Doctors, Revolt!

The 96 year old patient lamented that today's hospital is more like a factory.   He told his intern that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.” 

This is a moving article by Dr. Rich Joseph, a resident at the Brigham and Women’s Hospital in Boston.  His Op-Ed piece, Doctors Revolt!, published in the Sunday Review of the NY Times is a moving introduction to Lown’s fine book, The Art of healing.  It also chronicles a refresher course in humanistic medicine for Dr. Joseph at a crucial point in his career..

Here are notes from The Lost Art of Healing.

Medical Hysteria

Inappropriate medical activity is directly proportional to the gravity of the patient’s illness, and inversely proportional to the likelihood of real or lasting therapeutic benefit. This inappropriate medical activity can be called medical hysteria.  JM Naish, Lancet 1970

For a link to Full Text PDF.

How To Swim With Sharks: A Primer

by Voltaire Cousteau

In 1973, the hematologist Richard Johns, using the pseudonym Voltaire Cousteau, published an iconic essay on how one survives in academic medicine.  It has inspired many colleagues many of us for decades.  Strangely, an appreciation of Johns’ essay has been recently published by F. Shanahan in the Quarterly Journal of Medicine.

Forward

 Actually, nobody wants to swim with sharks. It is not an acknowledged sport and it is neither enjoyable nor exhilarating. These instructions are written primarily for the benefit of those, who, by virtue of their occupation, find they must swim and find that the water is infested with sharks.

It is of obvious importance to learn that the waters are shark infested before commencing to swim. It is safe to say that this initial determination has already been made. If the waters were infested, the naïve swimmer is by now probably beyond help; at the very least, he has doubtless lost any interest in learning how to swim with sharks.

Finally, swimming with sharks is like any other skill: It cannot be learned from books alone; the novice must practice in order to develop the skill. The following rules simply set forth the fundamental principles which, if followed will make it possible to survive while becoming expert through practice.

For Links:

References:

1. How to swim with sharks: a primer. Cousteau V. Perspect Biol Med. 1973;16(4):525-8. doi: 10.1353/pbm.1973.0039. Download How To Swim With Sharks (this is a reprint of the original)

2. How to swim with sharks: a perspective on Voltaire Cousteau's primer. Shanahan F. QJM. 2018 Feb 5. Full Text Link.
   

Functional Somatic Syndromes

This article is a classic reference on this common but poorly understood group of disorders.  It is well worth studying if you are interested in this topic.  The large group of illnesses that fall under the rubric of Medically Unexplained Symptoms are functional somatic syndromes.  

Functional somatic syndromes.
Barsky AJ, Borus JF. 
Ann Intern Med. 1999 Jun 1;130(11):910-21 

Link to download of Full Text of article.

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms.

The Medical-Industrial Complex

This is the classic first article about the medical-industrial complex.  It first appeared in the New England Journal of Medicine in 1980.   It is an imporant article, maybe needing to be updated.  My own feeling is that the concept of the Medical-Industrial-Academic Complex is more important -- but academics control what gets into our journals.  The most prestigious journals tend to benefit greatly from advertising dollars (can skew content) and the authors of scholarly articles are academics.  That focuses the literature on what academics feel is important.  Thus they report on diseases much more than illnesses.

The Medical-Industrial Complex
Arnold Relman
NEJM 1980; 303:963-970

ABSTRACT: The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to $40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also excercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interests of the public before those of its stockholders

The private health-care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need, i.e., services that are likely to be helpful and are relatively safe.

In the health-care marketplace the interests of patients and of society must be represented by the physician, who alone has the expertise and the authority to decide which services and procedures should be used in any given circumstance.

We should not allow the medical-industrial complex to distort our health-care system to its own entrepreneurial ends.

Arnold P Gold (1925-2018)

 NY Times Obituary

Dr. Arnold Gold, a pediatric neurologist whose belief in the importance of an empathetic bedside manner led him and his wife to create a foundation to inspire young doctors to practice compassionate patient care, died on Jan. 23 in Manhattan.

...

“So one day in 1988,” he said in the 2016 interview, “I was making rounds with the students and residents and a student presented me ‘the brain tumor in 209.’ And I said: ‘The brain tumor? Isn’t there a child involved in this? Tell me about the child, tell me about the family. Tell me how this is impacting on the family. Do you know any of this?’ ” They did not, he said.

At home that night, he told his wife of his concerns about where medicine was headed. As he recalled, she told him, “You know, Arnold, I’m tired of you griping about medicine. Do something about it or shut up.”

They began the Arnold P. Gold Foundation together in Englewood Cliffs, N.J., in 1988, hoping to clone Dr. Gold’s humane approach to patient engagement.

Mellanby on Scabies Transmission

Kenneth Mellanby did the classic experiments on scabies transmission during WWII on conscientious objectors. This report in the BMJ, September 1941 is a definite classic.  It also shows how concise an important paper can be.   About Ken Mellanby.

The Royal Road to Healing

The [Icelandic] Royal Road to Healing: a bit of a saga

Getz L, Kirkengen AL, Petursson H, Sigurdsson JA.

BMJ. 2011 Dec 19;343:d7826.  Free Full Text.

In the face of another person’s suffering, a listener can offer to be a competent, dedicated, and attentive co-thinker—not pretending to know the solution, but trusting the healing power inherent in an empathetic relationship.

[This essay] describes “the healing conversations between Ivar and King Eysteinn that took place almost 800 years before Sigmund Freud in 1895, formally presented the “talking cure.” King Eysteinn’s inquisitive style may not follow current advice regarding open, clinical communication. But it does build an elegant literary plot, which culminates beautifully, as the king abandons the idea that he can find the solution to Ivar’s suffering and reveals his insight into the healing powers of a respectful human relationship.