it makes sense for teachers to do this themselves by learning from each other about how best to pursue this important goal.
  4. Trust the students. Open, thoughtful deliberation requires activity on the part of the high school/middle school students. Telling them what's required doesn't do this, just as telling an athlete how to carry out a skill doesn't take the place of practice. The term "safe space" was used to describe the aim of fostering an environment that supports curiosity and inquiry. Of course, teenagers, like all human beings, are not always trustworthy. This part  of the discussion reminded me of one of my clinical rules of thumb - start with the most optimistic hypothesis that is safe and prudent and retreat from it as necessary. Thus if a patient with depression was not suicidal or at risk in other ways, we could start with the hypothesis that the condition would be readily reversible. If that proved true - great! If it didn't we'd move on to a more demanding approach.
Over the years of my work with high school and middle school teachers, I've come more and more to 
see their work as similar to health care in the shared aim of enhancing human capacity. If health care is a sacred calling, which I believe it very much is, so is the work the teachers are doing!

Sunday, May 14, 2017

Medicine and Mysticism

Even before I knew that Guanyin was the Bodhisattva of Compassion I was drawn to her image in the Boston Museum of Fine Art. (In Buddhist tradition, Bodhisattvas are beings who delay reaching nirvana out of the wish to alleviate human suffering.)

My own recent experience with medical care leads me to see concepts like Bodhisattva and Guardian Angel as telling us something important about medicine.

                                         Guanyin - 
                          Bodhisattva of Compassion

Two months ago I wrote about the condition that had given me many months of pain, severely disturbed sleep, and difficulty walking (see here and here). My primary care physician referred me to a hematologist who made a presumptive diagnosis of a platelet dysfunction and prescribed a medication that acts on the bone marrow to slow down the platelet production process.

Prior to the diagnosis I'd assumed that the mysterious condition was not going to go away, but now, two months after starting the medication, the symptoms have almost entirely cleared up. I'll have to take the medication for the rest of my life, and some complications could emerge, but I feel like "myself" again.

So what do these experiences have to do with Guanyin?

The medication I'm taking requires careful monitoring to make sure it's doing what it's supposed to do with the platelets, but not causing too much decrease in white & red blood cells, which the bone marrow is also busy producing. We've checked the blood nine times between the day I started the medication and this week. The results go to my hematologist who writes to me on the secure email her practice uses to interpret the results and suggest how to handle the medication.

I counted her messages in my inbox: 13 messages and a total of 386 words. That's less than 50 words/week.

From my own experience as a physician I doubt that our exchanges required much time. But in addition to the instrumental importance of the guidance I received, I was aware of a strong sense of emotional support and of being cared for that the 386 words conveyed. I identified two sources for that feeling. The promptness and reliability of the hematologist's response after my blood tests elicited a sense of security. And the happiness she expressed as my symptoms improved elicited a sense that my well-being mattered.

That's what Guanyin stands for in Buddhist culture, and likewise for Guardian Angels since they first appeared in the Hebrew Bible. Within the theologies, Bodhisattvas and Guardian Angels were vehicles for conveying divine love to us vulnerable mortals.

Health care workers tap into the same psychological and cultural substrate. The feelings I've had as a patient are the reciprocal of the sense of mission I had as a physician. Recently, at the end of an appointment, a patient said "thank you," to which I replied with the same two words. When my patient asked me why I said "thank you," I explained that being a physician (or a nurse, social worker, physical therapist...) is a privilege, and that the act of healing required collaboration between the involved parties.

I believe that if we could interview Guanyin and Guardian Angels, they would tell us that they were grateful for their opportunity to minister. There's a "mystical" element in health care that market concepts like "consumer" and "provider" are woefully inadequate for understanding.

(See here for a post about why secular clinicians might want to use religious language in their practices, and here for a post about love in the patient-doctor relationship.)

Monday, April 17, 2017

More Pharmaceutical Industry Price Gouging`

A recent New York Times article tells us that Lannett, a large generic drug maker, is echoing other companies I have written about in raising prices on its products by several hundred percent. Here's what Arthur Bedrosian, Lannett CEO, told a group of investors:
According to the investors, Mr. Bedrosian was asked if the price-hike business model in the drug industry was over. He chuckled and said no, adding that he had tripled the price of one of Lannett’s drugs that very morning. He did not identify which one, the investors said.
Mr. Bedrosian's "chuckle" may remind you of Donald Trump's cheerful boast about how he could grab women by the "pussy."

The market loves Lannett, which provides yet another example of market failure. In the future the market may ultimately punish Lannett the way it punished Valeant (see here and here) and Turing Pharmaceuticals, but by the time that happens patients will have been hurt and public and private payers will have been bilked of billions.

The NYT cites studies showing that when there are fewer than five competitors, our national theology of the wisdom of markets doesn't hold. That suggests a regulatory strategy that allows price regulation in the absence of adequate competition. Let's hope that Congress is prepared to act on the basis of protecting patients and the public from the kind of legal larceny the Mr. Bedrosian is chuckling about!

Saturday, April 8, 2017

A Personal View of the Medical Home concept

Into my mid 70s I felt remarkably fit. I was still playing tennis and taking my favorite hikes during the summer in Vermont. That changed when a mysterious problem I've written about in a couple of posts (here & here) set in.

As a result of the problem that developed, I've had more medical appointments in the last six months than in the previous 25 years. As someone with an interest in health policy & systems, my experience has sharpened my sense of what's required to make a "medical home" work. (For those who aren't familiar with the medical home concept, I've copied material from the Patient-Centered Primary Care Collaborative at the end of my post.)

Here's my patient's eye view of my experience:
  1. In the fall of 2016 I was floundering as to what to do about the problem, Whatever was causing pain and discoloration of my left foot/ankle/lower leg was still a mystery. My primary care physician (PCP) suggested seeing a dermatologist, something I hadn't thought of myself.
  2. The dermatologist said what she saw was unusual. She did a biopsy which, alas, came back as "non-specific changes," That meant we were still unsure. She could simply have sent me back to my PCP, but to her credit, she suggested that we get a second opinion from someone at the hospital my care group is associated with.
  3. Initially the referral went to the referral coordinator and an appointment was set with a presumably thoroughly competent dermatologist, but one who did not have more experience than the one I had seen. I discussed this with my PCP. He called the chief of the department who recommended a senior colleague who he said "is especially good with complex cases."
  4. I saw the recommended dermatologist who had some hypotheses about obscure possibilities and did two further biopsies which showed (a) clotting in the tiny blood vessels and (b) no inflammation. 
  5. With a narrower set diagnostic possibilities, the second dermatologist wrote to my PCP, recommending that I see a hematologist and suggesting some further blood tests. My PCP agreed, and referred me to an excellent hematologist with whom I had shared patients before I retired from practice ten years ago.
  6. By this time my blood count showed something new - an abnormal level of platelets, which are crucial for clotting. The hematologist prescribed a medication that acts on the bone marrow with the aim reducing the platelets. We've used the group's secure email to follow the counts and adjust the medication. We've only met in-person once, but the email communication has been very reliable.
  7. As the platelets have come down, the lower leg and ankle problems have completely cleared up. But the toes have not, and in particular my left fourth toe was exquisitely painful. Last weekend I saw an ugly open sore on the toe. I didn't know what gangrene looked like, but my imagination ran away with unpleasant possibilities.
  8. On Monday morning I was able to see an urgent care physician who allayed by fears and prescribed  oral and topical antibiotics. 
  9. I informed the hematologist and my PCP about the situation to make sure we were all "on the same page."
  10. Happily, the wound is improving, and the pain is markedly reduced. 
So what's the point of all these details?

For me it's this: in the same way that it takes a village to raise a child, it can take an "extended family" to treat a chronic condition. My experience has been one of receiving excellent continuity of care even though I've been bouncing between clinicians the way a pin ball bounces. But the clinicians were part of the same "family." They had access to the same electronic health record and communicated with each other - either directly or via my sending "FYI" updates to them. For the underlying chronic problem I've had my blood drawn at the practice's laboratory. The results get to the hematologist and to me within a few hours, and she has followed up with email advice very promptly.

My guess is that my treatment in the past few weeks has not occupied much physician time, but as a patient I have felt very attended to. When I was worried about toe pain and an open wound I was able to see a clinician promptly, and her findings went to my PCP and the hematologist I am working with.

I believe my experience shows how a "medical home" and "team care" can be more than euphemisms. Continuity of care doesn't require continuous appointments with a single physician. When a "medical home" functions the way a harmonious extended family does, it works!

Here's the material about the medical home concept for those who want to read about it in more detail:

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.
In 2007, the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ)

Features of the Medical Home

Adapted from the AHRQ definition, the PCPCC describes the medical home as an approach to the delivery of primary care that is:
  • Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health

Tuesday, March 21, 2017

Adding Value by Talking More

A recent article in the New England Journal of Medicine - Adding Value by Talking More - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.

Here's the final paragraph of the article:

As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.
The otherwise excellent article omits one crucial element. Talking more with our patients also increases physician satisfaction. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.

I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of Avant -garde Health, a health care technology and analytics company founded by one of the authors.

Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a concierge model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.

The kind of work behind Adding Value by Talking More is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."