Communication and Industry

Effective January 1, 2009 pharmaceutical companies are now prohibited from distributing branded non-informational gifts to physicians (eg Boniva pens, Viagra mugs, etc.) On the surface this seems to be a victory for patients. Study after study has shown that doctors' prescribing practices are extremely influenced by their interactions with pharmaceutical company representatives. Prescribing drugs based on gifts and not on evidence is a practice that could pose potential harm or lack of benefit to patients.

However, in a country in which capitalism and first amendment rights are highly valued, is this decision clearly right? Is this where we stop or is this a slippery slope toward cutting off communications entirely between industry and hospitals? Limiting physicians' interactions with pharmaceutical representatives leaves more money for pharmaceutical companies to utilize direct-to-consumer advertising. This creates undue influence on patients who are not only stressed about their illnesses but also are not educated about their own diseases nor the drugs they are being sold on. In addition, despite their frequent vilification in the media and in medical schools, most drugs we currently use would not be around without pharmaceutical companies and physicians need to be educated on these drugs in some manner. Communication and collaboration between brilliant minds is the lasting foundation of academic medicine and medical research. Should we really exclude the brilliant minds in industry from the discussion? Is complete separation in the best interest of our patients? Smaller pharmaceutical companies trying to compete with giants like Pfizer and Abbott may not have many other avenues to get the word out about their drugs as TV commercials are very expensive. Lastly, in a time when the daily headlines in the New York Times and on CNN are about Americans losing thousands of jobs and the fall of financial institutions, is this the time to put new restrictions on capitalism involving an actual product?

On the other hand, some restrictions are necessary. Perhaps this is a step in the right direction. A Viagra mug does not educate a physician about the drug nor its off-label use for pulmonary hypertension. Perhaps this will encourage pharmaceutical companies to use their advertising budget more for the education part and less for pure name recognition. As always, only time and rigorous studies with a firm evidence base will tell.

The Birth of the Clinic

I recently completed a primary care clerkship back in my hometown of Eau Claire, WI. I spent two days per week at a family practice clinic in the neighboring town of Augusta, where I had my first exposure to rural medicine. In Augusta I also had the opportunity to participate in a semiannual maternity care conference, where Amish women of the upper Midwest converge to discuss issues of home childbirth with health professionals. The dynamic of this conference reminded me of some chapters in French philosopher Michel Foucault's work, The Birth of the Clinic: An Archaeology of Medical Perception. Contending that Foucault is underrepresented at most of our nation's universities with the appropriate title of this particular work, considering my return to the place of my birth (and, incidentally, where I witnessed my first birth as a medical student) and the conference's focus on birth, let us examine the Amish midwives conference in the context of Foucault's Birth of the Clinic.

On a cold December morning in rural Wisconsin I found myself seated in a large circle that included a family practice physician, a few public health nurses, and thirty-two spry middle-aged Amish women, neatly bonneted and modestly whispering in German dialects. The physician politely welcomed everyone to the semiannual maternity care conference--most had traveled from various parts of Wisconsin, Minnesota and Iowa--and the day began similar to an M&M (morbidity and mortality) conference at an academic hospital: the women shared stories about complicated deliveries their daughters or friends experienced and what transpired, followed by a discussion about what could have been done differently, if anything. The rest of the morning consisted of interactive lectures on participant-suggested topics such as breech birth and post-partum depression. After a social potluck dinner (which included the best chicken noodle soup I've had in my life), the afternoon included presentations on dental hygiene during pregnancy, proper documentation for birth certificates, WHO recommendations for traditional birth attendants, maternal and infantile heart problems, and finally a review of monitoring vital signs. Informal conversations during breaks and sharing from more experienced midwives were also an integral part of the training.

The Amish came from Switzerland, then Alsace, and immigrated because of persecution. Wisconsin has the fourth largest Amish population in the US at 15,000. They observe the Ordnung, or code of conduct that is passed through the generations (i.e. limitation of modern amenities and regulation of dress), which is informed by the concept of Gelassenheit (yielding individual interests to higher authorities of the community and church). The Amish view illness not by the presence of symptoms, but the failure of daily function. Their agrarian tradition lends to folk medicine such as herbal and home remedies, rare visits to contemporary doctors, and hospitalization only in dire states of health. In terms of obstetrics, the Amish have a strong desire to have children at home, surrounded by family. Amish midwives are not formally trained but have a wealth of experience.

According to Foucault, The Birth of the Clinic is a book "about space, about language, and about death." "The clinic" actually refers to academic medicine. Essentially, the work describes the evolution of medical practice from local country doctors training apprentices (and the potential for charlatanism) to the establishment of teaching hospitals and centralized regulative bodies such as the Société Royale de Médecine in France. Instrumental in that shift was the reorganization of medical knowledge and subsequent nosology informed by research in anatomy, broader perceptions used in physical exam and tailoring of medical language. Two excerpts from Birth of the Clinic regarding the "codes of knowledge" still speak clearly to the present-day conference on birth in Augusta:

Before it became a corpus of knowledge, [the clinic's] decline began [with] the concentration of this knowledge in a privileged group...what was known was no longer communicated to others and put to practical use once it had passed through the esotericism of knowledge. (55)

In some ways, the esotericism of knowledge is still a hurdle for academic medicine. Perhaps academia's trajectory should be to augment research with a focus on outreach efforts to communities like the Amish, the uninsured, et cetera to put to use the expansive body of medical knowledge that already exists. While there are many areas of medicine where research is crucial, this maternity care conference is a welcome and useful example of academic medicine interfacing concurrently with its community origins, as it were. Further:

The locus in which knowledge is formed is...a generalized medical consciousness, diffused in space and time, open and mobile, linked to each individual existence, as well as to the collective life of the nation, ever alert to the endless domain in which illness betrays, in its various aspects, its great, solid form. (31)

Again, a tangible impact of the midwife conference is that it brings academic medicine, which can seem austere to traditional communities, back to the countryside. For example, reviewing WHO recommendations with the Amish, whether they take to many or few, represents a diffusion in space and time of obstetric care. In conclusion, it is possible to reconcile tradition with academics in a practical sense, without necessarily imposing one culture upon another.

Lancaster County Amish

References
James T. Eastman, Health in the Amish Community (lecture at UWSMPH, 1 April 2008)
Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (London, 1973)

Photo reproduced under GNU Free Documentation License

Dementia

My close friend's father died recently from complications of early-onset Alzheimer's disease.

When medical students hear "Alzheimer's" (especially those preparing for step 1 of the national board examination), most reflexively associate it with "cerebral atrophy, neuritic plaques, neurofibrillary tangles and amyloid angiopathy."

Certainly I am not the first to acknowledge that medical jargon can confound patient-centered medicine. Of the vast quantity of diseases about which medical students must learn, the cumulative suffering that such illnesses inflict is often masked by percentages of sensitivity and specificity, the distinction between incidence and prevalence, and seemingly obscure trivia (for example, that apolipoprotein E4 is a risk factor for Alzheimer's while apolipoprotein E2 is protective). True, health care providers must immerse themselves in medical technicalities to be able to manage disease. However, esoteric buzz words and statistics may also represent defense mechanisms (i.e. isolation, intellectualization and suppression) for coping with the overwhelming emotions that accompany debilitating illnesses like Alzheimer's.

Over the past five years I have seen the impact that Alzheimer's has had on one person, one family and one community. Multiplied by millions of cases of dementia worldwide, the buzz words and statistics become a blur.

Sometimes it's better to just be overwhelmed.

www.alz.org

Why cooking rocks

Studying for my gastrointestinal and clinical nutrition exams reminded me of something I wrote two years ago after I helped prepare a meal for Hurricane Katrina survivors in Minneapolis. I condensed my thoughts, inspired in part by the book Black Elk Speaks, into bullet points at the time and this weekend I figured they were worth regurgitating on the blog. I have also added visuals to incorporate some local flair.

Romanesco broccoli, known for its fractal inflorescence, purchased at the Madison Farmers Market.

Why cooking rocks

• Cooking poses an intellectual challenge that betters the mind and body. Preparing a dish or dishes demands organization of time and space. That is, cooking involves discrete mathematics. Humans have had to conquer the science of food (i.e. temperature variation, changes in physical state, etc) to optimize edibility and utility. Cooking also exercises the right side of the brain because presentation and preparation of food are artistic endeavors.
• Fulfilling a basic human need: We must eat to live (eating healthy and balanced foods, in particular, enhances this aim).
• Embracing the land: Consuming food is part of the carbon cycle. The origins of a dish’s ingredients are diverse. This is especially true for fusion cooking, but also true of mundane meals. Take [a baked potato with toppings] as an example: the potato, an underground root vegetable; broccoli, member of the cabbage family; chili meat and bacon bits, from animal muscle; cheese and sour cream, derived from animal lactation. Essentially we internalize and meld with many parts of the land.
• Embracing each other: Meals have an important anthropological feature, and eating together has positive social consequences. To quote Leigh Bush’s thesis Cuisine, Culture and Class: Understanding the relationship among three social phenomena in globalizing modern societies:

  The consumption of cuisine links it to both body and person, while [associated cultural factors] connect it profoundly to personality…Cuisine becomes physically integrated with the body, person and personality through the process of literal consumption.

• In general, food tastes good and exercises our senses.
  

In summary, cooking rocks because it sustains life, while connecting us physically to the earth and socially to other humans. It also nourishes the individual mind and spirit. The Meal is perhaps the highest synthesis of life, yet such a common activity that its mystique is often overlooked.

Stir fry composed of rice noodles, Romanesco broccoli, red bell pepper and eggplant.

Sisyphus, MD

The Myth of Sisyphus is a philosophical work by Albert Camus in which he outlines his concept of “the absurd” and applies it to the mythological figure Sisyphus, who was condemned to push a boulder up a mountain only to have it roll back down repeatedly for eternity. In true meta style, I shall write about a piece that was written about a myth, noting parallels to procrustean medical training and praxis. When I applied to medical school, my personal statements were based on the mantra “life rocks”, as it were, and therefore preserving life as a physician must be the highest and most rewarding of all professions. However, in the context of The Myth of Sisyphus, it is possible that health care comprises the most absurd of professions yet offers a unique path to happiness.

In the first chapter of The Myth of Sisyphus Camus lays the foundation for absurd thought. The “divorce between man and his life…is properly the feeling of absurdity” Camus states eloquently. Essentially, the absurd recognizes life’s futile search for meaning, especially considering life’s ultimate mortality. Camus offers permutations of its definition: “the absurd is born of confrontation between human need and the unreasonable silence of the world”, or rather the inability to reconcile an “appetite for the absolute and for unity and the impossibility of reducing this world to a rational and reasonable principle”. He finally notes that “the absurd is the essential concept and the first truth”.

The next two chapters describe four examples of the absurd life. The seducer, the actor, the conqueror and the artist are people who live fully for passionate moments within an absurd universe. Interestingly, the physician is a candidate for yet another example of the absurd life, for it can be considered doubly absurd to propagate the existence of mortal beings necessarily situated in the absurd dilemma.

In the final chapter, Camus analyzes the legend of Sisyphus—king of Corinth and “the wisest and most prudent of mortals”—concluding that Sisyphus is the ideal absurd hero. According to the myth, Sisyphus betrayed Zeus’ secrets and was to be chained in the underworld. Sisyphus craftily put Thanatos (Death) in the chains and thus no mortal could die until Death was released (an appropriate connection to medicine indeed!). Sisyphus then asked Persephone, Queen of the Underworld, to allow him brief passage to the upper world to ask his wife to make a sacrifice in honor of his death. Upon return to Corinth, he decided not to come back to the underworld but Hermes retrieved him for eternal punishment.

He is [the absurd hero] as much through his passions as through his torture. His scorn of the gods, his hatred of death, and his passion for life won him that unspeakable penalty in which the whole being is exerted toward accomplishing nothing.

Sisyphus’s punishment exemplifies the human condition—a seemingly futile struggle—yet Camus concludes that if Sisyphus comes to terms with his absurd condition, he can find happiness in it.

Connecting The Myth of Sisyphus to the culture of medicine calls for exploration of a concept related to the absurd, that of “hyperconsciousness”. Hyperconsciousness is the state of being overly-cognizant of the affirmations and tribulations of one’s situation and actions. It is the coincidence of the best and worst of times. It is unavoidable and requires a sort of Orwellian “double-think” to constitutively justify one’s actions. It confounds the absurd nature of the health professions, which has already been established philosophically, in a practical sense. Hyperconsciousness pervades medical culture from within and outside of the profession.

Endogenously, hyperconsciousness is evident when medical students tend to talk mostly about schoolwork as they party after exams, or when practicing physicians champion their specialty followed by complaints about insurance and limited free time. In fact, this blog is representative of hyperconsciousness in itself. Exogenously, meaning society’s view of the health professions from the perspective of social convention, medical training is typically criticized as being too long, too hard and too expensive (i.e. Sisyphean). There seems to be a double standard that the ideal job is one that pays the most with the least training. However, we are always free in thought if not always in action, and determine our attitude regardless of our situation. Additionally, even if medical training is Sisyphean, its many steps provide opportunity for new beginnings and the avoidance of routine. Relativism is the path to overcome the inertial force of the hyperconscious.

In conclusion, the health professions are indeed absurd, but its actors are absurd heroes. As Camus wrote, “outside of that single fatality of death, everything, joy or happiness, is liberty.” In other words, experiencing the absurd offers freedom. Ultimately, we define our profession's culture and happiness is the bottom line. Camus notes that happiness and the absurd are inseparable—happiness can stem from the absurd and the absurd can be secondary to happiness. However, from the first chapter of The Myth of Sisyphus Camus extends this reminder: “The preceding merely defines a way of thinking. But the point is to live.” In the health professions, life still “rocks”, literally and figuratively.

A portion of Sisyphus by Franz von Stuck

Writing about Writing

Pete recently shared this NYT article with Jacqui and me. It is about doctors who write. As I indicated in a previous post, I took a class last quarter that was geared toward writing about our experiences in medical training and beyond. This quarter, I took a class called Human Faces of Medicine, in which we read writing by physicians and non-physicians alike. The following essay came out of reflections from this class as well as thoughts and readings from Mind, Body and Pen, the previous writing course. For my fellow blog-mates as well as other medical students out there, if you haven't cracked open that "On Doctoring" book that we all got during orientation, now's a good time! There are many short essays, poems, and excerpts that make for good bedtime or summer reading.

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Wield the Pen, Yield the Soul
Examining the role of literature in medicine

Of all the factors contributing to the success of the literary endeavour… the human dimensions…remain[s] by far the most important, and certainly the most powerful element in any work of literature. Without such human values literature is reduced to journalism. ~Naguib Mahfouz

The practice of medicine has at its core the unique task of documenting humanity, which has also been the purpose of literature since time immemorial. It should come as no surprise then, that so many physicians have transitioned seamlessly from the art of medicine to the art of writing. As a result, the anthology of medical literature has been growing continuously, with contributions from both medical providers as well as those they care for. In the following discourse, I shall try to elucidate the purpose and value of this ever-expanding corpus. Doctors and patients both seek the truth, but they take different paths. By creating that which all humans crave, namely mutual recognition and a feeling of shared experience, literature is able to bridge that gap and at the same time providing therapeutic nourishment for both physicians and patients.

Medical diagnosis is not always an open and shut case. In fact, it often requires the keen observational skills of the physician. None are as skilled at detailing observations as William Carlos Williams, and perhaps none are as concerned with seeking the truth in patients. Williams’ story The Girl with the Pimply Face is one example of the physician’s scrutiny. He took in not only the object of the house call, but the whole family as well. Of the sister, the main character, Williams wrote, “She was just a child but nobody was putting anything over on her if she knew it, yet the real thing about her was the complete lack of the rotten smell of a liar. She wasn’t in the least presumptive. Just straight”(228). And of the parents, “I realized finally that she had been drinking. I turned toward the man, looking a good bit like the sun at noonday and as indifferent, then back to the woman and I felt deeply sorry for her”(236). Williams is a seasoned physician, and his stories frequently highlight what’s beyond the narrow pathological presentation of the patient. In doing so with precision and detail, he brings the reader into his clinical reasoning that includes what he describes in The Practice as “the poetry of life”(57).

In writing about their experiences, physicians are also attempting to grapple with their own responses during the process of patient care. In Lawrence Grouse’s The Lie, the attending physician is asked by his patient to give an honest prognosis. He is conflicted, thinking, “I am already fond of her an I do not want to lie. I squeeze her hand and smile. I am unsure how she will do”(40), but ultimately tells the patient a lie, that she will be fine. When the patient recovers, weeks later, the doctor lets the secret out because he “can’t help bragging”(41). The story ends abruptly with Annie’s surprise and anger.

Annie seemed shocked to hear this. She looks at me angrily and says, “Don’t you remember? You said you were sure I would live. I remembered that promise all the time! I put a great deal of weight on what you said, and you…” Suddenly, for the first time since the accident, and to everyone’s surprise, tears are in her eyes and she is weeping; she is inconsolable because I lied to her. (41)

The ending leaves us wondering, what was the purpose of the story? Who was the audience? It is at the same time speaking to us and not to us, an introspective afterthought. Perhaps the vignette was written years later, perhaps out of an absolution of guilt. Physician-writers such as Peter Pereira and Emily Transue would both agree with this characterization. Whether such writing serve as a lesson to those who come in their wake is unimportant; instead, what usually bears fruit is the attempt to understand their emotions surrounding a memorable patient.

While physicians are writing about the patients’ stories that moved them, the patients themselves have an interpretation of their illness narratives and the doctors who listened. Just as physicians are searching for the underlying truth, patients are seeking to understand their illness and to confront their mortality. Raymond Carver’s poem, What the Doctor Said, is his account of receiving a diagnosis of lung cancer. In just a few short lines, the patient’s response changes from a flippant, almost joking remark of “I’m glad I wouldn’t want to know/about any more being there than that” to the stunning effect as the gravity of the news takes hold, “I said Amen and he said something else/I didn’t catch and not knowing what else to do/ and not wanting him to have to repeat it/and me to have to fully digest it/I just looked at him”(302). The brevity and rapid cadence of the poem conveys both the fleeting experience of a terminal diagnosis and the whirlwind confusion of what has just passed. The patient leaves the room in a stupor, “I may even have thanked him habit being so strong”(302).

Doctors and patients travel different paths in understanding the illness that confronts them. But literature is where their paths meet. And herein lies the therapy of shared company. The comforts of mutual experience is universal, as Eduardo Galeano describes in his Book of Embraces:

Yes, indeed: however hurt and shattered one might be, one can always find contemporaries anywhere in time, and compatriots anywhere in space. And whenever this happens, and for as long as it lasts, one is lucky to feel one is something in the infinite loneliness of the universe: something more than a ridiculous speck of dust, more than just a fleeting moment. (245)

A most striking example of this mutual reflection can be found in William Carlos Williams’ The Practice and Anatole Broyard’s Doctor Talk to Me. Williams writes, as the physician: “We begin to see that the underlying meaning of all they want to tell us and have always failed to communicate is the poem, the poem which their lives are being lived to realize”(57). To which Anatole Broyard seemingly echoes, from a patient’s perspective: “Inside every patient, there is a poet trying to get out. My ideal doctor would “read” my poetry, my literature”(169). The rhapsody continues with astonishing reciprocity. Williams’ call for “the pursuit of a rare element which may appear at any time, at any place, at a glance...Mutual recognition [flaring up] at a moment’s notice”(55). Broyard is ready with, “The patient is always on the brink of revelation, and he needs someone who can recognize it when it comes”(169). Williams and Broyard agree, nearly half a century apart, that “there is no need for us to be such strangers to each other,” (Williams, 55) that by “letting the sick man into his heart…he can share, as few others can, the wonder, terror, and exaltation of being on the edge of being, between the natural and the supernatural”(Broyard, 172).

Literature serves a second purpose for those who experience medicine—that is to educate the physician and the patient about each other, thereby bridging a gap that is never crossed at the bedside. EM Forster once wrote, in Two Cheers for Democracy (1951), “What is wonderful about great literature is that it transforms the man who reads it toward the condition of the man who wrote.” Writing can be deeply introspective. It offers a window on the patient’s soul that cannot be auscultated or palpated, a connection with the physician that can never be reached despite infinite questioning by the patient.

Physicians are seen as natural storytellers. But more generally, Man is a natural storyteller. What makes the medical partnership unique is that the shared experience, filtered through the words of the caretaker and the patient, reveals undiscovered commonalities. Each, in searching for the truth in illness, finds through literature the truth of humanity, the secret to being a good doctor, the key to being a good patient. To leave you with a final excerpt from Eduardo Galeano,

Why does one write, if not to put one’s pieces together? From the moment we enter school or church, fishermen of the Colombian coast must be learned doctors of ethics and morality, for they invented the word sentipensante, feeling-thinking, to define language that speaks the truth. (121)

Through their writing, physicians and patients are simply composing different stanzas of the same poem.

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Works Cited:

Broyard, Anatole. “Doctor, Talk to Me.” In On Doctoring: stories, poems, essays, edited by Richard Reynolds and John Stone, with Louis LaCivita Nixon and Delese Wear, 166-172. New York: Simon & Schuster, 2001.

Carver, Raymond. “What the Doctor Said.” In On Doctoring: stories, poems, essays, edited by Richard Reynolds and John Stone, with Louis LaCivita Nixon and Delese Wear, 302. New York: Simon & Schuster, 2001.

Galeano, Eduardo. The Book of Embraces. New York: W. W. Norton & Company, 1992.

Grouse, Lawrence. “The Lie.” In A Life in Medicine: A Literary Anthology, edited by Robert Coles and Randy Testa with Joeseph O’Donnell, Penny Armstrong and M. Brownell Anderson, 39-41. New York: The New Press, 2002.

Williams, William Carlos. “The Girl with the Pimply Face.” In A Life in Medicine: A Literary Anthology, edited by Robert Coles and Randy Testa with Joseph O’Donnell, Penny Armstrong and M. Brownell Anderson, 226-238. New York: The New Press, 2002.

Williams, William Carlos. “The Practice.” In On Doctoring: stories, poems, essays, edited by Richard Reynolds and John Stone, with Louis LaCivita Nixon and Delese Wear, 52-58 . New York: Simon & Schuster, 2001.

Reconciling tradition and postmodernity

After my first post, a friend of mine who is a medical student in Chicago suggested that I discuss the increasing number of foreign language speakers as patients and how that impacts doctors’ ability to provide care. I assumed that the language barrier was the main obstacle in this issue and that translation is the primary path to its resolution. While translation is an area worthy of analysis (perhaps in a future post), this weekend I realized that providing health care also entails being a conduit of resources between society’s postmodern organization and patients’ traditional social structure.

In Madison there are six free clinics operated by UW medical students and faculty. The Southside location in particular has a large population of Spanish-speaking patients, from long-time community members to recent immigrants to visiting family members. Thus, many patients come from intimate communities with strong family orientation. Conversely, the modus operandi of the free clinics manifests the postmodern condition. Postmodernity classifies aspects of contemporary culture that are a result of globalization, the fragmentation of authority and the commoditization of knowledge.

For example, a number of cases this weekend required neither medications nor a physical exam. Rather, information was paramount. A simple dermatology referral became complicated because we were not sure if the clinic would operate on Easter weekend. In response, the patient asked seemingly simple questions: Who decides? How do I find out? Where do I go? Who pays? The answers are not so simple. Although the patient-physician relationship is traditional in nature, financing the clinics’ capital and orchestrating referrals are often what comprise the final connection. The accruement of monetary donations coupled with in-kind donations of medications, supplies, space, time and their distribution, is inherently postmodern. Instead of a traditional locus of power based in a closed community, financial and legal stipulations create a system-based locus of power.

While the immediate community encompasses the traditional limit of concern, postmodern limits of concern are of global proportion. Immigration requires a shift to global limits, and information must be processed in a postmodern way to accomplish this shift. Interestingly, patients make this transition, yet the aim of wellness is to maintain a traditional way of life characterized by community, family, optimism and intimacy. In short, postmodernity at the free clinics is merely a means to a traditional end. Or, it might be said that as patients navigate the pro bono health care system, they are simultaneously attached to decentralized and traditional systems: a postmodern construction in itself.