Tuesday, May 4, 2010

Ventures of a Young Physician in Narrative Medicine

I have multiple things to write about, especially from my experience in my second ABIM Foundation meeting, where we discussed the feelings elicited on all of us from the reading of an article written by a physician who died from ALS and had a terrible experience as a patient before her death. Her article was published after her death at Annals of Internal Medicine, and it is a true fountain of inspiration to recall and rescue our most intimate values as physicians and human beings. We are not health-care technicians. We are doctors and should act up as advocates of our patient's wellbeing in all spheres - bio-psycho-social. We should always ensure a warm and compassionate environment.
In the article, the doctor recalls how much she suffered when she had an EMG (electromyography) done; this is a study where needles are inserted in the muscles with electrical stimulation in order to record the nerve action potential. It is quite painful and a torture in itself. The author writes how the attending physician, who was a presumed recognized neurophysiologist, was cold and detached. He was teaching the residents while performing the EMG, and in a fascinated mood described "the typical and pathognomonic electrophysiological characteristics of ALS". ALS or Amyotrophic Lateral Sclerosis is one of the most devastating diseases the human being can face. It is one of the most frustrating diseases for any physician, given the lack of cure even in 2010. It is famously known as "Lou Gehrig's disease" as the famous ballplayer died from it. It affects both your upper and lower motor neurons, and cause a steadily progressive and devastating neurologic damage.
I was wondering how the academic environment and fascination for teaching should not detach from acknowledging the patient's suffering itself. I wonder how the physician could have been more toughttful and perhaps hold on making any "academic" comments in front of a colleague who simply suffered the invisible "saber stabs" in her soul by hearing the veredict of an unavoidable destiny.
I enjoy involving the patients in the academic discussions. Teaching them and improving their health literacy is satisfying. This week, for example, I treated a patient with severe pulmonary hypertension coming for a pre-operative evaluation; his chest roentgenogram (fancy word for chest X-ray), revealed an unsuspected pneumothorax. In the setting of pulmonary hypertension this is quite worrisome as if untreated can be fatal. The patient was upset of requiring a confirmatory chest CT-scan, as the image was not categorical at all; as well as if confirmed, may need to be admitted. By that time, I have already discussed the case with his primary pulmonologist. He couldn't understand what was the meaning of the pneumothorax. I draw in a blank piece of paper the chest anatomy, the virtual pleural cavity and the lungs, and explained how the lung compression by the pneumothorax would yield in an dramatic increase in the pulmonary hypertension in addition to the worsening of hypoxemia by the collapsed lung with a VQ mismatch. His anger faded (slightly); he accepted to be transferred to the Emergency Room and get the CT scan.
My point is that we need to understand the patient's frustration; sometimes their frustration is due to their lack of understanding and our lack of explanation. Once they are able to acquaint the rationale of our medical decision making, they can accept it in a smoother and less painful way.
We as physicians and teachers need to strive in rescuing humanism in Medicine and teach our students the value of the individual as a human being an as a member of society; the medical students should learn from early stages in their career to interact with suffering. We should not train health care technicians who will be skillful exam takers, get into fancy surgical residency programs aiming to make a lot of money from a given specialty. They should aim to be compassionate doctors who want to help their patients to achieve wellness, and a sense of well-being from all the standpoints - bio-psycho-social. They should aim to be pillars of the society and more than being recognized as doctors, be recognized as humanistic and compassionate human-beings because at the very end we aim to provide care, comfort, healing and mitigate suffering as much as we can.

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