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What is the Fine Art of Healthcare?

picture of me in FAOH wkshpI have developed an innovative and interdisciplinary program at the University of Miami that uses art to hone observation and communication skills in the service of clinical diagnosis. Working in partnership the Lowe Art Museum, Miller School of Medicine, School of Nursing and Department of Psychology have filled a gap in medical education to strengthen healthcare.

Over the last five years I have read over 100s of publications, watched a number of videos, and listened to webinars that explore ideas, challenges and solutions for healthcare in the 21st century. Through weekly blog posts I look forward to dialogue on these issues.

 

Toward the clinical humanities: How literature and the arts can help shape humanism and professionalism in medical education Posted January 6th, 2014 in Humanities in Medicine, Professionalism Humanities, by Joanna Shapiro, PhD

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Many articles, panels and presentations have focused on questions regarding the relationships (if any) among the humanities, humanism, and professionalism. These questions may never be definitively answered (nor, perhaps should they be). Nevertheless, below I share some of my own in-progress thoughts that I hope add light not heat to this ongoing debate.

Professionalism itself is a contentious subject, with many competing definitions. However, to be meaningful, professionalism must, as Robert Coles knew, engage the moral imagination (ref 1). To me, the most important meta-questions a future physician can engage with (preferably every day of her life) are fundamentally moral ones :

  • What kind of doctor do I want to be?
  • Who am I and who can I become within the practice of medicine?
  • How do dominant discourses in medicine and society influence me, my patients, and our community in negative or positive ways?
  • What is my commitment/responsibility/ to my patients and my community and how can I best serve them?

The questions above should be asked by anyone and everyone who enters the health care world.  As a matter of fact the questions can be used to guide all professions.

Read article:

 

Doctored: The Disillusionment of an American Physician, by Sandeep Jauhar

doctoredIn ‘Doctored,’ Shortcomings of Health Care and Doctor
Sandeep Jauhar’s new memoir, “Doctored: The Disillusionment of an American Physician,” tells the story of two midlife crises: the author’s own, and that of modern American medicine, now in about its fourth decade under managed care. Both prove to be frustratingly intransigent, with only small signs of hope.
Dr. Jauhar has traveled the paths of personal and professional angst before, in his 2007 medical memoir, “Intern: A Doctor’s Initiation,” which recounts his trying first year of residency at New York Hospital in Manhattan. In that book, he wrote: “For me, it was a disillusioning time; I spent much of it in a state of crisis and doubt.”
Life as a full-fledged physician doesn’t become much better, at least not for Dr. Jauhar, who takes his first job at Long Island Jewish Medical Center and becomes the director of its heart failure program. (He is also an occasional contributor to The New York Times.) Full of ideals about saving lives and providing compassionate, ethical care, he finds himself underpaid, overworked and pressured to cut corners in every direction.

In this, we gather, he is not alone. “Doctored” describes a profession that is like so many of its patients: full of malaise and desperation. Doctors are reported to commit suicide at a higher rate than other professionals, and Dr. Jauhar cites a 2008 survey in which only 6 percent of 12,000 physicians rated their morale as positive.
Then again, Dr. Jauhar is constitutionally dissatisfied. Just ask his father, who says of his wife, the author’s mother, “Like you, she is not a happy person.” (Some of the best scenes feature the father, who comes across as comically histrionic, neurotic and self-absorbed. “If you lose your job,” he tells his son, “we are finished. I will be the first to have a heart attack!” And then he tosses in: “And make some friends, Sandeep. You have no friends.”) Then Dr. Jauhar has his wife to contend with. Also a doctor, she keeps putting off her own job to stay home with their toddler, while telling her husband to bring home more money. “Money doesn’t buy happiness,” he counters. “Yes it does!” she replies.
The author is sometimes operatic in his complaints. Worried about his mounting pressures, he writes, “My obligations were like the concrete embankments along the expressway, preventing me from getting off.” He tries yoga, psychiatry, jogging in the rain. He describes his stomach troubles, his sleeplessness, his bad moods.
To relieve the money stress, he does something he dreaded and hoped to avoid: He moonlights on weekends and evenings for a private cardiology practice. It’s in these Faustian passages on the commerce of medicine that the memoir becomes an extraordinary, brave and even shocking document. Dr. Jauhar’s sharply observed anxieties make him a compelling writer and an astute critic of the wasteful, mercenary, cronyistic and often corrupt practice of medicine today.
He is brutally honest, not just about his own shortcomings, but about those of colleagues, bosses and institutions. There is the cardiologist who pressures him to perform expensive, unneeded diagnostic tests; the hospital, which wants him to see patients for ever-shorter sessions; the pharmaceutical company that pays him on the side to give “lectures” but will let him use only its slides and data.
Dr. Jauhar sees a 74-year-old patient who has been referred to the hospital for heart-valve surgery. He recommends against the operation because she is frail, her symptoms are managed by medicine, and the surgery is risky. But he is told to approve it anyway so he doesn’t insult the referring physician. “If you mess up relations with a referer,” his mentor says, “you can get fired.”
If things are broken in the world of managed care, there’s plenty of blame to go around. The insurance companies have taken away doctors’ autonomy. The fee-for-service model leads to overtesting, disorganization and redundancy. The fee incentives and a culture of liability lead to what Dr. Jauhar calls “wanton consultation.” As Alexander the Great once put it, “I am dying from the treatment of too many physicians.”
But it’s not just the system, Dr. Jauhar writes. Many of the doctors themselves are greedy, defensive and untrustworthy — including, at times, himself.
Of his collusion in ordering unnecessary nuclear stress tests, he writes: “Of course, good intentions didn’t exonerate me. Even beyond the wasted money, what about the false positives, the radiation exposure, the downstream invasive procedures?”
He added, “I used to despise the unethical behavior of doctors in private practice, but in reality, I was no better than they were.”
In trying to appease his wife, he ends up hating himself. Although it seems to take him a painfully long time, he finally figures out they can reduce household expenses by moving out of Manhattan. Focusing on just one job, he can strive to be the kind of doctor he hoped to be. And that means the kind of doctor who not just treats patients but cares for them.
Caring for people is why most doctors go into medicine in the first place. Dr. Jauhar’s greatest joy comes from these small day-to-day exchanges, even if his time with patients is short and increasingly circumscribed. Yet in the profession as a whole, the trust that patients place in their doctors has never been more at risk.
Perhaps the solution to both midlife crises is “doctors focusing on the their noble craft, their relationships with patients, the stuff over which we have some control.”
“Ultimately,” he concludes, “this may be the best hope for our professional salvation.”

Why Doctors Commit Suicide

18-Egon_Schiele_059There is no doubt in anyone’s mind that doctors are under an extreme amount of pressure but there is little that seems to be done about it.  In a NYT’s article entitled Why Doctors Commit Suicide (see here)  the article explains that as many as 400 doctors a year kill themselves.
We now know that doctors are not gods and need a way out; somehow someway to express their anger, fears and frustrations:  “We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at the first incorrect prescription we ordered, the embarrassment of not knowing an answer on rounds that a medical student knew. A medical culture that encourages us to share these vulnerabilities could help us realize that we are not alone and find comfort and increased connection with our peers. It could also make it easier for residents who are at risk to ask for help. And I believe it would make us all better doctors.”

Cardiologist Speaks from the Heart about America’s Medical System

Norman Rockwell

Saying Grace, Norman Rockwell

The honesty of this interview was a sober awakening to some of the issues that effect physicians on a daily basis.  In the interview on NPR, by Terry Gross, here, Dr. Sandeep Jauhar speaks candidly about doctors who face challenges, both financially and ethically, because they are mired down with paper work and malpractice insurance costs and he believes that a large part of the problem with our medical system is that doctors send their patients for too many tests; and there are multiple doctors, for one patient, and they are “not communicating with one-another”, so there is no coordinated patient-care.  Another point is that doctors are dealing with “defensive medicine” which ends of costing billions of dollars.

Dr. Jauhar goes on to say that as a salaried doctor he isn’t so concerned with reimbursement fees so one of the incentives to send out for more tests isn’t as great; that doctors who have their own medical practices, and are worried about overhead fees and liability insurance have more of “need” to send patients for expensive tests.

Can it be that one way to help the situation may start with communication and reimbursing for “care coordination”.  This is one positive part of the ACA; medicare will now start reimbursing for care coordination.

When Patients Read what Their Doctors Write, by Leana Wen

opennotesfinal7_wide-87daf1eba6d6f1f1ebea18692a6d855db1b39f89-s40-c85There’s a movement happening: some doctors are letting their patients read their notes.  What does this mean for the medical field? ” After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there’s more trust and more accuracy.”

Read article here:

 

The Experts: How to Improve Doctor-Patient Communication

The DoctorAs a follow-up article to the WSJ’s April 8th article:  The Talking Cure for Health Care, an article called:  The Experts:  How to Improve Doctor-Patient Communication (see article here)   A group of medical and health care policy experts discussed what they believed to be important skills for future doctors and good communication, active listening and team work ranked high on all of their lists.

 

The Talking Cure for Health Care: Improving the ways doctors communicate with their patients can lead to better care—and lower costs

WX_Talking_Cure

The Talking Cure

Where was this article years ago?!  It seems so simple, yet according the IOM more people die everyday because of miscommunication.  The article: The Talking Cure for Health Care, in the Wall Street Journal, dated April, 2013 (read article here) explains that “Doctors need to work on their people skills. It’s something patients have grumbled about for a long time.  Doctors are rude.  Doctors don’t listen. Doctors have no time.  Doctors don’t explain things in terms patients can understand.”  Easy for the Wall Street Journal to say but how can doctors or future doctors get around the complicated medical system, in which they are mandated to see a patient in only 15 minutes.  It hardly gives anyone enough time to ask questions and get the informed responses needed to find a solution.

Apparently medical schools, health systems, malpractice insurers and hospitals are trying to help doctors improve their bedside manner.

The Structures of Growth: Learning is no Easy Task, by David Brooks

One might ask themselves what does a NYT’s op-ed column have to do with medicine?  In today’s NYTs (June 17, 2014), David Brooks comments on getting better at something and how really difficult it is to reach the pinnacle (or as he says, “the tipy-top”).  Because for those who have accomplished tipy-top growth has not been linear but has evolved through time.  And that people who are striving to the best reach plateaus (see article here).

Growth in any field requires repetition until it’s ingrained and it is only just that rote memory. I started taking sailing classes and our teacher told us to do knots “over and over and over again until it’s muscle memory”.  I played tennis for years and all we did were drills (until we played a match).  It wasn’t until we were out on the court did we realize that those drills really were worthwhile.

What medical students need to understand, in my opinion, is that a knowledge base is a must, and until they really understand a disease and all of its moving parts can they begin to make differential diagnoses (and then throw out those diagnoses and start over) and get ‘creative’.  When I say creative I don’t mean experiment around with someone’s life but they must be able to connect with their patients; to listen actively, ask questions, probe, fill in the gaps, in order to really

The Call of Stories, by Robert Coles

Man with head

The Call of Stories

After reading a post, submitted by a professor of literature, on the importance of infusing the humanities into medical education, and discussing a book, by Robert Coles (who was a medical professor/doctor, at Harvard Medical School) I decided to buy the book.  It’s filled with all sorts of wonderful recommendations for books, that can be helpful to medical students, in understanding stories and their importance.  Coles discusses authors like William Carlos Williams (who was a medical doctor), Walker Percy, George Eliot, George Orwell, Tolstoy and James Agee.  These are just a few, out of many, that he discusses.  Coles (who was a psychiatrist) believed that by delving into great works of literature, to try and understand what motivated important characters, in said works, would help him in his own practice.

I highly recommend The Call of Stories for anyone interested in great works of literature!

The Physical Exam as Refuge by Danielle Ofri

Physical exam

‘Have a Medical Examination: keep sickness away

That’s it put down the computer and your cell phone and spend 15 quality minutes looking at and listening to your patient.  In the Well blog of the NYT’s a piece was written by Danielle Ofri that points out what a physician can learn by touching the patient.  Maybe the term touching has a deeper meaning?  (Read article here)