werner@aecom.UUCP (Craig Werner) (11/02/86)
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POMM1
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A Piece of My Mind
JAMA Sept 6, 1985 -- Vol 254, No. 9
Messages
Perhaps the fact that the Great Depression hit just as she
and my father were starting to raise their family had something to do
with it. But no matter. Already as a small child I was aware that in
the handling of money my mother was more than simply thrifty; she
was downright frugal. Extravagances and luxuries did not exist. She
never bought anything, for example, unless she was certain she would
use it. And not only use it, but use it to the best purpose and for
the longest possible time. The one exception was a new, frilly,
never-worn nightgown that whe kept in the bottom drawer or her bureau.
But even that had its purpose: "In case I should ever have to go into
the hospital," she said. And so the nightgown lay there for years,
carefully protected in its tissue wrappings.
But one day, many years later, the time came. The nightgown with
its now yellowed lace and limp ruffles was taken from its wrappings and
my mother entered the hospital, seeking an answer to the mysterious
fevers, sweats and malaise that had plagued her like a 'flu since Autumn.
The time was early January, in the deepest, darkest days of a cold winter,
just before her 69th birthday.
We did not have long to wait for an answer. It came with the
finality of a period at the end of a long sentence of strung-out clauses:
Lymphoma, disseminated, progressive. Privately, her physician told me
he was sorry, there was probably only a matter of two or three weeks left,
certainly less than even a month.
For days, I agonized over what to do with this information that
only I had been told. Should I tell the family? Should I tell my mother?
Did she already know? If not, did she suspect? Surely she must after so
many months of malaise. Could I talk about it with her? Could I give her
any hope? Could I keep up any hope she might have? Was there in fact any
hope?
Some relief came when I realized her birthday was approaching.
The nightgown she had saved all those years she was now wearing, but it
was hopelessly dated. I resloved to lift her spirits by buying her the
handsomest and most expensive matching nightgown and robe I could find.
If I could not hope to cure her disease, at least I could make her feel
like the prettiest patient in the entire hospital.
For a long time after she unwrapped her birthday present, given
early so she would have longer to enjoy it, my mother said nothing.
Finally, she spoke. "Would you mind," she said, pointing to the wrapping
and gown spread across the bed, "returning it to the store? I don't
really want it." Then she picked up the newspaper and turned to the
last page. "This is what I really want, if you could get that," she said.
What she pointed to was a display advertisement of expensive designer
summer purses.
My reaction was one of disbelief. Why would my mother, so careful
about extravagances, want an expensive summer purse in January, one that
she could not possibly use until June? She would not even live until
Spring, let alone Summer. Almost immediately, I was ashamed and appalled
at my slumsiness, ignorance, insensitivity, call it what you will. With
a shock, I realized she was finally asking me what I thought about her
illness. She was asking me how long she would live. She was, in fact,
asking me if I thought she would live even six months. And she was
telling me that if I showed I believed she would live until then, then she
would do it. She would not let that expensive purse go unused. That
day, I returned the gown and robe and bought the summer purse.
That was many years ago. The purse is worn out and long gone, as
are at least a half a dozen others. And next week my mother flies to
California to celebrate her 83rd birthday. My gift to her? The most
expensive disigner purse I could find. She'll use it well.
Jane A. McAdams
Chicago, IL
.pa
POMM2
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A Piece of My Mind
JAMA, 254:1361 (Sept. 13, 1985)
Sudden Intimacies
For over a year this infant had spent more of his time in the
hospital than out. He had a form of Histiocytosis X with
immunodeficiency, but no one truly knew the prognosis. We had all hoped
for the best: that he would slowly outgrow the disease while we treated
the interminable complications as they arose. He was a darling boy, with
a round face, a willing smile, his father's tendency to crinkle up his
nose, and blond hair that stood up vertically on his head. He was
readmitted to the hospital because his fever had returned and the
eczematous rash had flared up. None of us thought that he would die.
But, he developed a right-sided facial palsy, began to choke on his
secretions, and had to be intubated. Seizures followed, with coma and
eventual brain death due to uncertain cause.
One week before his death, the boy's father brought in a new
toy, a stuffed dinosaur emblazoned with swirls of color. As was
customary with him, the father began to brandish the animal in order to
evoke some flicker of interest from his comatose son. "Hey, bud, look!
A dinosaur! Hey, look at it!" Nothing happened. Then, the boy's one good
eye opened slightly and fixed on the brightly colored animal prancing so
closely to his face. A small smile tugged at the left corner of his
mouth, and slowly his right arm reached out to embrace the toy. Within
a minute, the smile faded, and the boy lapsed back into coma. We all
cried. He died the following week without regaining consciousness.
What fulfills the physician? Certainly, the diagnostic
challenge, the financial security, the altruistic glow, and the grateful
thanks all provide a measure of satisfaction. But all too often,
success becomes bracketed by failure, a deluge of new information erodes
the sense of professional mastery, money ceases to compensate fully for
the time and toil, the good one attempts to do goes awry, and the
thankfulness of patients becomes admixed with fear and suspicion.
No, for me fulfillment comes from the sudden intimacies with
total strangers -- those moments when the human barrier breaks cracks
open to reveal what is most secret and inarticulate. A word can betray
the deepest emotion. A look can reflect a world of feeling. Illness
strips away superficiality to reveal reality in etched detail. This
revelation can fuse together disparate lives in unexpected kinship. Is
it the reat of death, the dreaded pain, the sorrow, or the loss? The
physician who can see is there to share in it. Is it the joy of birth,
of unforeseen recovery, of reunion with one considered lost? The
physician who cares can rejoice even as a family member. Who else so
often listens to the vagaries of fate, and feels another's moment so
personally and powerfully? And who else has such a chance to realize
that it matters less whether a moment is one of supreme sadness or
supreme joy that it does that the moment itself is supreme?
This is the physician's priviledge: to be lifted out of the
dross of common days in order to experience such clarity of feeling. The
intensity of birth and death, pleasure and sorrow as expressed in the
lives of others has the power to nullify personal boundaries in sudden
communion. Then, the world is seen in its proper proportions, and the
tenuous miracle of existence is underscored. Surely it must profit us
to feel this deeply, with the hope that somehow, in the sweep of that
feeling, we might yet learn to appreciate the wondrous happening of our
own lives.
Michael Radestsky, MD, CM
Denver.
.pa
POMM3
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A Piece of My Mind
JAMA, Oct. 18, 1985 254:2134.
Layman's Terms
Cummunicating well with patients can be a challenging affair.
Patients often appeal to their physicians "to talk in layman's terms."
This idea, reasonable on the surface, can actually be part of the problem
that prevents their clear understanding of their conditions.
I would submit that emplying layman's terms is not the best means
of discussing medical problems with patients. The terms themselves come
from suprisingly diverse, sometimes untraceable sources. A common medical
term over time and use may degenerate into a catch-all layman's term, or a
common-use phrase may be falsely elevated to the "status" of a medical or
scientific term.
Let me use "pinkeye" as an example. Its definition is "acute
contagious cunjuctivitis," but its meaning has become blurred (no pun
intended). I saw a patient with bilateral viral conjuctivitis and told
him that he had a contagious infection. He responded, "Thank goodness
it's not Pinkeye!"
A pediatric nurse with bilateral bacterial conjuctivitis said "I'm
glad it's not pinkeye so I can go back to work in the nursery."
A woman with viral conjuctivitis wondered if she had pinkeye. When
I asked her what she meant, she answered, "Pinkeye is what you get when
you use your eyes too much."
A patient with severe iritis announced, "I have pinkeye." Yet
another patient clutching his hand over his eye groaned, "It's pinkeye!"
Angle-closure glaucoma was closer to the truth.
Finally, "My eye doctor told me my lazy eye would make me more
subject to pinkeye."
That last statement raises some questions. What is a lazy eye? Is
it a more hyperopic eye? Is it an esotropic eye with or without good
vision? Is ti an amblyopic eye, or has it been traumatized, again with or
without normal vision? Who is the patient's eye doctor? His optician?
His optometrist? His opthamologist?
Obviously, opthamologists aren't the only ones who have problems
with layman's terms. I can imagine that dermatologists spend much of
their time sorting our their patient's confusion about how the rash the
have self-diagnosed as "eczema" is actually due to the "hypoallergenic"
lotion they use so liberally.
Perhaps pediatricians must explain how every cold is not "strep
throat" that requires an injection of penicillin.
Neurologists must be wary when using the term "concussion." Its
definition is "loss of consciousness as the result of a blow to the head,"
but to many lay persons "concussion" has come to mean anything from a
skull fracture with coma to a minor bump on the head.
Meanings of terms change and was once precise may no longer be.
The art of communication in medicine requires clear, accurate speaking at
the patient's level of understanding. This is not accomplished by talking
in layman's terms. The burden is on us as physicians to reeducate our
patient about his terms when they no longer exactly define what his health
problems are. With the better understanding this communication allows,
the patient will probably think that he has a good doctor who talks to him
in "layman's terms."
Donald L. Blanchard, MD
La Grande, Oregon
.pa
POMM4
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A Piece of My Mind
JAMA Nov 23/30 1984, 252:2886
Classic Case
"N.W. is a 42-year old white male who received the diagnosis of
squamous cell carcinoma of the lung two years prior to this hospital
admission after presenting to his physician's office with complaints of
blood-tinged sputum and shortness of breath. His physical exams
revealed..."
The speaker rambled on in the cold matter-of-fact banter of modern
medicine as the diseased products of Mr. W's autopsy were projected on the
screen.
"The slide illustrates quite nicely a metastatic nodule in the
right cerebral hemisphere..."
My mind drifted back to the night NW was brought to the hospital.
It was a cold dark night with the autumn drizzle enhancing the eeriness of
the florescent corridor. The tone of my pager sounded his arrival; the
nurse warned me that he didn't look good. The room was dinly lit when I
arrived; his wife and two sons were silently gathered at the foot of the
bed. His eyes were transfixed on the ceiling, bulging, threatening to
explode. Sweat poured off his body as he summoned the remnants of his
waning strength to suck air into his cancer-ridden lungs. I shook him and
shouted, "How do you feel?" (My stupidity amazed me. " How the hell do
you THINK he feels?" I thought to myself.) His gasps persisted as his
empty gaze turned slowly towards me, but he didn't have the strength to
reply.
I bounded into action, reflexly ordering blood tests, cultures,
X-rays, cardiograms, IV fluids, antibiotics, respiratory treatments,
oxygen -- everything the medical armamentarium could offer to make this
poor creature feel more like a human being and less like a frightened fish
washed ashore and left to suffocate on an empty beach. His gasps grew
louder, more agonal, more like the death rattle. I worked on through the
night, racing down the halls with arterial blood samples, methodically
puring over the old charts, the lab results, the graphs, and the
textbooks, realizing more and more that the game was over, and that just
as this arduous night would end, so too would this man's life.
I stood beside him as the sun peeked into the room. The left side
of his body was twitching spasmodically. His respirations grew shallow,
less frequent, and more innefective, and finally stopped altogether. I
turned off the Oxygen, then the IV, and closed the lids over his weary
eyes. His long struggle was finally ended and his new found peace must
surely have been euphoric.
After NW died, I found his family in a smoke filled waiting room,
anxiously drawing thick clouds of smoke into their precious lungs. I
wanted to say I was sorry, that we did all we could, but their cigarettes
destroyed my sympathy. His death had lost its meaning, and I had lost
any hope that we would ever see the light.
Robert J. Havey, MD
River Forest, IL
.pa
POMM5
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A Piece of My Mind
JAMA, Nov. 8, 1985 254:2596
When the World is Your Ashtray
Are you losing confidence in your ability to smoke in the face of
stiffer health warnings? Or worse, do you feel as if it just isn't worth
the effort anymore? Don't be discouraged. Blind faith is the key to success
in any endeavor, but acheiving just the right balance of puffery and
downright denial can be tricky. It is especially difficult when your best
friend -- a smoker of 30 years -- is beginning to experience hemoptysis.
[coughing up blood]
I think I've solved the problem with several hints that will bring
your confidence level back up before you have to undergo chemotherapy.
Just remember that the tobacco companies wouldn't take out all of those
full-page newspaper and magazine ads if they wanted you to stop.
* Associate with smokers. It's downright annoying to have non-smoking
friends ask you to sign "clean air" petitions while you're enjoying coffee
and a cigarette. If you don't make friends easily -- especially with other
somkers -- pal around with names like Lorillard or R.J. Reynolds.
* Use effective advertising. Display a tasteful sign on your office
wall: "Thank you for not breathing." This will compete with the other
side's more popular "Thank you for not Smoking." As clean air fanatics
enter you smoke-filled office, ask if they mind not breathing. When they
say "no," light up.
* Remember the medical approach. Tell how through willpower alone you
stopped smoking for more than three years. When you became ill, however,
your physician insisted you start again. Now he believes smoking saved
your life.
* Request a restaurant table in the no-smoking section. After you've
been seated, take out a cigarette and place it between your lips, unlit.
Notice how many non-smokers turn pale. A few may collapse from shock.
This suggests that nonsmokers have a higher incidence of heart disease --
something the tobacco companies have maintained all along.
* A similar tactic is to request an airplane seat in the smoking
section, directly behind several nonsmokers. Aim your battery powered
portable fan, then light up. When you hear the yells, uttered
incoherently in the aisle, turn to a neighbor, who is also puffing away,
and casually mention how irrational nonsmokers are.
* Have faith. Secondhand smoke won't hurt you, especially if you are
the one producing it. On the other other hand, if your spouse or roommate
is a nonsmoker, secondhand smoke may be harmful. In that case, he or she
had better learn to smoke as soon as possible.
Your local tobacco shop offers instant smokestarter clinics. If
most folks aren't hooked within four weeks, there's a money-back guarantee.
* Stick to cigarettes with optimistic names. Next month a major
tobacco company introduces their low-tar brand for terminally ill patients.
"Hospice" cigarettes offer dying patients a chance to continue to puff in
hopeful contemplation the the 45,000 scientific studies linking smoking to
sickness are in error.
Remember that using these hints will be rather like taking your first
puff when you began the habit. The assorted miseries of coughing, nausea,
stained teeth, smelly clothes, and ill health will vary, depending on how
much you smoke. But once you've put these suggestions into practice, don't
be suprised to hear low-pitched moans wherever you go. It is likely to be
your heart or lungs begging for mercy.
George Banks, MD
Tustin, California.
.pa
POMM6
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A Piece of My Mind
JAMA, March 8, 1985, 253:1402
Not on My Shift
She was a 72 year old woman who had been recently transferred
by helicopter from a smaller hospital. She had started bleeding from a
duodenal ulcer and was in serious condition. The attending surgeon and
medical consultant both agreed to try agressive medical management because
of the risks of surgery. But she continued to bleed despite treatment
and was taken to surgery that evening.
It was a Saturday night, and I was getting a report from the
surgical resident who had been on call the previous shift. "We had quite
a time with your patient last night," he said. "She survived the
operation, but I think she'll probably die sometime today."
"Not on my shift," I blurted out without thinking.
As I went through my surgical rotation in medical school, and now
in residency, this situation had come up many times. There was always
one patient on a service who was close to death. The residents did
everything possible not to let that person die on their night on call. It
was inevitable that the patient would die, but to let that person die on
your shift was a sign of failure.
My night on call started as usual: an admission from the emergency
room to rule out appendicitis, a traffic accident victim with only
superficial wounds, a few calls to the floor. Then I was called to the
intensive care unit. My patient's blood pressure was dropping, and her
urine output was low. From that point, I was in and out of the ICU all
night; increasing her fluids, transfusing blood, adding a dopamine drip,
inserting a catheter and an arterial line, giving albumin, putting her
on a ventilator; it went on and on.
Finally it was 7 am, time for me to give the report to the next
surgical resident. I described the evening's work with my patient and said
that she was in serious condition, that I thought she would probably die
during the day.
The oncoming surgical resident flashed back, "Not on my shift!"
Lynn A Crosby, MD
Omaha, Nebraska
--
Craig Werner (MD/PhD '91)
!philabs!aecom!werner
(1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517)
"..pursuing Dharma, Artha, and Kama (although not nearly enough of the last)."