Thursday, April 23, 2015

Why My Patients Are Like Herbie Hancock Albums

So I've been reading a lot of autobiographies lately. Well, reading and listening to them - audiobooks are one of my new favorite things. I especially love listening to autobiographies because they're usually read by the author him-/herself. Hearing them tell their own stories in their own words can be such a cool experience. The latest stories I've been told are those of the great jazz piano player and electronics explorer Herbie Hancock. Now entering his 7th decade of making music, Hancock's book could be used as a primer on music history, and he discusses his own unique experience with each new wave of musical change.
Herbie Hancock was a proliferative musician with over 40 albums of predominantly instrumental jazz. With his last three albums he decided to explore vocal jazz. I had originally glossed over these albums, not being big on vocal jazz when they came out. But hearing Herbie Hancock talking about the thoughts behind these albums, the stories behind their recording, and the incredible musicians and ideas that made them possible...I went back and listened to them. And I couldn't believe I had not skipped out on them before. There's so much great stuff on these records!

As I listened to Herbie reflect on his career, I couldn't help but be led to reflect on my own education and fledgling career. And how patients' stories, in their own words, are what will help me see their problems in new light.

My medical school class is officially post-Match Day (actually, it's taken me so long to write this post that we are closer to graduation day - 7 days!). We have found out what we are doing for the next several years of our lives. Whether we are going on to medical residency, or research positions, or other great ways to apply our medical knowledge, it's been a wild ride. Four or more years of slogging our way through lectures (both exciting and boring), histology slides, research labs and statistics, 8-hour-long exams, hospital wards, and surgical operating rooms. My first real post (after the introductory one) on this blog was inspired by that first week of medical school. Looking back on those posts, it's funny to note the evolution in my thinking - or at least, the inner conflict that happens now.

Medicine is constantly changing. I am only just beginning my career, but even in the last four years of my training, my class and I have seen the rise of widespread electronic medical records (EMR) and the sweeping changes of the Affordable Care Act (which, whether you like it or not, has made some significant and at times impressive changes). We've seen doctors finally get to the point where it has become necessary to push back against frivolous malpractice suits. And we've also finally seen those same doctors reach the point where they have to realize that they are human, and they make mistakes, an important realization in order to try and prevent the legitimate malpractice lawsuits.
And, arguably most poignantly, we've seen a new plateau in the evolution of the doctor-patient relationship. I see old doctors every day who came into medicine as the most respected men around, when what they said was the final word. They made the decisions for patients, and no one questioned them.

Now, these same doctors find themselves and their suggestions (no longer orders) to patients questioned, and sometimes ignored. They work with a constant underlying fear of being sued if the smallest thing goes wrong. And they are at the mercy of insurance companies and reimbursements. In order to make the money that used to come much easier to them, they have to see way more patients in a day. Where previously they never worried about billing and getting paid, now it's a constant subtext to every medical action and order. They have to document everything, and they have to do it in just the right way or risk losing money on the encounter. They have to deal with drug-seeking patients who will berate them while putting them at risk for malpractice suits. They have to try to reason with (for example) chronic diabetics who refuse to do anything to control their blood sugar and then cannot believe they have to get their foot amputated. And they have to try and help and educate patients who, through no fault of their own, have been suckered by sensationalists like Vani Hari (the Food Babe) and Dr. Oz who convince them to disregard science and medicine for unproven and, more often than not, false remedies.

All of this is part of the ongoing grudge match between the family doctors of old, who essentially became part of the family as confidante and friend, and the modern doctor (whether generalist or specialist) who has to perfect the art of the 15-minute visit in order to see as many patients as possible in order to get paid something that justifies the long hours he/she is putting in, while spending even more time inputting progress notes and orders and wrestling with EMR. It's a tough battle, and no one is happy about it. The patients don't feel that we spend enough time with them (which we probably don't), and the doctors start to see patients as their computerized charts, as their most acute problem rather than the real, whole person. 
In light of all of that, I am never surprised when a doctor gets jaded and starts to hate his/her job. I am saddened, but never surprised.

And that is where patient's stories come in. Dr. Arnold P. Gold (co-founder of the Gold Humanism Honor Society) and Dr. Rachel Naomi Remen (author of Kitchen Table Wisdom) are two of the world's biggest leaders in a renewed surge in restoring the humanistic element to medicine. As one of my favorite Buffalo doctors (and teachers) puts it, it's about "separating the iPatient from the real patient." It's the next round in the aforementioned grudge match. Just the other day I heard from an attending who had come from talking to a particularly nervous patient, and said, "It's not enough to hear what the patient's saying. You have to make the patient feel like - or realize that - they're being listened to." It's about forming partnerships with our patients. Not just dictating their care, but helping them take charge of their care, while guiding them in its management. We have always been taught to get the history from the patient about what their medical problems are, but there is a deeper meaning to be found in hearing what makes them tick, and what drives them, and what their goals are. And that deeper meaning helps us to form better partnerships with our patients.

Of course there are patients who are just non-compliant. There are patients who just don't care about their health. There are patients who just want the high of hospital-grade narcotics. And there are patients who take WebMD to heart and make their health worse just by worrying about it too much.

But I will always remember a patient suffering from new-onset congestive heart failure who was starting to get on the team's nerves because she was threatening to leave against medical advice before her symptoms were resolved and kept complaining that we were keeping her there (even as she could barely sleep without being in a seated position and felt short of breath with minor exertion). We were all getting annoyed that she could not see her own continuing symptoms, until our attending came to us one afternoon and explained that he had just come from talking to her. She was trying to leave because she was in a struggle with her medical insurance and wasn't sure if she could afford the hospital stay. She misunderstood her condition, thinking she could just go home to recover in a few days and it would be done. She did not understand why we were still diuresing her and waiting on an echocardiogram to assess her heart function. As he sat down and discussed the merits of the treatment, and the dangers of exacerbations that could bring her back to the hospital, and the social worker began to work with her insurance problem, she suddenly became that much more patient with us. And, more importantly, we suddenly became more patient with her. Now that we understood what she needed from us, and why she felt the way she did, we suddenly could not believe we had been so quick to write her off before. It was a learning experience for us, especially for me as a student. And it's one that I remember every time a patient disagrees with a treatment plan or wants to go home before we feel he/she is ready - it's not always that they are trying to be difficult. They often have their reasons, and I need to understand and appreciate that. I watch my residents now and I realize that many of them have learned this lesson already, and I again understand that this is part of modern medicine.

Another example that I have mentioned on this blog before - you'll notice that when I talked about the Food Babe and Dr. Oz, I didn't include Jenny McCarthy. As much as I hate the message that Jenny McCarthy puts out in the world regarding vaccines, I know her main drive for that is her children. She is, at the heart of it, a mom trying to find something to hold onto in the face of her child's struggle, and from what I have seen, there is very little that is more difficult than watching your child struggle. It does not make the message right (though there are those that disagree with me there), but it makes me less spiteful towards her and towards anyone who is anti-vaccination. Just like hearing Herbie Hancock's stories helped me go back and understand and appreciate his vocal jazz albums more, so it goes with "difficult" patients and their stories.

To go back to the book, while I could music-nerd out over Hancock's name-dropping and pioneering, what struck me most about the book is how well the title describes his personality: Possibilities. Hancock's attitude is about embracing new things, integrating new technology and musical ideas while trying to preserve history and learn from his successes as well as his failures, and those of others in the industry. That attitude is exactly what new doctors take into their medical careers. And now, as I stand with my classmates on the cusp of graduation, I can't wait to see the possibilities that unfold.