[HSF] (OT?) Medicine as practice: what every surgeon should know

Mon Aug 20 09:32:15 EDT 2007

>
Nihilism:   "The belief that all endeavors are ultimately futile and  
devoid of meaning."
Don't despair Tea, on the nihilism scale  Ani scores a perfect 10 and  
you only manage 8.
If you had  smuggled a million bucks of parasite treatment into the  
steamy jungles, you wouldn't have even scored.
Don
On 20/08/2007, at 12:42 AM, Tea Acuff wrote:

> This post is a sequelae to thoughts on my brief attempt to provide  
> care in rural Nicaragua. I have included the description of that  
> effect for reference for any that missed or wish to refer to the  
> details.
>
> My first impression of the task to provide medical care in  
> Nicaragua was that of an incapacitating nihilism. Not unlike the  
> description of the residents today (and probably yesterday) that  
> seem unwilling to prepare for an operation, I minimized my need to  
> study for what seemed a daunting lack of knowledge and resources  
> for my "mission". Surely we all remember that feeling from many of  
> our firsts: first H and P as a medical student, first pelvic exam,  
> first day as an intern, first "real" operation, first month in  
> practice, etc. As mentioned I even "forgot" my only personal tool,  
> my stethoscope, the first day. Sound familiar?
>
> As I reflected on the why of this, being a practitioner of more  
> than 20 years having set up both new pediatric and adult heart  
> programs, why did I assume a nihilistic attitude at a rural  
> medicine clinic where no doctors of any kind are readily available?
>
> I think it comes from our standard or orthodox view of medical  
> practice, which I would better call the naive view, similar to  
> descriptive accounts of religious belief. It is a residual of the  
> Lockean enlightened "tabula rasa" or blank slate. (Not unrelated to  
> this discussion, John Locke is philosophically known as an  
> empiricist.) It is a similar view for education or any "learned"  
> field. In this presumed, if not officially espoused view, the  
> doctor is one who accumulates a large amount of information and/or  
> skill about the "real" and scientific world which makes his service  
> as a benevolence to those in need for either reasons of incapacity  
> or ignorance. This may further explain the doctor's proclivity to  
> not see the need for his own care despite the fact that, he/she  
> will also succumb to life's entropy.
>
> This nihilism in the face of daunting need for information and  
> responsibility makes clear sense to all neophytes of medicine  
> either by virtue of time or situation. What is not so obvious is  
> the other pole of this view. It is the certainty or at least  
> colonial-like conceptualization that the "knows better" and  
> conceived "benevolent" action confers on its adherents. I use  
> colonial not to suggest malfeasance, but to convey the sense of  
> correctness supported by the guidelines and mores of those that  
> import their principles on others.
>
> That I completely failed to fulfill virtually any component of my  
> side of this orthodox but naive view, yet patients waited hours for  
> a week worth of analgesics or H2 blockers, caused a profound and  
> solitary realization of the mission of a physician independent his  
> wealth of resources (as a cardiac surgeon in the USA) or lack of  
> the same (as my situation in Nicaragua). Heroics are nice for us  
> adrenalin addicts, but the true role of physician is to provide  
> comfort and reduce to that extent possible the discomfort in which  
> we find our patients and their loved ones. Period. Sometimes we are  
> wildly successful, but most often we are able to obtain only more  
> modest gains. In the scope of all that is life, modest or temporary  
> relief seems a better description of our work than that of the life  
> givers we seem so wont to assume.
>
> A few of the patient situations that I encountered may better  
> specify my more formal thinking about the practice of medicine. One  
> 60ish year old woman had among a variety of complaints a swelling  
> in her neck. By physical exam of this area she had a mat of nodes  
> in her right supraclavicular fossa. By history she had a year or so  
> ago an abdominal or pelvic operation in Guatemala (despite the  
> admonition that no other care was available per my hosts) which was  
> likely a malignancy. Although there was a small chance that I could  
> be mistaken, I decided that she was "dead man walking". I could do  
> little except share my "suspicion" that she may have her cancer  
> back and she might wish to reevaluate that if she could. I wondered  
> whether she was worse off in Nicaragua or my home town. I was  
> betting that in the USA we had a better chance of making her time  
> left worse or at least "invaliding" her than we had of making it  
> better. She likely faced a more purposeful
>  existence in Nicaragua. Why should this be so? Have we as doctors  
> fairly squared our limitations with our successes? Is our treatment  
> of our "end stage" disease in the US more humane than that in  
> Nicaragua? Or is it less, either outcome merely by default and not  
> thoughtful design?
>
> As I was giving out a dollar's worth of analgesics for headaches or  
> to those sore from carrying burdens daily, I wondered whether the  
> pitiful value I was offering was a better value than the LVADs we  
> offer to the pitiful patients that we discuss on HSF. If we look at  
> it through the prism of personal economics (patient pays for the  
> full value), I imagined both would have been less available than we  
> currently observe, but likely the LVADs would be even less funded.  
> Ben has already commented that social LVAD funding makes little  
> sense from a developed country down under. I doubt he would say the  
> same for the lack of generic drugs like ASA or ibuprofen.
>
> LVADs are just a convenient extreme example, but not different in  
> kind for an understanding of how to understand our practice of  
> medicine. Societies, or the regulators and their complementary  
> physicians, have already noticed that the naive view of medicine  
> has its flaws. But I do not think the addition of economic (or my  
> dismissive, Marxist) perspective alone adds much to the over  
> arching understanding of medical practice. Rather it tends to re- 
> enforce a bi-dimensional  (eg, cost versus care or recommendation  
> versus incentive) aspect of medical care, and its largely  
> ineffective corrections such as "financial disclosures" and  
> regulation of "conflicts" of (economic) interest.
>
> This related "economic" or barter pattern I also noticed during my  
> patient interactions. After a while I noticed a stylized pattern  
> between the patients complaints and their expectations of which  
> drug I would/ should give. It seemed as over time the complaints  
> became more "focused" toward particular "stories". It was like  
> there was a verbal barter for that which I had to offer the "right"  
> drug. I imagined in retrospect that the "patients" debriefed their  
> fellow patients and correlated their stories to match that which  
> they wanted. For myself I "naively" tried to "practice" what I knew  
> which was little. It may have been that they all had much of the  
> same complaints, and that this style came from us. Part of this  
> surely was. However, I never had much idea what would be the  
> symptoms for parasites, and the complaints did not match much of  
> what I did read about parasites. While it is possible (does anyone  
> reading know) that "children grinding their teeth"
>  became a symptom for "parasites", it seems more likely that this  
> was an acceptable and imaginative synonym created by the patient  
> culture for "I need parasite medicine". Toward the end of the  
> clinic some patients returned and/or flatly asked for parasite  
> medicine, if I failed to make the connection for which I could make  
> no medical sense. This is not what we typically mean by the  
> economic influence of medicine, but defining it as economic informs  
> our predictable and insipid solutions. This barter was more of a  
> dance than an economic contract.
>
> So I moved from the more naive (orthodox) view,  that is I know (or  
> should know) and would give to the tabla rasa of misunderstood  
> needs of the patient, to the likely hood that what really was  
> occurring was a barter between different cultures of doctor and  
> patient. That I was not privy to most of their culture and even  
> language made it somewhat more clear to me that this might be the  
> case. In different words in the phrase we appeal to over and over,  
> I could not imagine what I would want for "my mother or loved one"  
> in terms of their culture. I am sure that we all have had glimpses  
> of the same divide and this barter in our own practices. The  
> question then becomes how often do we cross the line naively or by  
> design in our own practices? Does everyone (populations) or anyone  
> (individuals) really "want" in the language from the patient  
> culture or "need" from language from the doctor culture LVADs,  
> chemo, or bypass with or without three valves? Whom are we
>  serving and why? If they (our patients) had to pay would that  
> separate the cultures of care more realistically? Do we entice by  
> advertisement, anecdotal success, guidelines and technology, or  
> subsidized care? Who does not want something for nothing? Who can  
> actually have it? Any answer or direction to seek to answer these  
> questions is dependent on our presuppositions on the nature of  
> evidence or knowing and the model of interaction between doctor and  
> patient in the practice of medicine.
>
> Enough for today. For anyone interested next time: Is there a  
> better formal model for exploring medicine as practice? I think a  
> different model leads to some interesting questions.
>
> tea_______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------