Says Who??

Verstehen, through shared perspectives


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FIRST DO NO HARM

First do no harm. Immediately our minds turn to physicians when we read or hear this phrase, yet the reality of “Pill Mills” in our cities and neighborhoods is one factor fueling the present crisis of faith in our health care system for many people. We are a nation that labels and stereotypes with great abandon, and with the numbers of criminals using an MD degree to illegally provide narcotic prescriptions for the price of an office visit, the negative label on the entire pain management profession was no doubt inevitable.

I was guilty of supporting that label, myself. For sixteen years I lived in a region where in the beginning, alcohol and marijuana were the primary recreational drugs. Over the years, however, I saw many beautiful, bright and charming young people become addicted to narcotics, and the drugs became easier and easier to obtain even in that isolated part of the country. A few years back, I learned about growing numbers of pain clinics in the region, and that students were “safely” obtaining legal prescriptions for their recreational drugs. The words “pain clinic” became anathema to me.

After I retired and moved close to a city several hours from where I had worked, my back pain was so severe and disabling that my primary care physician told me he was going to refer me to a pain management physician. I was stunned, then just plain mad. “No, thanks!” I told him, and he may have understood the unspoken question “Have you lost your mind,” though I tried to hide it. It took some time for him to convince me, first that the physician in question was highly skilled in interventions like epidural nerve blocks for the pain, and second that he was completely legal. Even so, I did not hesitate to inform said pain management specialist that I did not need his services except for the epidurals.

I like to think that I am a fairly open-minded person, and six months later (and in much better health largely as a result of the care received from my pain management physician) I am now a patient in the pain management clinic, where my physical intolerance of narcotics and other medications is taken in stride. That is to say, I finally remembered my sociological training (to say nothing of my own teaching on the subject) and realized that no matter what my experience was in my former place of work, it did not come close to describing an entire branch of medical expertise and practice.

First, do no harm. But physicians are not the only group that should make decisions with this caveat in mind. I, for one, had to accept that the caveat applied to me, as well. How much harm did I commit in my righteous indignation over the felonious pill mills? I hope not as much as our legislators and law enforcers have done by tarring innocent physicians and patients with the stereotypical labels of pill pushers and drug seekers.

Legislators can bring about costly changes in the way that laws are made and enforced, resulting in potential harm to many people. The current “war” on opioids is a prime example.

Lawmakers are subject to pressures from the press, from their financial supporters, and their colleagues. Faced with the need to satisfy so many groups with vested interests, to first do no harm often seems to be the farthest thing from these officials’ minds. However, a few states have passed legislation designed to protect both patients with chronic pain and the physicians who prescribe for them. Indiana is one such state.

In 2012, an Indiana Senate committee introduced a bill that would become IN SB246. The final version of this bill http://www.in.gov/legislative/bills/2013/SB/SB0246.2.html was passed in 2013, based on advice from a panel that included physicians and the Medical Licensing Board.   The Medical Licensing Board then enacted an Emergency Rule effective on December 15, 2013 http://www.IN.gov/mlb . The Emergency Rule established standards and protocols for physicians who prescribe controlled substances for the treatment of pain.

You will note in reading the rules that there is a clear separation between medical license regulations, and activities termed felonious that must be prosecuted. The law covers the latter category only, and leaves control of errors in staying within the bounds of regulations to the proper authority: the Medical Licensing Board. This is precisely where many other state, local and federal government bodies have gone overboard, causing unnecessary pain and grief – even loss of life—to innocent persons by including professional regulations with actual laws. As a result, people have been needlessly targeted – “profiled,” to be exact—as living outside the law. People such as respectable physicians, living within the law, as well as persons who have been non-addicted, chronic pain sufferers, trying to manage their suffering “just enough to cope,” to remain productive. All have suffered needless, devastating, harm.

To some, the Indiana Emergency Rule seems very strict. However, given the reality of drug abuse, illegal drug trafficking, accidental and purposeful suicides using opioids, and the growing number of people misusing a medical degree to set up “pill mills,” I choose to defer to the wisdom of the Indiana Senate and the advisory committee that worked with them. I believe they tried to first do no harm. In actuality, the Emergency Rule does not prevent physicians from prescribing opioids for chronic pain patients. Both physicians and chronic pain patients are protected when both groups stay within the parameters of this legislation. Anxiety over the new rules should be lessened as prescribers become familiar with the details.

If we are to be successful in striking the balance between battling drug abuse and providing effective pain care, we must begin with education, followed with continuous reassessment of the results of our words, our laws, and our practice of medicine. Succumbing to the hysteria currently surrounding the prescription of opioids for pain care will take away the hope that chronic pain sufferers might find pain relief “enough to cope.” This will propagate a great deal of harm to millions of our fellow citizens. Laws that lead to the arrest of compassionate physicians, who are genuinely attempting to help their patients, create a situation in which great harm could befall upon innocents.

Thanks are due to those state legislative groups who have not bowed to the hysteria that would ban these pain relievers. Thank you, Indiana Senate, for thoughtfully drawing up a law that does not harm the citizens of our state. We can only pray that other states will follow your example; perhaps even improve upon it. As long as they also…

First, do no harm.


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OBSERVING HOPE

There is a price to be paid for developing the skill of critical thinking. Its practice may cause us to focus on seeing the negative. In order to appear wise, we strive to unveil what is hidden, or lacking, in the ideas presented to us.  (In so doing, our perception becomes more narrowly focused on negative reactions to what we perceive.)

Once it was possible for this negativity to be pretty much confined to academic discussions, news op-eds, and a few people whose sole interest in life was complaining about everyone and everything else.  Today, it is more likely for everyone to attempt to outdo the latest—and possibly extremely well-constructed—rant against their chosen evil, or injustice, and the challenges from those who disagree.  It only takes moments to put our latest and best critical assessments of anything on line, for the world to see and challenge, immediately.  In order to keep the cause at the forefront, we almost have to live and breathe not only the reality of what is happening, but also keep up with what is being said about it.  Sometimes, we reach the point where we just can’t listen or read any more:

sane or well informed

             When this happens to me, I find that it is because I have neglected my own most important antidote to “negativity overload.”  I have forgotten to actively seek and observe HOPE.

There is an old story about the man who entered a stable and saw a young boy energetically (and messily) shoveling manure out of a stall literally covered in that substance.  Intrigued by the huge smile on the boy’s face, the man inquired as to what the boy was doing.  The boy never stopped shoveling as he replied “With all this manure, I know there is a pony in here somewhere.”

To state the obvious, it is sometimes necessary for us to recognize the signs of hope instead of dwelling on the signs of disaster, and to keep working with those signs until what is hoped for may be seen.  We must remind ourselves to seek, and then to see, where hope lies in a given situation.  We need to observe hope in the same ways that we observe holidays, respect, and just laws, for example.

Where have I most recently observed hope in an unjust, troubling world?

  • Just when I had become so disillusioned with all politicians that I didn’t want to see, hear or know them, I met a State Senator whose integrity is beyond question.  Who works ceaselessly to improve conditions in our state, and has led the way to legislation that is helpful and makes sense, despite the inability of other states to do so.  Whose smile and warm handshake extends to his eyes, and who actually listens when you talk to him.  There is hope.
  • Just when I gave up hope of receiving medical care that would take my own unique medical conditions into consideration; when I had given up and accepted that a computer would now and forever come between me and any meaningful conversation with my physician, I met a whole town full of physicians who do not allow a computer in the examining room while working with patients.  They make eye contact with their patients, and actually listen to them.  And even though hampered by the “15-minute per patient“ rule now in effect in most medical organizations, for that brief 15 minutes your doctor knows you as a person, cares about you, and does his or her very best to help you.  There is hope.
  • Just when I gave up hope that there would be any way out of the present hysteria over narcotic prescribing and the resultant rise of over 100 million chronic pain patients to the category of “discriminated against” and therefore oppressed, I read the following articles:

Education allows you to prescribe with confidence and optimize patient care. https://www.glms.org/Default.aspx?PageID=551 

And an even more exciting concept:

Basic Pain Care Certification

http://jamespmurphymd.com/2014/08/06/basic-pain-care-certification/

The first article provides for physician access to the latest information about pain management certification; the second is the strongest hope that I have observed that we can substantially address the problems of drug abuse and addiction, and still safely care for the needs of millions of patients with chronic pain. The reasons are outlined in the article.

Right now, this is a hope observed.  Like the little fellow in the stable, we have to work for it to make it real.  But all the signs are there:  as the boy said, “there is a pony in here, somewhere.”

What is the HOPE you need to observe around you?

 


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THE HEALERS

Wood-carving-pointing-at-the-Great-Zim-Ruins-590x393He was a handsome Shona man, in traditional dress, and he spoke English fluently with a refined British accent. His dark eyes could not hide his amusement at finding a middle-aged white female American in his place of business: A traditional healer’s hut, just outside of Harare, Zimbabwe. He was the traditional healer, and I had cajoled a Shona colleague into taking me to visit him because I was–as usual–almost terminally curious–this time, about exactly how the widely-known and respected traditionalist had so much success in his practice of the art of healing. I had just explained this to him, and asked if I might have a consultation.

“Certainly, you may” he began, “but you must understand that I cannot work with you the same way that I work with my own people, because you would neither understand nor believe everything that I tell you. I am willing to help you and talk to you as the white American person that you are, if you desire, and come as close as possible in that way to giving you the experience of the traditional healer that you seek.”

Now I was really interested. The Healer (I was beginning to think of him in capital letters, now) was obviously well educated, extremely intelligent, and willing to provide me with at least a glimpse into the world of his Shona ancestry. Yes, I wanted to see and hear what he had in mind.

trad healer workHe invited me to sit on some rugs on the floor in front of him. We were surrounded by the anticipated tools of his trade that he would routinely use to divine the causes and cures of the diseases of his own people. He did not use them with me.   Instead, he began by detailing a number of physical problems that I had:   I had suffered back pain for a long time, he told me. OK, I thought, that is good observation–I moved and walked like a person with back problems. Then he discussed the problems that I have with my right foot. He was continuing to be very observant– the scar from the surgery to correct a trimalleolar fracture three years previously was now very, very faint.

He progressed in this vein for a short period of time, then, smiling mischievously, he informed me that my (long deceased) maternal grandfather was providing him with information about my spirit that needed to be addressed. I was suitably impressed with facts from my personal history that he then presented, but I was also aware that fortune tellers in my own country are often able to elicit and/or supply the same kinds of information with equally uncanny accuracy.

At the end, though, he began to advise me about how to correct some actual imbalances in my life. Here, I was able to completely appreciate traditional medicine’s understanding of the reciprocal relationships between the health of the individual and the health of the family, and/or the community. Additionally, his advice included definitive steps to renew a relationship with the earth itself, and a new understanding of the value of doing that. When I finally took my leave from him, I felt renewed and refreshed, yet he had done nothing but talk to me, reflecting back to me how he saw my life and how I could optimize my physical and spiritual health. (Note for Epilogue: It worked.)

Later that week, while on the plane returning to my home in South Africa, I reflected on questions of how this healer had both exemplified the traditional qualities of the Healer ever since ancient times, and used very modern understandings of the potential needs of someone from a culture not his own. I compared my visit with him to my experiences both working with and professionally consulting physicians in my own home country of the USA. When did the most effective Western healers I knew utilize similar tools to those of this Healer who had the wisdom and knowledge from ancient times, combined with very modern knowledge and skills?

  1.  Acknowledging my cultural roots, the African healer immediately and consistently maintained eye contact with me. This was all the more useful to me, because for months I had struggled to properly show the respect of downcast eyes demanded of many southern African peoples in the presence of a superior; in this instance, his being both male and having the status of Healer, I should have maintained this respectful position. If you who are of my culture believe that this is easy, you should try it sometime! I had learned that I must ignore my compulsion to earnestly seek eye contact with male African leadership (in order to allow my honesty and concern to be evident). In those situations, it would have proven the exact opposite and offended the one whose support and trust I sought. This Healer, however, set aside his own pride and dignity to allow me to be myself and to gain the most from our visit. Western physicians who maintain eye contact—who actually SEE their patients, and allow themselves to be seen in this personal intimacy—are already ahead in the process of healing. Western healers who are also well informed about the cultures and habits of the populations they serve, are best equipped to provide real healing to those peoples.
  2. The African healer, prior to any real conversation, conducted a visual examination that was both careful, yet discreet, but thorough enough to pick up on major issues of my medical history. He then confirmed his observations verbally with me. While Western physicians rely on carefully questioned medical histories, regarding both past and present issues, the most effective of these also incorporate information gained from careful and complete visual examination of the entire patient, including how they walk, move and sit. Even though the information acquired may not be immediately relevant, they might take the time to confirm their observations with the patient.
  3. Having dispensed with any possible physical symptoms that might need to be addressed, the African healer moved on to more spiritual, and/or psychological problems. Again, he provided an overview of his observations (as revealed to him by my grandfather, in his interpretation), and began discussing how to address any that I agreed needed to be addressed. The most effective Western physicians of my experience incorporated a concern for their patient’s total well-being, and sought to first verify, then connect any need to integrate this knowledge with their treatment of the current condition.
  4.  Both physical and psychological/spiritual issues were connected to my family and my physical environment by the African healer, who utilized both my family history and my present environment—including the earth itself—in his treatment plan. Western medicine acknowledges these elements of many illnesses, but traditional cultures never separate the patient from family, community, and earth in the diagnosis of illness, as well as in the treatment thereof. In Western medicine, if we have to address these “side” issues, they are usually referred to other specialists. From my experience, however, effective physicians still retain a healthy respect for the role of the social and physical environment of their patients, and how these may powerfully effect healing.

 

For a long time, I missed the experience of a number of these comforting and important characteristics of the Healer when it was necessary for me to seek treatment for the ailments of increasing age. It has been both a blessing and a deeply healing experience for me to find myself in a place where so many physicians, as well as other health care providers at all levels, consciously hold to the highest and most humane standards of the sacred calling of Healer, even while embracing all that modern medicine adds to that calling. I can’t praise them enough for their courage, and for being willing to add all these things to the time-consuming and demanding professional lives that they must keep in balance.

8783005-surgeons-and-medical-assistant-wearing-mask-and-uniform-operating-patient Nor can I stress with enough force and determination my belief that this calling, and the fulfillment of the vocation in its highest standards, is allowed only to human beings who have been gifted with the empathy, compassion and commitment to carry it through successfully.

 

IT CANNOT BE FULFILLED BY INSURANCE COMPANIES, LEGISLATIVE BODIES, BUREAUCRATIC STRUCTURES OF MEDICAL CORPORATIONS, OR COMPUTER PROGRAMS!

8950296-smiling-doctors-with-stethoscopes-over-blue-background