Says Who??

Verstehen, through shared perspectives


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I AM NOT A ROBOT (not a Luddite, either)

robot pt

Last summer my beloved Mercury Milan decided to give me mechanical problems, for the first time in the five years I had owned it. It simply refused to start occasionally, without any causality that my mechanic or I could discover. After several nerve-wracking months of this (along with the inevitable and infuriating responses from mechanics: “It starts just fine for me”), I was ready to drive it into the Ohio River. It probably would not have started so I could get it there, though.

I finally convinced a mechanic at the dealership to put the car on the computer for diagnosis. As both a former nurse and present patient, I liked that word diagnosis, and had no qualms about using it for the vehicle I had anthropomorphized by naming it Mahitabel, projecting both positive and negative emotions and reactions on its “behavior,” and more recently developing a love/hate relationship with it. The diagnosis, according to the computer, was that on several occasions in the past few months someone had tried to start my car with a key that did not belong to the car. Therefore, it did not start.

It took about ten more minutes of questioning by the mechanic, who proposed the possibility that someone was trying to steal my car, and answers by me insisting that this made no sense at all, before he looked carefully at my car key. It was bent, and one tiny place may have been chipped. He made me a new key and my buddy Mahitabel and I have traveled together predictably and smoothly ever since.

My point? The computer (a machine) understood more about my car (a machine) than both the mechanic and the owner. Yet both the mechanic and the owner had to engage in some research and analysis on the human level before the “diagnosis” could be corrected and treatment applied. The computer supplied data based on its programmed knowledge of the vehicle; the humans provided the ability to utilize both inductive and deductive reasoning, applied to real-life, present-world situations, to ascertain the actual problem.

This brings me at last to the reason I am writing this post. Two years ago, I posted “The Healers,” in which I compared the observations and insights of an African traditional healer with the best of today’s physicians, noting that in each case the healer was most effective when working as a caring and observant human healer to a human patient. I concluded that computers could not take the place of any physician true to his or her calling https://www.maryleejames.com/2014/08/08/the-healers .

Two years later, I have more reason than ever to challenge the efficacy of computers in the exam room of a physician’s office. In fact, I would go so far as to say that along with insurance company rules and overreaching legislation intended to make physicians toe the (sometimes contradictory) lines drawn by groups of people who lack the training and calling of the physician, the present demands of computer program doctoring have the capability of being the last straw that finally destroys medicine as we know it.

As the title to this article insists, I am not a Luddite. I love technology, especially when it works. I love the capabilities of the internet, and the ability to keep up with friends and relatives both far and near. I enjoy being able to get online on a busy day and save myself hours of shopping, and have the desired object delivered to my door within 24 hours. I love needing an answer quickly, and finding it; needing an outline of resources for research, and locating them with ease. But it is also these answers and resources that become the problem. I have to exercise my ability to discern the junk from the credible; the scams from the honest reports, because all that this wonderful piece of machinery can provide me with is the data that has been entered, just like my experience with the computer at the car dealership. It can’t make human judgements for me. Without my education and my experience, the overwhelming amount of unquestioned data could get me into a lot of trouble.

Therefore, I am concerned about the time my physicians must spend entering data about me into a limited machine. I am a sociologist, after all, and acutely aware of the reality that whenever humans are the subject of analysis, results are immediately complicated by a lack of predictability, and of psychological understanding; accuracy is also complicated by the uniqueness of every human being and his or her response to a given situation, whether physical or otherwise. And no situation for any patient is completely within the realm of any one discipline. We are affected by more than our pain—we are emotionally affected by its consequences, or by outside considerations that have nothing to do with the pain, but that affect our lives. We are affected intellectually by our understanding of the meaning of the pain, and what it may mean for ourselves and those closest to us; this translates again into emotional effects, which may or may not complicate the situation of the pain and therefore any understanding of the real diagnosis and best treatment.

That only considers the tip of the iceberg. It is dehumanizing to both doctor and patient to reduce medical practice to the inadequate data that can be acquired from, or placed into, a machine. It is dehumanizing to try to explain one’s most frightening and intimate problems to someone who may never look you in the eye, or ask a question not required by the computer program. Especially when that computer operator is frustrated because he or she is not familiar with the program, or because it is not working properly. How do you know if the diagnosis or treatment is going to be safe and effective under these circumstances?

Worse, how do you trust that the information entered into that computer is correct? I can’t tell you how often I have read reports of my office visits only to wonder whose record has been confused with mine. I have read “patient states” something I not only did not state, but that wasn’t true. I have read reports of findings of physical examinations that never took place….and also failed to accurately reflect my physical condition at the time. Yet in years past—even after computers were commonplace—when doctors simply dictated their reports of office visits the results were informative, correct, and usable. I know, because for years I used to type up those dictated reports, and saw letters of thanks from recipients like other physicians, insurance companies, and physical therapists who were able to understand and make use of them.  I even learned a lot of medicine from their logical presentation of cause, effect and treatment.

Even more important, however, is the effect of human touch: The caring hand on a shoulder while explaining a difficult prognosis; the gentle holding of the hand of a terrified patient. The healing effects of caring human touch cannot be measured, and certainly cannot be replaced by a machine of any kind.

I do not propose to take computers away from medical practice, but only that the computers not take the physician away from medical practice. We were intelligent enough to invent computers, and I would hope that we would be intelligent enough to discern the times when their data gathering and sorting capability can be used to best advantage, while the very human, intuitive and caring abilities of our physicians remain in the human realm where they are most effective. Perhaps then physician suicides might drop from more than 400 each year, and more brilliant young people might consider the medical field desirable.

 We need human physicians, because we are not robots.

robot doc


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“ALTERNATIVE” VS. “SUPPLEMENTAL” PAIN CARE

The latest heresy propagated by the misguided War on Drugs, particularly the version that is an opiophobic war against pain patients and their physicians, is that engendered by both pop and professional psychology. In short, it is the claim that to control one’s own pain by controlling thought processes is a better alternative than pain medication for chronic pain. Thus, mental self-control is added to physical therapy, diet, and exercise, as purveyors of these so-called better methods hope to gain the income they saw going to legitimate, board certified pain management physicians who actually provide relief from pain. The heresy is that theirs is an alternative therapy, when in fact for far too many chronic pain patients it is at best a supplement to actual pain relief by medical methods.

Before addressing this heresy, allow me to outline my credentials for debunking it. For 46 years I have suffered from degenerative disc disease. At the present time, there is no part of my spine unaffected by this process, no part that fails to add to the pain. At four different places in my back and neck, there are outgrowths (stenosis, protruding disc material, arthritis and one spinal meningioma) intruding on the spinal cord itself, with resulting radicular pain, weakness in extremities, and the potential for paralysis. In addition, 14 years ago I was diagnosed with Type II Diabetes, with severe diabetic neuropathy. Walking produces paradoxical pain and numbness, often resulting in missteps and falling if I do not actually see where my feet are.

Because I have always been unable to take pain medications (as well as many other medications), early on I accepted the responsibility for dealing with my pain pretty much on my own. To the extent possible, I considered it a “mind over matter” situation and learned to compartmentalize the pain while I worked full time all those years, was divorced and learned to support myself, gained first a nursing certification and then a Ph.D.  While these “alternatives” to pain medication made life possible up to a point, it remained very difficult and the control was as often geared toward forcing myself to keep going as it was to training my mind away from the pain.

I held positions that were demanding and stressful, often working 60-70 hours a week and rarely getting more than 3-4 hours sleep because of the pain. As both a nurse and a professional social scientist, I was knowledgeable about the supplemental psychological and physical methods I was using. But no matter how well I used distraction, being useful, loving my job, and being positive; no matter how I accepted my pain as simply another part of my life and tried to minimize its presence in my thoughts and mind, it continued taking its toll on my body and my life. THESE SUPPLEMENTAL METHODS OF PAIN CONTROL WERE INSUFFICIENT, NEITHER REMOVING MY PAIN NOR REDUCING ITS EFFECTS ON MY BODY.

Three years ago, all the defects in my efforts to control chronic pain came to a devastating but inevitable concluding failure. The discs on either side of a lower thoracic vertebra “imploded”—displacing the vertebra, and creating scoliosis from that point upward in my spine. The pain, added to what I already suffered, was too excruciating for me to fight. Additionally, other disease processes were becoming worse from the long-term stress: my diabetes was out of control, I had cardiac problems, allergies, and severe gastric issues. I retired from full time work at the age of 72, and moved to a city where I hoped to find good medical care and a church family where I would feel at home. I did not think it would be for long, and often my pain was so exquisite, so unrelenting, that I prayed for the relief of death.

That, in summary, is the story of my life without pain medication. It was a long nightmare of having to give over so much of my personal energy to keeping pain levels manageable that I had nothing left for the responsibilities of any kind of family or personal life. Pain was the constant companion of my days and nights for so many years that I had forgotten many of the pleasures of a life free of pain. Don’t get me wrong—I am not looking for the reader’s sympathy. I am simply stating facts, not just for myself, but also for the millions of chronic pain sufferers in the USA who also live with untreated or undertreated chronic pain because of unjust and unreasonable regulations about what kind of treatment and how much of it they are allowed. Regulations too often created by people without the credentials or experience to understand the “unintended consequences” of their need to control a situation that has nothing to do with legitimate pain care, and everything to do with a dysfunctional understanding of addiction.

There is obviously more to my story, and that is because my selection of this city proved to be an excellent choice. Here, I was referred to a pain management physician with the skill, compassion and integrity to not only medically provide periods of full relief from my pain, but also to help me find a pain medication that I am able to tolerate. I now know with certainty, for the first time in my life, that the so-called “alternatives” to pain medication do not qualify for the term “alternative.” They simply are NOT EQUAL to the task of relieving severe, chronic, disabling pain that takes its toll on both mind and body. They can be excellent supplemental methods for maintenance of the effects of tolerable levels of pain (which differs in EACH AND EVERY patient, as do the effects of all forms of pain management) but they are no match for the pain suffered by those of us whose lives of debilitating chronic pain are defined by pain management or the lack thereof.


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THE WAR ON DRUGS HAS BECOME THE WAR ON PHYSICIANS AND PATIENTS

The following article first appeared May 20, 2014 as a guest blog on Dr. Jeff Fudin’s http://paindr.com/blog/ website under the title Patients with Chronic Pain Syndromes are Not Idiots http://paindr.com/patients-with-chronic-pain-syndromes-are-not-idiots/.

From the early days of human habitation on this earth, societies have revered (and also feared) their healers. Even now, from Africa to South America, and wherever modern medicine is difficult to find, the skills and knowledge of healing have been passed from generation to generation of traditional healers. In rural areas of our own nation, many communities still seek medical assistance from ‘grannies” who rely on local herbs and traditional lore to help their neighbors.

So how has it happened that in the 21st century, one of the most technologically advanced nations on earth appears to be conducting a campaign against modern, trained and licensed physicians that echoes some ancient, primitive fear of the healer? We live in the age of Reason. We understand science, including anatomy and physiology, and understand that healers do not possess magic powers that might either hurt or heal us.

Despite this advanced understanding, we have allowed lawmakers and insurance companies to turn our healers into objects to be bullied, threatened, arrested and tried under charges of murder, with prosecutors demanding a death penalty when they have no evidence whatsoever that such a crime took place.[i]

After years of study and practice, sacrifice and struggle, 21st century physicians enter their professional world with dreams and aspirations already shattered. Many have student loans that limit their disposable income for many years into the future. Many more will find that the option of setting up a practice on their own is an unattainable dream – that they will be working for larger organizations and answering to employers who lack both medical degrees and understanding, where the bottom line is profit driven. All will have to deal with insurance companies that limit what they are able to do for their patients, no matter how much the patient might need the medication or procedure. Those companies have even at times contacted their patients, without the knowledge of the physician, and suggest other treatments or tell the patients to ask their doctors for a different treatment[ii]. Somebody tell me – have the laws against practicing medicine without a license been repealed?

And that is not the worst of it. Today, a physician who tries to treat patients according to the knowledge and skills that they worked so diligently to earn is now at risk of losing everything—their licenses, their homes and families, and even their own lives. ALL THIS, NOT BECAUSE THEY HAVE DONE ANYTHING WRONG!!! On the other hand, they can’t seem to do anything right. If law enforcement doesn’t destroy them, they are in danger of being robbed or even killed by drug-seeking patients. [iii]

I could easily believe that it is the failed war on drugs that has created the need for law enforcement to redirect our attention by turning the war against physicians – and their patients, who will suffer without medical care. Sociologists like myself frequently inquire “Who Benefits?” when deciphering seemingly irrational social behaviors. In this case, the lawmakers and enforcers themselves would look like people who would benefit from a better public image by this redirection of the public’s attention.

They say it is because the physicians prescribe too many “pills”, and turn their patients into addicts. Not true. Only a small percentage of patients who follow the orders given by the physician become addicted – addiction is a disease that occurs most often when drugs are abused, against medical advice. Most abused drugs do not come from physician’s prescriptions, but from families, friends, unsecured home supplies, or drug dealers.[iv] Dependency may occur, on the other hand, because people must depend on the medications that help them. Physical dependency is not unique to opioids alone, and can be resolved by tapering when the need for the medication is over. A similar approach is needed with several medication classes such as antidepressants to avoid serotonin withdrawal or beta blockers to avoid hypertensive crisis. Because lawmakers and others often incorrectly blend the lines, differences between physical dependence and withdrawal, we allow people and organizations with vested interests to feed our fears and turn us against the only people qualified to help us.

It is no wonder that over 80% of practicing physicians are reported to have stated that they do NOT want their children to become physicians. It is no wonder that more than 400 physicians are reported to commit suicide, annually.[v]

Why are they targeted, when they are not the problem? Let’s look at the real problem here: Addiction is real. Drug-related crime is real. Drug cartels that launder their profits and use some of the “cleaned” money to lobby politicians are real. Even MD degreed providers who misuse the privilege and set up “pill mills” are real (I refuse to call them physicians). There are solutions to all of these problems, and none of them include punishing physicians and other licensed clinicians with the goal of securing political points. We must stop making the problem worse, and focus on the real lawbreakers. We do know who they are!!

I write this letter, ironically, perhaps, because I am not able to take pain medications or many other drugs that could mitigate against the chronic pain that I have lived with for more than 45 years. Like many older people (who, by the way, may be less likely to become addicted to drugs because of the changes age brings to our physiology[vi]), chronic pain (from degenerative disc disease) has exacerbated other illnesses and ultimately severely limited my life. I have written this letter in gratitude for the four physicians who compassionately and patiently took the time to untangle and address the mingled symptoms that I presented with a few months ago, and who have given my life back to me despite my limited ability to process medications. (And yes – one of those four physicians is a board-certified pain management physician. There are other ways to manage pain when patients cannot take drugs.) With some understanding of what it must take to hold on to that compassion and professionalism in an irrational and vengeful world, I declare that these physicians, and physicians like them, are the true heroes of our day. We need to let them know.[vii]

ENDNOTES

[i] Trial Verdict: Dr. Baldi Not Guilty on All Charges http://whotv.com/2014/05/01/baldi-trial-not-guilty-on-all-charges/
What are Patients to do when Law Enforcement Closes Clinics? http://missoulian.com/news/state-and-regional/ravalli-county-health-officer-says-patients-of-raided-florence-clinic/article_cf2e1690-bac0-11e3-848e-001a4bcf887a.html
Ex-doctor faces families in murder preliminary hearing http://www.news9.com/story/25395877/ex-doctor-faces-victims-families-in-murder-preliminary-hearing

[ii] Here I cite my own experience with the insurance company that covered my last place of employment. Over a period of several years, my colleagues and I received messages from the insurance company about changing our medications – such as when I was on a prescription medication for GERD, the company insisted that I must discontinue it and take an OTC medication because unless I did, they would discontinue payment on the prescriptions. We were also advised in frequent mailings to discuss alternative treatments with our physicians.

[iii] The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …
Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html

[iv] “For this crisis physicians take the brunt of the pundits’ blame, despite the fact that more than two-thirds of the diverted medications are acquired from family, friends, and acquaintances – not from a prescription by their doctor. http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

[v] Pain Physicians Have High Rates of Burnout http://goo.gl/P3z1cY
Dr. Gary Shearer: Suspended Northern Kentucky pain doctor dies of ‘suspected suicide’ http://www.wcpo.com/news/local-news/boone-county/florence/dr-gary-shearer-suspended-northern-kentucky-pain-doctor-dies-of-suspected-suicide

Physician Suicide http://t.co/4vhF63eD6NReferences from this article:
1.Adams D. Physician suicide: searching for answers. American Medical News [serial online]. April 25, 2005;Available at http://www.ama-assn.org/amednews/2005/04/25/prsa0425.htm.2.Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. Jun 18 2003;289(23):3161-6. [Medline].
3.Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. Jul 2004;57(1):1-4. [Medline].
4.Holmes VF, Rich CL. Suicide Among Physicians. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle. Washington, DC: American Psychiatric Press; 2004:599-618.
5.Middleton JL. Today I’m grieving a physician suicide. Ann Fam Med. May-Jun 2008;6(3):267-9. [Medline].
6.Noonan D. Doctors who kill themselves. Newsweek. Apr 28 2008;151(17):16. [Medline].
7.Petersen MR, Burnett CA. The suicide mortality of working physicians and dentists. Occup Med (Lond). Jan 2008;58(1):25-9. [Medline]. [Full Text].
8.Worley LL. Our fallen peers: a mandate for change. Acad Psychiatry. Jan-Feb 2008;32(1):8-12. [Medline].
9.Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. Nov 2011;213(5):657-67. [Medline].
10.Hendin H, Maltsberger JT, Haas AP. A physician’s suicide. Am J Psychiatry. Dec 2003;160(12):2094-7. [Medline].
11.Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).

[vi] “indeed, bad choices, bad behavior, and drug misuse lead to crime, accidents, social instability, and addiction. The developing adolescent brain is particularly susceptible to addiction, while the elderly brain is practically immune.” http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

[vii]“ Unless patients wake up and fight for the providers of care, we are headed for the sickest system in the world.” http://www.kevinmd.com/blog/2014/03/dissatisfied-doctors-provide-good-patient-care.html …


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Has the War on Doctors been Lost?

According To Margalit Gur-Alie (founder, BizMed), “There really is no war on doctors. There is a war on patients, and doctors are merely collateral damage [emphasis mine]. You [doctors] are an exploitable asset, to be bought and sold like cattle…” http://www.kevinmd.com/blog/2014/06/really-war-doctors-theres-war-patients.html. In this ingeniously constructed article, Gur-Alie turns the entire idea of “social capital” –- heretofore a positive concept within which we value human dignity, and also show how the poor and oppressed of the world can become the authors of their own freedom-—on its head.

Assigning the term “social capital” to patients, doctors (formerly wealthy and powerful, by inference) as social capital are nullified at worst, and become mere agents of the “owners” of production –- in this sense, the insurance companies, and probably beyond them the international economic cartels that control them –- doctors whose sole purpose is to maximize the productivity of the “covered lives” assigned to them.

The article is interesting on several levels. One of the benefits of growing old is that you get to watch old theories die and be reborn in new calls to action on behalf of a new chosen population. In this neoMarxist work, we see the Bourgeoisie (both new “owners” and the old “owners” – doctors) on one side, and the Proletariat (workers, or patients in this case) on the side populated by the oppressed. The final section of the paper is a manifesto, calling the (workers of the world) patients to arm themselves with knowledge, and unite to save themselves.

I’m all for it! To a sociologist, this is conflict theory doing its job. My problem with the article is that the conflict perspective is only one of the many that are useful for understanding any complex social issue. Like any perspective used alone, it can narrow our understanding of the issue to the point of defeating its own cause by essentially disregarding facts that don’t fit in its worldview, even while stating them. In this article, for example, Gur-Alie claims that there is no war on doctors, then spends the first four paragraphs of the article exposing what has happened, and is continuing to happen, specifically in order to disempower the medical profession as a whole.

By implication, the author is saying that the war on doctors began when the first HMO opened its doors, and is proceeding as scheduled to the inescapable “new world order” in which doctors will be mere employees, judged only by their financial productivity (like piece-workers in a factory?). Here is where I have trouble understanding whether the author sees this as a bad thing, or merely a fait accompli.

At any rate, whether near its end or only begun, there is a war on doctors. And, as so clearly outlined by Gur-Alie, on patients as well. It is manifest in the current drug wars, and in the attempted coup being conducted by insurance companies to claim ownership of medical practice.

This war may become as life-threatening as any fought with the more conventional weapons of destruction.