Clinical skills

Information is a Fundamental unit in Biology

2012-01-24T04:45:00.000-08:00

Friends,

This essay, in 2 parts, has been in the making for over3 years. I have been thinking about this idea even longer. I was not surewhether I am stating the obvious and therefore it is trivial. Or, am I out on alimb and therefore making a fool of myself? I have discussed these ideas with afew scientists. Some of them are currently reviewing this. However, a recentarticle in Scientific American confirmed for me that my ideas are worth sharing.Physicists are already looking at this question. Therefore, I decided to postit in order to get feedbacks, correct mistakes and improve before a formal publication.

Hope you will have time to read this essay. I request you to please send me your commentsand critical questions.

Thank you.

Information” is AFundamental unit in Biology

Part 1

“Information” is oneof the fundamental units of nature, just like matter and energy, space andtime. This is particularly true in biology. This insight is supported byseveral common observations and numerous studies in biology and medicine.Ancient philosophies, in both the east and the west, refer to this observation.Thus, this essay is not about a new observation, but a personal synthesis.

Information has to be recognized as a fundamental unit of Natureto explain the visible universe made of matter and energy unfolding in spaceand time.

There were several triggers for this personal realization.

My encounter as a physician with children who had geneticsyndromes led me to think about genes as carriers of information and how adefective gene leads to defective information and a disease. It was no surprisewhen I read that Claude Shannon, the father of Information Theory, started hiscareer with a doctoral dissertation on “ An algebra for theoretical genetics”.

Encounters with children who had metabolic syndromes andimmune defects also led me to think of signals, information processing andtheir defects. What “tells” the white cells to come running to a site with aforeign body? What “tells” T cells to annihilate themselves when their job isdone?

Metabolic homeostasis is based on information processing. Whatis the clue for insulin to be pumped into the circulation? Is not the “influx”of sugar into the blood stream a bit of information for the pancreas?

Looking at biology in general, information andinformation-processing are the absolutebasis of life, including reproduction(DNA and genes), exchange of energy (breath and metabolism), exchange ofinformation with external world (all the senses and the mind/brain functions),internal messages (chemicals, hormones etc) and maintenance of integrity of thephysical self (immune functions).

Daniel Koshland,¹ a distinguished scientist, who used to be theeditor of Science identified seven common thermodynamic and kinetic factors bywhich “life” and living systems operate. He described them in the acronym “PICERAS”and called them the “Seven Pillars of Life”. They are: 1. Program – organizedplan describing both the ingredients and the kinetics of interaction betweenthe ingredients. 2. Improvisation – allowing the programs to change if and whenthe environment changes. 3. Compartmentalization – providing special containersin which concentrations of essential chemical ingredients can be maintained in anideal state and protected from the outside. 4. Energy – availability ofcontinuous source of energy and ability to exchange energy in an open system.5. Regeneration – includes regeneration of essential constituents andreproduction. 6. Adaptability – different from improvisation in that this is abehavioral response from within the existing repertoire and not a change in thefundamental program itself. 7.Seclusion – of pathways that “allows thousands ofreactions to occur with high efficiency in the tiny volume of a cell, whilesimultaneously receiving selective signals that ensure an appropriate responseto environmental changes.” Every one ofthese features is dependent on information(in the form of codes or signals or stimuli), information processing (in theform of transmission of signals with instructions for action) and responses.

The other direction which led me to the concept ofinformation at the core of biology is my practice of meditation for 40 yearsand investigations into the nature of human consciousness. This wassupplemented by my reading of several recent books on the neuroscience ofconsciousness. Ramana Maharishi, a mystic and asaint whom I had the privilege of seeing in the 1940’s asks us to reflect onthe “I” which is at the core of every thought. He calls it the “bareawareness”, “pure awareness” or the “transient I” ². Some neuroscientists call it the “coreconsciousness”. It is the backgroundawareness on which all of our perceptions, memory formation, memory recall, andthinking take place. In one recent book on humanconsciousness, Dr.Nunez proposesa “crazy” idea that mind and brain are intertwined at a quantum level just asparticle and energy are.

Finally, there were two experiences with nature which mademe realize that a basic sense of awareness (without a sense of ownership) isessential for all human thoughts and perceptions. Awareness impliesinformation.

The other day I soaked some green gram (a variety of pulse/beans from India) in water to make sprouts. When I opened the lid the next dayto assess progress, I was looking at “life” unfolding in the form of tinysprouts and bubbles of gas. The once “lifeless” seeds are now “breathing”. Inscientific terms, the seeds are responding to the presence of water. They arenow exchanging energy with the environment. In the process, the form of theseed is changing in front of our eyes.

Causes and conditions are right, once again, for the dormantcodes of life in the seeds to express as life. The cause was there already. The“seed” became “aware” of the new environment and the “code” in the “seed” isunfolding. The effects are here. The cause is information specific for thegreen gram coded in the molecules and atoms of the seed. The unfolding of thatinformation is life. But, what is life? Where did the “first seed” receive itscode, its information for life? Those questions enter the realm of philosophyand metaphysics.

With life comes awareness. All forms of life are “aware” inthe sense of being in touch with itself and with the environment. We know it bythe way all life-forms react and respond to the environment. Individual cellsof the body do. Micro-organisms do. Even a virus does. Animals do. Trees do.

Trees grow their limbs towards sunlight. They anticipate thearrival of winter and of spring. Trees tend to pollinate at the same time.Trees seem to “remember” past events! How is that possible? Obviously theysense the change in the inclination of the sun, duration of sunlight, humidity,temperature etc. Whatever it is, trees and plants are “aware” of some clue,some signal, some information in the environment and respond.

A few years back, I observed a pair of ospreys raise afamily over a period of many months. They had built a nest in the Choptank riveron a wooden pillar meant for mooring a boat. We had a vacation home in Marylandand this nest was literally in our backyard. I observed this osprey pair fromthe day they built their nest through an entire breeding season. I observed how the mother laid her eggs,protected them through rain and shine, saw them hatch, fed the chicks andstayed with them until the youngest learnt to fly!

How did the female and the male know that they are a “pair”,leading to loyalty and caring? What told them that they have to build a nest?What made the male help the process? Once I saw the mother stay on top of theeggs through a harsh thunderstorm. What made her do that? How did she know thatthose were “her” eggs? When the mother was hatching, I have seen the “father”bring fish for her. How did he know? I have seen the adult birds take turnscaring for the chicks. It was amazing to see the mother teaching the young onesto fly. And she stayed in the nest until the youngest and weakest learnt to flyand then one day all of them were gone!

Obviously the birds are conscious. They are aware. Theyknow. They do not have our language. They do not know “love”, “loyalty”, “commitment”etc the way we do with our extra capacity for language. In principle, they“know”. They know their territory. They know where food is. They know theirbabies.

Neurobiologists and behavioral scientists have mapped outthe circuitry in the brain to explain many of the behaviors in humans, animalsand birds. The biology of growth and propagation of plants and tress is wellknown. But my primary focus is on information as the inherent, fundamentalforce of life process and its survival.

“Information” IS the basis of life. What is information?

“The bit is it” said John Wheeler ³. What is a bit?To Claude Shannonand the information scientists^3,4, forwhom the physics of communication is the focus, bit is a piece of information.It is a message. It is a code. For the information scientists, the focus isabout sending a message from here to there. The contents do not matter.Emotions involved in the message do not matter. Not even the purpose.

My focus in thisessay is on the content of the information and its purpose. In the second partof this essay, I plan to relate these biological facts with Information Theoryas proposed by Claude Shannon and others.

The root verb for the word information is in forme which means to form, to shape. Informationin biology is a message, a code for a “purpose”, to shape new things. Accordingto the information theory also, Instruction (for something) is one of thecomponents of information.

Claude Shannon’s definition of the word Information is“whatever reduces uncertainty among alternative outcome probabilities”. Although this definition is loaded withmathematical and theoretical concepts, the word outcome is important both ininformation sciences and in biology. In information sciences the outcome refersto what bits of information get transferred from here to there. In biology, Informationprocessing at the level of the molecules and electrons defines outcome in theform of what happens to the cell and the organism – to life itself.

Information (message)in life sciences is a code for a potential future event, physical orbiological, inherent in Nature; therefore inherent in matter and inenergy. I used the words, potential andfuture. For information to unfold, for the potential to unfold, causes andconditions have to be right. The information, the code, the message can beaccessed only in the future.

Information technology is about sending a bit of informationthrough space - from one place to another with fidelity. In biology,the primacy is in sending information through time.

A message (information) is carried on physical agents, byphysical agents. Therefore, it can be or is an attribute of a physical agentand inherent in it. Physical description of nature is information based.Floridi ⁴points out how “The universe is fundamentally composed ofdata…….with material objects as a complex secondary manifestation”. Like butter in milk; like a plant in the seed.

Information is a fundamental unit of nature, like matter andenergy. At least in biology, information in the form of codes is the basis oflife and of consciousness.

Information is accessed in space and in time. It can beaccessed any number of times without depleting the source. It can be accessed nowor later. But it needs time to unfold. Thus,information is tied intimately with time and space. Unfolding of informationgives the sense of time and the sense of unidirectionality.

What we now call “emergent properties” in biology isinherent information unfolding over time into complex phenomena. The potentialfor the emergent property has to be there in the original units and buildingblocks of cells and tissues. Whether this is true in the physical world also isnot clear to me. My guess is that it has to be at the molecular and quantumlevels.

When defining the word “datum”, Floridi ⁴pointsout that the presence of pure data, before they are interpreted or subject tocognition “is empirically inferred from and is required by experience, sincethey are what has to be there in the world for our information to be possibleat all”.

Past events can be inferred from the unfolded information. Milkcan be inferred from the butter, the seed from the tree. But the source cannotbe reconstituted from the effect. You cannot put the tree back into the seedfrom which it “emerged”. Time is unidirectional, at least in this universe. Unfoldingof information in time makes the process unidirectional.

Information can point to the source. But it is not thesource. It is an attribute of the source.

Matter, energy, time and space are the basic units of thephysical universe. When you add “life” to the universe, awareness becomes anadditional essential element. Awareness implies a source of information and areceiver. It also implies a medium oftransfer of information and a mechanism for the transfer. Finally, in biology, information is for a “purpose”.

Information implies a source, a medium for transmission, theprocess of transmission, receptor unit and outcome. This is common at alllevels for exchange of energy, exchange of information with external world,internal messages, maintenance of integrity of the physical self and reproduction.The source determines the output, but with plenty of variations. This dependsupon external (environmental) and internal (mechanisms of transduction) conditions.Some message sources are simple and some complicated. The same is true of thereceptor and responding systems.

In biology, everystep is made up of such a flow of information, at the macro level and at themicro level.

Let us take inflammation for example. Inflammation is thename given to a series of events that occurs in the tissues of a livingorganism – plant, animal, bird and human – as a reaction to the presence of a“foreign” body. What the tissue detects when a “foreign” body enters is a pieceof “information”.

The body senses something “different” and the outcome isinflammation. What is that something that is different? It is a signal or bit of information in theform of products of the foreign body. It is called PAMP and DAMP. (Pathogenassociated molecular patterns and Damage associated molecular patterns”) whichconstitute the “information” to the tissue that something that should not bethere is there. This is all or none type of message. The response ismodification of the three dimensional structures of certain proteins inside thecells. One such protein is NLRP3 whichstays auto-repressed until “activated” by one of the damage signals (DAMP orPAMP). The response is “unfolding” ofthis protein. This unfolding then becomes the signal or information for thenext series of steps leading to the production of a protein called IL 1beta.

Il1beta acts and produces its effect on tissues that resultsin the bodily signs of inflammation such as fever, body pain and swelling ofthe inflamed site etc. In order for these to occur, Il1beta attaches itself toa receptor on the surface of the cells. This receptor has connections to theinside of the cell as well. The receptor is in a particular three dimensionalstructure when not engaged by the Il1 beta protein. Let me call it “potentialinformation” (or a 0 position or an off position of a switch) in the receptor.When the Il1beta protein attaches to the receptor it undergoes a change instructure which is a 1 or an “on” position for the “inflammation switch”. Thisin turn triggers a cascade inside the cell. The change in structure is the information. (Or is it the changed structure that becomes theinformation?)

As we shall see in Part 2 of this essay, according to theInformation Theory of Claude Shannon and others, the 0 and 1 positions of thereceptor (the data) are the basis of lack of uniformity of this universe.

The information is now passed on down the line inside thecytoplasm of the cell till it reaches the inside of the nucleus. After several more precise attachments tospecific proteins the message reaches the specific genes which produce theproteins necessary to fight the foreign invader. At every step it is a bit of informationpassed down to the next step in the ladder. At every step it is a “mechanical”or a chemical fit between the signal or code and the “receptor” which causes achange in structure of the receptor. This makes transmission of information possible. At every step it is thethree dimensional configuration in space that allows the signal to move forwardin time (downstream effects). Changes inthe structure of any one of the codes (information) in this pathway result ininadequate or excessive response to stimuli (a bit of information) and thus to physicalinjury.

When we go one level deeper, what makes the threedimensional interactions possible? This enters the domain of chemical bonds,energy exchanges and Van der Waalsforces. Since I am unfamiliar with these topics, I decided to learn howthree dimensional structures influence biological functions. I read books andarticles on the subject and discussed ideas with a protein chemist and aphysicist.

I wish to focus on two articles to make my point. One was onthe three dimensional structure of glucocorticoid receptor⁵. The other paper was on how the structure ofTLR4-MD-2 complex determines its ability to react to (with?) bacterial antigens⁶.

Glucocorticoid receptor (GR) is a protein responsible forthe effects of glucocorticoids on the physiology of the body. One end of the GRconnects with the hormone, glucocorticoid and this is called the ligand bindingdomain (LBD). The other end is calledthe DNA binding domain which is necessary for the production of proteins thatcause the effects of the glucocorticoid. In the paper I read, the authorsstudied the three dimensional crystal structure of the GR in complex with onechemical (RU 486) which inhibits (antagonistic) the downstream effects andanother chemical (dexamethasone) that activates the downstream effects(agonist).

There are 4 different crystal structures of GC – GC1,GC2,GC3 and GC4. The authors show how the orientation of helix 12 in GR3 whichbinds RU 486 is exact opposite to that of the same part of the molecule in GR4which binds dexamethasone. The steroid (both RU 486 and dexamethasone) is heldin place by hydrophobic residues that outline the cavity in which it binds tothe receptor. The steroid is kept in orientation by two hydrogen bonds from theA ring of the steroid to Gln 570 and Arg 611 and a water molecule in thereceptor protein. On the other end of the steroid with the D ring, the 17 betahydroxyl group bonds via a hydrogen to Gln 642 and a water molecule to Cys 736.It appears that the A ring sits in a portion of the GR with conserved sidechains. The connection between the 17 beta hydroxyl group and Gln 642 gives thespecificity for recognition of the ligand.

Three dimensional structures allowing for contacts betweenspecific areas of the agent with an information and the receptor through whichthe information is translated are determined by hydrogen bonding and relatedforces.

A similar observation is made in the response of the body tobacterial antigens (in this study, it is LPS) through the innate immune system. The extracellular domain (the part that staysoutside the cell) of TLR (a part of the innate immune system) dimerizes (joinswith another one of the same receptor) when it binds with the LPS ( called itsligand). This triggers the recruitment of specific adapter proteins inside thecell resulting in an inflammatory response.

Specifically, TLR 4 in association with MD 2 is responsiblefor the recognition of LPS. LPS interacts with a large hydrophobic pocketwithin the MD2 molecule and bridges it with TLR. This fit depends on thephosphate groups in the LPS. “The two phosphate groups of lipid A bind to theTLR – MD2 complex by interacting with positively charged residues in TLR 4, TLR4* and MD 2 making a hydrogen bond to S118 of MD 2”.

Summarizing these two sample studies, information at themolecular level is coded at the level of chemical bonds and van der waal forces.This information is needed for modification of three dimensional structure ofproteins and other molecules. Proper three dimensional fit between proteins andother substances allows for interactions with consequent downstream effects.Therefore, the fundamental piece of information (code, signal) must be at thelevel of ions and chemical bonds where physical laws and laws of the quantumworld operate .

Seth Lloyd isquoted as saying: "To do anything requires energy. To specify what is donerequires information".

Is it, therefore, possible to build a theorythat places information as an inherent property of nature in biology? If it is, should it be placed at the levelof the ions and formation of chemical bonds? Or, should it be placed at thelevel of atoms and electrons? Is the information in the original three-dimensionalstructure of the protein or the molecule itself or is it in its potential forchange under certain conditions? Is information an inherent property of thelarger molecule or of the energy bonds? Will this approach give us new avenuesof investigating emergent properties of matter into biological entities?

When we take ClaudeShannon’s definition of “information as whatever reduces uncertainty amongalternate outcome probabilities….”, itis reasonable to hypothesize that information is a basic unit at all levels inbiology – even at the quantum level since particles at the quantum level aregoverned by statistical laws.

This is a speculation at present. However, there are somestudies in quantum biology⁷. For example, studies on the ability of drosophila to sensesmell of two kinds of acetophenes, one with hydrogen and one with deuteriumshow that quantum mechanical properties are involved in the sense of smells atleast in the fruitfly. This involves a quantum phenomenon called electrontunneling. This mechanism may also be operational in our sense of sight and thefit between the vibrational frequency of the light and the photoreceptor.

More recently information theory has been applied in cellbiology⁸. Channel capacity, noise reduction and entropy ofprobability distributions are the basis of application of IT in thecommunication systems. Now signal processing in the TNF pathway (signaltransduction pathway) has been studied using these concepts to quantitativelypredict and measure the amount of information transduced at a single cell leveland also show that “noise reduction” takes place at a single cell level when acell receives signals of different strengths from several sources⁹.

Living forms (objects) are made of “matter”. Once theseforms get “animated”, we get “life forms”. At a basic level, life is energyexchange. Life depends on energy exchange depending ultimately on the sun. Lifecannot exist without energy exchange; but energy exchange can go on withoutlife.

Living forms have a sense of awareness. All living creaturesare “aware”. They all react to the environment. This is possible only if thereis a “receiver” and a “responder”. Thisis “awareness” at a fundamental level. Without awareness and ability to respondto internal and external signals, life cannot exist. Awareness is ofinformation. Information exchange is dependent on energy exchange.

Enter higher life forms and human beings with their specialbrains and their capacities. Their awareness is different. Their brains arecapable of meta-awareness, an awareness of awareness. When this is explainedand understood through the use of symbols of language and of concepts, we reachthe highest form of awareness (third-order) in the humans.

Earlier, I had referred to a bookby Nunez. His point is that mind andbrain are two aspects of Nature just as matter and energy are, particle andwave are. He says that consciousness (awareness, information) is not generatedin the brain; but it is a fundamental property of nature and of the brain.Information is not generated but is inherent in nature.

Brain is a sensing mechanism and at a higher level it iscapable of sensing the process of sensing, which is awareness. We have a brainand therefore we are capable of being aware. We are aware of our brain and ofthinking because we are aware. Without brain, “information” will be there, but“who” cares? Without life, there is no functioning brain and how is awarenesspossible? This is circular reasoning. But, as pointed out by Molitor ¹⁰,we use this logic with other aspects of nature. For example we say that“charges are acted on by electrical fields” and “electrical fields aregenerated by charged particles”.

In summary, Information is inherent in the universe andinformation exchange is a fundamental requirement for life forms to exist. Everycell, every tissue, every virus, bacterium, plant, animal and human live byexchanging information within oneself and with the other living and non-livingentities in our environment. Informationexchange is the basis of metabolism, immunity, reproduction, genetics , memory,and communication. I wonderwhether it is logical to think of information as inherent in matter for energyto act on in space and time at the micro and macro levels. Can any usefulhypothesis be generated by placing information at the core of biologicalphenomena more precisely?

Information definedas “potential for a future event” is inherent in nature and by implication inmatter and in energy. The actualization of that potential is a future event inspace and time. Matter changes or has potential to change. Energy-levelschange. Information is stable and the source can be tapped any number of timeswithout loss of information.

The other point is that information theorists refer to bitsof information as a code. This makes sense when you look at the genetic code,immunological memory and human consciousness. These are all possible because ofcoded information passed along and interchanged. Ultimately these have to beexplained at the energy-exchange level which is again transmission andreception of a “code” or a “bit” of information.

“Bits” of information for a future event (the effect) haveto be inherent in the cause. At a physical level, atoms and subatomic particleshave “potential” to become what we see in nature, however improbable it may be,when causes and conditions are right. Particles at the quantum level aregoverned by statistical laws. Therefore, quantum principles will have to beinvoked at this level.

My sincere thanks to Dr. Dan Brennan and Dr.Peter Kim forteaching me some fundamentals and directing me to basic books on InformationTheory and Physical Chemistry. I thankDr.Karyl Barron for her suggestions and encouragement.
References:

Koshland D. PICERAS – Seven Pillars of Life. Science 2002; 295: 2215-2216.
Cornelssen, Lucy. Hunting the I. Sri Ramanasramam, India. 2003.
Wheeler, J A and Ford K. Geon, Black Holes and Quantum foam: A Life in Physics. New York: Norton, 1998.
Floridi F. Information – A Very Short Introduction Oxford University Press. 2011
The three dimensional structures of antagonistic and agonistic forms of the glucocorticoid receptor ligand – binding domain. J Biol Chem 278: 22748-754, 2003
The structural basis of lipopolysaccharide recognition by the TLR-MD2 complex. Nature 458: 1191-1196, 2009
Brooks, M The weirdness inside us. New Scientist October 2011. Pages 34 – 36
Thomas PJ Every bit counts. Science 334: 321-322, 2011
Cheong R, Rhee A, Wang CJ, Nemenman I and Levchencko A. Information transduction capacity of noisy biochemical signaling networks. Science 334: 354 - 358, 2011
Molitor SC Book review of Brain, Mind and structure of reality by Nunez PL. JAMA 304: 218, 2010

Balu

Informed Consent

2012-01-01T03:46:00.000-08:00

Is it truly an informed consent when a piece of paper is given to you to sign on your way to the operating room? The first insult is that the Consent Form is presented at an awkward time when you are so scared you do not even know what to ask. Next, the “informed consent form” is written in such a “legalese” you will need a lawyer to interpret what it says – preferably the same one who wrote it! Finally, the consent form goes into such great detail on everything that can go wrong, that if you really start thinking about each one of them, you may choose to suffer than sign that paper!!

It is sad that what should have been done to involve patients in a thoughtful decision making process has been made into a “risk management tool”. These consent forms do not even perform that function well. Evidence accumulated over the past several years has shown that the “informed consent” forms fail to truly inform the patients. They do not help avoid malpractice suits either.

A study that analyzed the consent forms collected from several US hospitals showed that some of them were “short and vague”, some of them “long and confusing”, many of them used legalistic language and only 25% of them went beyond just the description of the procedure to include information on risks, benefits and alternatives.

The status of informed consent was the topic of an essay on “Uninformed Consent” by Ms.Debra Franklin in the March 2011 issue of the Scientific American. She describes new tools of technology that are being developed to include and involve patients in the process of obtaining informed consent. These tools formalize and organize the components of Informed Consent and emphasize “education” of the patient so that when the patient signs a consent, it is truly an “informed” consent. Although these tools have not been tested, this is a good start.

These “software” tools of technology are interactive and are either aimed at doctors or at patients. I looked at two of them, mentioned in the article by Ms.Debra Franklin. They are Emmi Solutions and iMedConsent.
Emmi Solutions is patient centered, interactive, uses images, written at a level most people can understand, is in English and Spanish and is based on input from patients and doctors. The program I opened was on Angioplasty. The topic is presented under seven headings: Your Body, Your Condition, Pre-Procedure information, details of the procedure, Post-procedure recommendations, Risks and benefits and Alternatives.

iMedConsent is for physicians. Templates with details on several hundred procedures are available. They can be modified to suit the specific needs of individual patients. The program I looked at was on Cholecystectomy. This also followed the same format as the Emmi in explaining the body, the condition, preparation, procedure, post-operative instruction, risks and benefits and alternative.

Obviously these tools need testing. Also, what about patients who do not have computers or cannot interact with computers?

Ultimately, face-to-face “communication is essential no matter what the approach”. The computer will help to make sure the conversation did take place and all the elements of truly informed consent were covered. It will also assure us that the interaction is documented. Prudent, “compulsive” clinicians have been doing these all the time. Machine can only formalize the details and the process and inform everyone that it was done.

Like the gold

2011-12-01T03:24:00.000-08:00

Looking at my old journals (daily dairy), I found several observations based on my personal experience as a pediatrician. I plan to re-write some of them for these blogs. Here is the first one.

She comes from a horrible social background. She is past the age of innocence. God knows what all she had been up to. But, now….

She is a pathetic looking girl - sick, seriously sick with lupus. Has lost all her mental faculties, so it seems. She cannot remember what happened yesterday. Her legs have become useless, cannot even hold her up to stand. She has no bladder and bowel control.

The mother is mixed up. She is so mixed up she cannot even come to see her daughter. But she is a mother with feelings, full of them. A helpless woman. Each time there is sad news (and she gets plenty of them everyday) she disappears. No one knows where she goes to. Is escaping her way of coping? Does she go wandering to forget her miseries?

Coming back to this young girl, she gets sudden and brief moments of clarity. At that moment, she knows what is happening to her and gets scared. Won’t you? You can see her face and read her fears. Amidst those sunken eyes, bald head, dried lips, is a mouth full of ulcers through which a pathetic cry comes out. She has tears in her eyes. Then comes a special spark in her face and with a gentle and pathetic smile she says: “Dr………. I am scared; will you pray for me?”

I hold my tears but hold her hands and say: “Of course, I will T…., I will pray for you”. For that one moment I see the Divine Spark in her eyes, the same Spark that lit me, and lit all of us. With that, the technician wheeled her to the operating room. Ms. T….. never saw her personal, miserable world again!

Yes, even in the midst of suffering, hopelessness, helplessness and sadness, the Spark of Life can be seen, even if for only a moment.

Socrates had objections to Written words

2011-11-01T02:36:00.000-07:00

In Sanskrit there is a statement: “sahasram vada; ekam abhi ma likha” which means “Say 1000 words; but do not write even one”. Vedic tradition grew up on verbal recital and memorization. Greek tradition was also following the same course – until written words appeared at about the time of Socrates. It appears that Socrates was worried that students will obtain information from written words, but will not know how to think critically. We know he was wrong.

At present, we the “digital immigrants” worry the same way about our young “digital generation”. We worry that in the midst of these images and bits and “bytes” of information, the next generation may have problems with critical thinking skills. There are a few studies to substantiate such a concern.

The new generation of “technology-assisted” learners, are somewhat akin to the “book-assisted” learners that Socrates worried about. Our young ones learn from images and sound-bites and rapid summaries. There is no helping hand. Students multitask. They skim through information. They want instant answers. They forget that information is not knowledge and that they have to take an active part in making knowledge out of this information.

As pointed out by Maryanna Wolf in her book on Proust and the Squid (HarperCollins 2007) and in a recent issue of Science (August 19, 2011), writing and learning from written words was not natural for the human brain. It took at least 2 millenia for the human brain to evolve and adapt its structures and networks to this uniquely human activity. Will the neural networks developed over the past two millenia be useful in the new learning environment? Or, will the brain evolve new strategies to adapt to the new world of learning through images and streaming bits of information? How can we help the new young generation develop their reasoning and analytical skills and improve the so-called executive functions of the brain?

Socrates was of the opinion that spoken words are full of meaning and emotions, with added stress and nuances during the delivery. Written words are rigid. Written words “cannot talk back” if you ask a question. Nor can it offer clarification. Written words can be mistaken for reality if not examined critically with the help of a teacher, he thought. Decoding the words and their meanings is not the same as knowledge acquired by thinking about the thing words stand for with all their connections and implications. Socrates thought that reading from books might lead to superficial, false knowledge and “empty arrogance”.

The second objection was that written books will be harmful to memory formation. We all know that it is true to some extent. It does not destroy memory; but there is less need for it. It is not all bad. Computers can store memory better than we humans can. They can store lot more facts and more important, they can recall in fraction of a second and without ever forgetting. So why use the brain like a “filing cabinet”?

The benefit of the arrival of written words and books was that the brain needed less territory and energy to store memory. That allowed the brain to develop its correlative and analytical functions. The other advantage of written words was that accumulated knowledge could be transmitted to the next generation. Clearly, the arrival of written words is the basis of human civilization.

With information technology, we can store more information in less space than in books. We can look for correlations and patterns with simulations and complex calculations. However, information is not knowledge. By focusing on information, looking at moving images and disappearing screens and with the use of immediate feedback and quick rewards, are we losing our ability to stay focused and think through a problem?

The answer to this last question happens to be “yes’ and “no”. Yes, our youngsters are not focused, they multi-task and are quick with joy-sticks but not with executive functions. At the same time, children’s ability to think analytically and creatively and to stay focused can be improved with the use of the same technology. It is interesting to note that working memory is an important component of creative and analytical thinking and this can be enhanced by specially developed computer programs.

What are the executive functions of the brain? These are the qualities needed to control our impulses, focus on a problem, think creatively, assign priorities, make proper judgments and plan for a course of action. These functions depend on development of neural networks which connect the sensory, motor, emotional and rational parts of the brain. Many of the circuits are not fully connected till late adolescence.

All of (Most of us) develop these functions over the course of our young lives. Can we facilitate the developments of these functions in children? Sure, we can. Recent studies on helping young children to develop executive functions show that approaches that seem to work include “computerized training” with specially developed lessons, hybrid computer-noncomputer programs, special “Tools of the mind” and classroom curricula. (Science 333:959-964, 2011). Yes, information technology can be used to maintain those functions which we are afraid our younger generation may lose.

Finally Socrates thought that written words will result in loss of control over language. I do not know what he meant. Socrates probably thought that learning from written mode will lead to superficial understanding since there is no teacher to push the student to ask questions and ask for clarifications, make sure the student understands the meaning of words and the structure and the beauty of the language. The student is likely to move on with incomplete knowledge (not looking up the dictionary and ask for clarification) and thus lose control over knowledge. He said that “Once a thing is put in writing, the composition, whatever it may be, drifts all over the place, getting into the hands not only of those who understand it but equally of those who have no business with it…..”. In essence, we know how when a word is put on print, we lose control over it. We do not know who will use it and for what purpose. Is it not true even more when something is written into cyberspace?

As a physician-educator, I know that those concerns are still valid. Look at text messages, e mails and Twitter. There is no need for spelling or grammar. In medicine, when a clinical question arises, the students are able to get a reference or two about the subject in a second by signing into Pubmed or Google Scholar. They read the abstract but only a few go to the original and read it carefully and critically to assess the quality of research and the validity of the conclusion. Much less time is spent on deciding whether the “information” in that article is relevant to the specific situation.

This problem is even worse when patients search the internet and come up with everything that can go wrong with their condition. They do not realize that most of the material is unfiltered and untested and there may be even some dangerous ideas. The anxiety generated becomes worse than the disease itself.

We all know that Socrates was wrong in opposing written words and “books”. If he were alive he would admit his mistake. We also know that his concerns are of relevance once again. However, the age of information is here to stay. It has unleashed an explosion of available information. But information is not knowledge. The technology of acquiring information should not become an end in itself. Like all new technologies, information technology comes with its strengths and weakness. Like all new technologies, we will not know the full impact of this technology on individual learning and on the society for several decades to come. We do not know how this will alter the need for our brains to rearrange its circuitry for analytical thinking.

We have to adapt the information technology and adapt to it wisely and with prudence.

References:
Proust and the Squid. Maryanne Wolf. HarperCollins, New York 2007.
Science Issue of August 19, 2011

Technology affected Learners

2011-10-18T17:06:00.000-07:00

The American Academy of Pediatrics conducts a survey of graduating residents each year. Results of a survey conducted between May and September of 2010 showed that a majority of them use IT tools for acquiring medical information, patient care and for personal communication. They use photos and video clips for both personal and professional purposes. Wisely enough, they use physicians-only social networking sites for professional purposes. (AAP News September 2011, page 17)

The current generation of learners is called the digital “natives”. They acquire information and use it effortlessly. Their learning style and skills are different. Teachers have to be aware of it.

In a lecture given by Prof.Krishnan at Hyderabad, India, young folks growing up with technology are called “Technology affected learners”. He makes SIX points about technology assisted learning. I list them here together with my comments (in italics) on what teachers can do to make the learners think.

1.Knowledge is free. (“Information is free”. You have to create knowledge out of it. We do not have to use the brain like a filing cabinet. Computers do a better job of “remembering” vast amount of data. Our brains are better used to think with the information)

2.Learners have less time to learn. (You have to make the time to learn)

3.We shape our own learning. ( Develop your own tools for thinking)

4.Peer network is the new expert. (Beware of the self-appointed “expert”)

5.Knowledge sources are always suspect (Check out the source for yourself. Make sure you know who is sponsoring it and why)

6.Newton’s Third law of Learning: For every point of view you find on the internet, there is an equal and opposite point of view. (You can find an article to support your point of view on any clinical problem! Beware and keep an open mind)

To this I will add what Margaret Mead said many years back. The days of vertical learning are over. These are the days of horizontal and parallel learning. You can learn from your students and the younger ones. You do not teach and/or learn. You share information and knowledge.

Wisdom – that is another story.

Ethics, Objectivity and Subjectivity

2011-10-03T14:30:00.000-07:00

Recently I attended a conference on ethics. It was too didactic to my taste. Even the case discussion was centered on objective principles of biomedical ethics as given in text-books. Adequate emphasis was not given to problems related to personal values, emotions and communication.

Competency of patients to make medical decision was mentioned as part of autonomy; but there was no discussion on how to evaluate that competency, particularly that of an emotionally distraught mother of a pediatric patient. That made me think.

It appears to me that the excess emphasis on “objective” criteria in an area full of values and emotions is a reflection on the history of how the field of medical ethics evolved. Modern medical ethics has three major roots – humanism, science and law. First, the maltreatment of victims of war as subjects of cruel research during World War II. Then, there was the famous experiment in Tuskagee where several patients were infected with syphilis without their knowledge. Second, this is the age of science. Measurement is a fundamental part of science. Every subjective symptom and quality need to be quantified and measured. That obsession still goes on. Third, when patients sue their doctors, it is difficult for the court to decide whether the patient’s rights were violated and whether there was any breach of ethics. It is helpful to have objective criteria for proper application of law. They are all good reasons. It appears that ethical criteria are driven primarily by legality.

The weakness of the current ethical criteria is the excess emphasis on objectivity. Of course, we need objective criteria to “judge”. But that does not take into account the following realities. The future is, for the most part, unknowable. The physician has to make decisions under uncertain conditions. The situations are loaded with emotions of patients, the relatives, the doctors and other medical personnel. The situations are also loaded with personal values of the patients and physicians and everyone else involved with the patient.

Indeed many of the problems arise because of differences in expectations and values. This in turn is based on unequal information. Patients have a limited and often incomplete or distorted appreciation of the facts. They might have read up on an issue. That does not mean they know the risks and benefits as well as the physician. Non-physicians and support personnel with limited medical knowledge who are involved with patient care may have their own view of realities and values.

Ultimately it comes down to good communication between all parties concerned. If there is good, easy, honest communication, many of these situations can be avoided. Actually, in two of the patients presented that day, the problem was one of communication – not violation of objective principles of ethics.

What are the "values" of Science?

2011-09-01T02:49:00.000-07:00

Professor Ismail Serageldin of the historical Alexandria Library of Alexandria, Egypt has written a remarkable editorial on the values of science (Science Vol 322: page 1127, 2011). It is in the best scholarly traditions of Alexandria. He points out how the values needed for an open, democratic society are the same values that science demands.

First, Truth, only absolute truth. This can come from anyone who can back up the conclusions with evidence, and not imagination, wishful thinking or “manufactured-data”.

“Science is open to all regardless of nationality, race, religion or sex”.

“Truth and honor are of utmost importance. …..A scientist may err in interpreting data, but no one can accept fabrication of data. What other field of human activity can rival this level of commitment to absolute truth?”

Modern scientific work is team work. “Contributions are also cumulative”. No superstar can claim he or she did all the work. It is routine to see a listing of all the collaborators and contributors and supporters at the end of any scientific article or talk in the field of biology and medicine. It is that democratic and transparent.

“Science requires the freedom to think, to challenge, to imagine the unimagined. It cannot function within the arbitrary limits of convention, nor can it flourish if it is forced to shy away from challenging the accepted. Science advances by overthrowing an existing paradigm or substantially expanding or modifying it. Thus there is a certain constructive subversiveness built into the scientific enterprise……. This constant renewal and advancement of our scientific understanding is a central feature of the scientific enterprise. It requires a tolerant engagement with the contrarian view that is grounded in disputes arbitrated by the rules of evidence and rationality”.

“Science demands rationality and promotes civility in discourse. Ad hominem attacks are not accepted. Science treats all humans equally”

Is scientific enterprise perfect? No. Are scientists beyond all human failings such as vanity, self-promotion, fabrication of data? Most of the time, “YES”. There have been violations, of course. But the scientific community does not tolerate them. “Truth and honor are of the utmost importance”.

Dr. Serageldin quotes Jacob Bronowski and points out how all of the values and requirements of science as described in earlier paragraphs are what civilized, democratic societies need. The scientific enterprise adopts all of these values with exceptional vigor. “These values also provide the basis for enhancing human capabilities and human welfare”.

Before I close this essay, may I suggest to you a remarkable movie on the life of Hypatia, a female philosopher-mathematicians who was the Chief Librarian at the Alexandria Library in the 5th century CE? The movie is available in DVD format and the title is Agora.

Is Professionalism measurable?

2011-08-14T10:16:00.000-07:00

The essay that precipitated my reaction carries a different title: “A Behavioral and Systems view of Professionalism” written by Cara Lesser and her colleagues (JAMA 2010:304; 2732-27370). My title shows my bias.

I am for science. I also have a skeptic view of trying to make every qualitative function into a measurable one for the sake of scientific study! Objectivity is important, I agree. But, let us not treat subjectivity as if it is a dirty concept! It is Ok to talk about love, trust, quality of life, and professionalism from the subjective point of view. You may be able to show that one is more “this” or “that”, but putting a number on them does not make them more or less important.

Leaving subjective bias, the points made in this paper are important and worth pondering. The authors start with the observation that “ professionalism is not a simple set of text-based ideals for practice, rather it is an approach to the practice of medicine that is expressed in observable behaviors”. These observable behaviors are grouped under two key domains: 1. individual interactions with patients, family members and colleagues in the healthcare team and 2. Organizational interactions.

The core values that should drive professional behavior included in this framework are: “1.compassionate, respectful, collaborative orientation with a focus of being in service of the patient; 2. Integrity and accountability; 3.pursuit of excellence; and 4.fair and ethical stewardship of health care resources”. A grid is developed to include specific examples of behavior under the four core values in each of the two domains.

Two other related areas mentioned in the essay are: 1. professionalism cannot be practised in an atmosphere which does not allow physicians to perform in a professional manner as had been pointed out by Cohen at al in 2007(JAMA 2007: 298; 670-673). 2. Some of the skills essential for professionalism in practice "such as self-awareness, self-control, situational awareness, alternative strategy development, crisis communication” can be and should be taught to trainees.

Health care in the era of Internet

2011-07-31T13:09:00.000-07:00

In my Handbook on Clinical Skills, I did not write much about the strengths and weaknesses of the use of e mail and the internet in patient care. Therefore, I am adding a few blogs on this topic.

A friend of mine told me recently that his hospital has gone digital completely. He said that all medical records and the laboratory results are digitized and are available to the doctors and patients. My initial question was: “How many patients have access to internet and how many use them for this purpose?”

Digital medicine is here to stay. It is a powerful tool and can make medical care more efficient, if used wisely. For that to happen, we have to understand fully its strengths and weaknesses. At present it is used mainly as a repository of information with instant access. Can it truly improve health care, make it more efficient and be cost effective? Or will it add one more layer of complexity requiring costly equipments and more personnel,thus leading to the cost of medical care?

How can we assure accuracy of data entry? How can we make sure digital medicine does not increase the disparity of medical care between the “haves” and the “have-not’s”? What about patients who are too old, or those living in isolated communities and those with language problems?

In this era of technology, we seem to think that every human problem can be solved by one more technology. We forget that each new technology comes with its own set of problems. We tend to forget that some problems need changes in the attitudes and behavior of individuals and of the society in addition to or instead of a technological solution.

(I heard about a new book that deals with these issues. It is Digital Medicine: Health care in the Internet Era by Drs. DM West and EA Miller published by the Brookings Institution Press. I have not read the book, but the review I read was a favorable one.)

Sub-Sub Specialization

2011-07-03T04:19:00.000-07:00

Several years ago, I came across a comment by one Professor Engel (I do not recall his first name or the name of the Journal) regarding specialization. He said: “ A specialist is one who knows more and more about less and less, till he knows a lot about nothing; and a generalist is one who knows less and less about more and more till he knows nothing about everything” (not an exact quote). Those days are upon us already. Efforts are under way to recognize specialized training in extremely narrow fields such as obesity and congestive heart failure. This was the focus of an essay by Drs.Cassel and Reuben in a recent issue (March 24, 2011; Pages 1169-1173) of the New England Journal of Medicine.

When I started in my medical career, a general physician was an internist for adults and children, a general surgeon and an obstetrician, all rolled into one. Even then, it was not possible for one to be proficient in all these areas. Internal medicine, surgery, obstetrics and gynecology, radiology and pediatrics had separated as specialties. Sub-specialization had also started with orthopedic surgery, neurosurgery, ENT surgery etc. Pediatrics had not sprouted sub-branches yet. Internal medicine had started specialization in allergy, heart disease, gastrointestinal diseases and TB (forerunner of pulmonolog.

Scientific investigations in biology and medicine led to newer technologies specific to each organ and explosion of knowledge about diseases in every organ system. It was impossible for any one person to master this knowledge without extended period of training. After the training, when a physician declared himself to be a specialist in his/her field, the society needed assurance that these individuals were competent to practice the specialty.

Sub-certifications started in internal medicine in the 1940’s with four specialties mentioned earlier.Six more were added in the 70’s, 2 in the 80’s, 4 in the 90’s and 4 more in the early parts of this century. Pediatrics had also started sub-specialty boards starting with neonatology in the 70’s. More recently, a few specialists started focusing on specific areas within each of these sub-specialties. For example, electrophysiology of the heart became a focus of study by some cardiologists. This focus led to more research and more knowledge and an extremely few who became experts. Their trainees in turn declared themselves experts in this area of focus.

Drs. Cassel and Reuben raise the following questions in their essay. Each time a new area of expertise is recognized, what should be the role of certifying bodies in assuring to the society about the competence of individuals who claim such an expertise? What is its responsibility towards the society? What is its role in managing proliferation of specialties, resolving conflicts and tensions between specialties about each other’s “turfs”? In addition, what is the cost of training, certification, re-certification and insurance coverage for focused practice which will be passed on to the patient. Finally, where is the balance between fragmentation of care by creating more specialties and assurance of quality of care by certifying those who have had adequate training?

ABIM has defined this problem well by creating criteria for recognition of subspecialties and of Focused Practice through Maintenance of Certification (MOC). Criteria for subspecialty certification include: a unique body of knowledge in the field, has clinical applicability, is based on and contributes to the research base of medicine and improves patient care. The criteria for focused practice are: several internists focus in that area, while others may not practice in that focus area at all and this meets an important social need and offers evidence that focusing practice in that discipline improves patient care. Based on these criteria ABIM has launched certifications in Hospice and Palliative care and Congestive Heart Failure as subspecialties and Hospital Medicine as focused practice. Other specialties may also follow similar trends.

The era of sub-sub specialization is here. We need to manage it well so that the quality of care of patients improves in a cost-effective manner without fragmentation of care.

Consciousness, Empathy, Self and Wisom - 3

2011-06-19T12:22:00.000-07:00

More recently the term Self has also come under scrutiny. The idea of self is both physical and philosophical. William James is credited with showing that the so-called “self” (he called it the me self) has three components: the material self, the physical self dealing with one’s care of one’s own body with clothing etc, the social self that is recognized as a consistently predictable individual and the spiritual self which determines one’s internal philosophical values.

I will leave out for the present, the “self” as defined by philosophers and religious scholars who suggest that there is a non-material entity called self or atma or spirit which activates the functions of the human body, including that of the brain and independent of the body. I am also leaving out the study of “self” by neuroscientists such as Antonio Damasio who suggests that there is a proto-self, core self and autobiographical self.

Based on the suggestions of William James, one group of neurologists defined self as “temporally stable, trans-situational consistencies in behavior, dress, or political or religious ideologies”. Since patients with dysfunction in frontal lobe functions have been shown to exhibit dramatic changes in their beliefs and self-care, these neurologists studied 72 patients with fronto-temporal dementia. The studies included documentation of change in the core aspects of “self” as defined above, such as changes in style of dress, social presentation, political and religious ideologies and self-concept related to their work.Imaging studies (MRI and SPECT) were also completed on these patients.

Seven patients showed dramatic changes in “self” as defined above. Six of those with change in their “self” showed clear structural abnormalities on fMRI with asymmetric loss of function in the non-dominant frontal lobe.
In other words, some of the components of what we call “self” in our daily, practical usage are represented in specific areas of the brain.That is not surprising at all.It is surprising that it took so long to figure that out.

The reason I am summarizing all of this is because with an increase in aging population, we see many patients with loss of mental functions including awareness, a personal self and judgment. In addition, patients with several types of neurological diseases based on organ pathology manifest behavioral problems and mental illness in which they have lost or have exaggerated mental functions. I believe neuroscience can help our patients based on solid evidence. It is obvious that these studies are important in understanding mental illness with objective data and are essential to developing reliable treatment modalities.

In addition, compassion, empathy, altruism, wisdom are important in the making of a physician. If we understand what wisdom is and what empthy is, we may be able to train our future physicians better.

Further reading:

Singer T, Lamm C. Social neuroscience of empathy in The Year in Cognitive Neuroscience 2009: Ann. N.Y. Acad. Sci. 2009; 1156: 81–96.

Budson AE, Price BH. Memory dysfunction. New Eng J Med 2005; 352: 692-699.

T R Insel . Faulty circuits. Scientific American April 2010 pages 44-51.

J W Buckholtz et al. Dopaminergic network differences in human impulsivity. Science 2010; 329: 532-534.

Mohammadreza Hojat, PhD, Michael J. Vergare, MD, Kaye Maxwell, George Brainard, PhD, Steven K. Herrine, MD, Gerald A. Isenberg, MD, Jon Veloski, MS, and Joseph S. Gonnella, MD.The Devil is in the Third Year:A Longitudinal Study of Erosion of Empathy in MedicalSchool. Academic Medicine 2009;84(9):1182-1191.

Steve Twomey. Phineas Gage: Neuroscience's Most Famous Patient - An accident with a tamping iron made Phineas Gage history's most famous brain-injury survivor., Smithsonian Magazine, January 2010.

Damasio A. The Feeling of what happens. Harcourt Brace. 1999

Consciousness, Empathy, Self and Wisom - 2

2011-06-12T04:39:00.000-07:00

Empathy is an essential requirement for any physician. Also note that empathy and altruism are characteristics of a “wise physician”. At a time when patients think that physicians value technology more and do not truly understand their suffering, it is important to re-establish the value of empathy in patient-physician relationship. (DeWitt Stetten, a brilliant physician- scientist said that his ophthalmologists were interested in “vision”, not in his blindness). Patients are more likely to comply with treatment regimes when they feel that their physician is empathic. They are more likely to feel comforted and supported by an empathic physician.

However, empathy is a double edged sword. Too much empathy may cause earlier burn-out among physicians. In an interesting study from the Thomas Jefferson University School of Medicine, 400 medical students were studied for their level of empathy during the entire four year period of medical school. The researchers used a well-tested questionnaire to study empathy and noted that medical students show decline in their level of empathy during the third year of medical school. It is also interesting to note that women in general show more empathy. In a separate study senior physicians were noted to learn and modulate their level of empathy so they do not burn out.

We also know that it is possible to learn empathy. Meditation studies on Buddhist monks have shown that areas of brain which are active when one experiences compassion is more active in an experienced monk practicing compassion-meditation than in a novice. In other words, it is possible to improve the neural correlates of empathy and hopefully empathy. If we can teach skills in developing appropriate empathic connection with their patients, it may help prevent emotional stress and burnout among our young physicians. It may also enhance professionalism and patient-physician relationship.

Is it possible to study the neural circuitry involved in what we call wisdom? Some may say that it is a quality that cannot be studied and quantified. But, it is possible to list qualities that are present in someone whom we call “wise”. Indeed all cultures have an idea of what wisdom consists of.

In an article summarizing neurophysiology of wisdom, Meeks and Jeste show that many of the elements which are listed as component of wisdom are common in different cultures. They are “rational decision making based on general knowledge of life, pro-social behavior including empathy, compassion and altruism, emotional stability, insight and self-reflection, decisiveness in face of uncertainty and tolerance of divergent values systems”. Interestingly, neuro-imaging studies show that prefrontal cortex and the limbic striatum are the two regions of the brain connected with several of these mental functions, when studied separately.

The limbic system is involved with emotions. Prefrontal cortex is essential for what are called the executive functions of the brain. Executive functions control and regulate other behaviors and include the ability to form concepts, think in abstract, adapt to new situations and change behaviors as needed and plan future actions based on observation, experience and insight. Wisdom involves balancing one’s emotional and rational aspects. Therefore it is not surprising that when you define wisdom by its component parts, it is possible to find out what its neuroanatomy is.

Consciousness, Empathy, Self and Wisdom

2011-05-25T16:38:00.000-07:00

(Dear reader: This is the first of a series on the neuroscience of these topics and their relevance to the practice of medicine and medical education. The references will be given at the end of the series. In addition, if you are near New York City, hope you can visit the special exhibit on the Brain at the Museum of Natural History. It runs through July of 2011. Thanks)

Consciousness, empathy and wisdom were in the domain of philosophers and religious scholars. Not any more. Neuroscience has started studying these functions of the human brain. The results of investigations by the neuroscientists are exciting and will have practical applications in understanding normal and abnormal mental functions. It will have an impact on the way we care for patients, particularly those of mental illness and Alzheimer. An understanding of empathy and wisdom may help us physicians in our own development and in medical education too.

Observations of patients undergoing brain surgery and patients with head injury and tumors had helped localization of functions to specific areas of the brain, even before the availability of recent research techniques. (Please read articles by Broca and Penfield and books by Oliver Sacks for details). Ancient Egyptian documents (Edwin Smith Papyrus) describe paralysis of the right half of the body in a person who fell off a chariot and had injury to the left side of the head. More recently the famous Mr.Phineas Gage had a remarkable recovery from a missile injury to the frontal cortex of the brain and lived to show changes in his personality and behavior suggesting that this area of the brain is necessary for our “executive functions”.

Now there are powerful tools such as fMRI and SPECT which can study the brain of normal persons in action when experiencing specific emotions and during specific mental activities. An even more powerful tool called optogenetics may open up study of the brain at a cellular level.

Observations of patients with specific mental deficits and functional imaging studies have shown that memory functions of the brain are mediated by several areas of the brain, each one specific for particular aspect of memory. Episodic memory (eg: remembering what you ate for lunch or dinner yesterday) depends on the medial temporal and prefrontal cortex. Semantic memory (word and speech based) depends on the integrity of the inferolaterl temporal lobe. Procedural memory (eg: driving) are mediated through cerebellum and motor cortex. Working memory for spatial details is carried out by prefrontal cortex and visual-association areas.

More recently, studies using functional imaging show that coordinated activity in specific areas of the brain (neural circuitry) determine specific mental functions, mood and behavior. For example, coordinated processing of information between amygdala, hypothalamus and hippocampus is involved in determining our moods. Fear circuitry involves amygdala and ventromedial prefrontal cortex and dopaminergic circuitry is involved in reward and expectation of reward functions. Abnormalities in the functioning of these circuits have been implicated in depression, Post Traumatic Stress Disorder and impulsivity.

Several years back, the so-called “mirror neurons” were described in the ventral premotor cortex of the brain. These neurons get activated when a subject is involved in a specific motor activity such as grasping an object. What is interesting is that this area will get activated in an observer also. Since then we know that this mirror activity is not confined to observing someone in activity. It is applicable to seeing someone else in pain. Activation of specific areas of the brain occurs both in someone who is experiencing physical pain and someone dear to the subject who is observing this experience.

It appears the that “the ability to project ourselves imaginatively into another person’s perspective by simulating their mental activity by using our own mental apparatus “ is involved in our ability to read each other’s mind. “To understand what another person is doing, we simulate his movements using our own motor programs; to understand what another person is feeling, we simulate his feelings using our own affective programs”.
For example when one experiences pain, several areas of the brain show increased activity. They include periaqueductal grey, thalamus, insula, anterior cingulate (areas 24, 25, 32 and 249,329) and prefrontal cortex (areas 9, 10, 44). When someone dear to you is getting stuck with a needle for a medical procedure and you are watching it, the same areas of the brain that light up in the other person will light up (become active) in you also. In other words, this is the neural correlate of empathy.

We can see how “mirroring” of neural representation is important in human relationships and in the survival of early societies. This is the neuro-biological basis of empathy, compassion, helpfulness and altruism. This leads me to a discussion of empathy in medicine.

Shallow thinking

2011-05-08T07:35:00.000-07:00

The younger generation is called digital natives, as opposed to us “oldies” who are called the digital immigrants (Mark Prensky, 2001). They are growing up in the information age. The volume of information available at one’s finger-tips, at the click of a mouse is truly mind-boggling. I do not think our human brain is capable of managing all of this information. It will adapt, but over time.

There are a few known facts about the brain. For example, the amount of information arriving at the retina (the actual image-capturing part of the eye) is estimated to be the equivalent of 10 billion bits per second. But, only 10,000 bits per second reach the area of the brain where vision is processed. The brain is made to survey the entire scene and make a quick decision and therefore it tends to leave out many details. It tends to abstract a manageable pattern without worrying about the particular.

It is also known that the brain cannot deal with approximately more than 7 bits of information at a time. Here also, the ability to abstract helps since that gives the brain less number of items to deal with. Indeed, the brain seems to do best when it can compare two items at a time and keep eliminating all the options except one best answer.

In my companion site on “Time for thought”, the emphasis is on how to think for yourself. It is important to learn how to get the most reliable, practical information from this vast amount of good, bad and outright wrong and harmful information. Then you have to think. You have to think carefully, because when there is too much information, the brain tends to be shallow in its analysis. The brain can think deeply, paying attention to all the details, if the information is manageable. But, with too much information, the thinking gets shallower. There is a whole new book on how the internet is changing the way our brain works. It is called The Shallows. (Nicholas Carr, Norton, New York. 2010)

Collect all the information you want. Go for the original and substantiated information. Assign time to look at what you collected. Discord useless, wrong and irrelevant information. Then spend time thinking.

Diary of a Dying Cancer Patient

2011-04-04T04:21:00.000-07:00

I was deeply moved by reading notes from the diary (journal) of an adolescent boy dying of cancer. This young man needs a special salute for his courage to reflect on himself and document his feelings and experience. He needs our thanks for making his journal open to all of us by stating: “This book – Anyone who wants to read “. His physician who was given the privilege to read the journal has provided us with a summary of this boy’s experience (Arch Pediatr Adolsec Med 2011; 165: 28-32).

It appears that there are five major themes in his journal. They are: adolescent development issues, various methods he used to escape from the “illness” portion of his life, changing relationship, dealing with symptoms, particularly pain and fatigue and spirituality. Although it is one person’s experience, this is valuable in understanding what the needs of patients with terminal cancer are. It is only by understanding what the needs of patients are that we can provide helpful services.

May I add two comments on related topics? 1. In his struggles to find meaning and purpose in life, this courageous boy finds out the need for faith in something “Bigger” as a source of strength, when he realizes that he is losing the battle. We need to remember that this struggle may be different depending on the age of the child. For those of you interested in knowing more about the development of faith in children, please read a simple essay by Dr.Patricia Foserelli in Contemporary Pediatrics (January 2003, pages 85-98).

2. One method that has been shown to be helpful to combat stress is keeping a journal. Indeed a study on stress-reduction among physicians in critical care showed that the two most helpful activities were meditation and journal-writing.

Bedside rounds and the so-called “difficult” patients

2011-03-08T12:07:00.000-08:00

I read an essay on how to use bedside rounds to teach medical students about “difficult” patients. This was by a psychiatrist (What would Osler do? Learning from “difficult” patients. Kahn MW. N Engl J Med 361: 442-443, 2009).

Doctor Kahn points out how he structured the interviews with patients for this exercise. This had two parts. The first is to let the patient vent his or her feelings, frustrations and anger. Having used this technique myself, I agree how often the patient calms down after someone is willing to listen to them, however unreasonable they may be.

The second portion is to ask questions such as “Where do you live? Who is there to help you at home? What are some things you enjoy in life?”. It is not adequate if we ask. We have to listen – truly “listen deeply with compassion" and without judgment as Rev.Thich Nath Hanh and Dr.Carl Rogers would recommend. How else can we find out what the real problems are for the patient and how the patient perceives these problems. The quote from Osler by Dr.Kahn is perfectly appropriate: “ It is much more important to know what sort of a patient has a disease than what sort of disease a patient has”.

Bedside Patient Rounds

2011-02-07T04:27:00.000-08:00

The Greek root for the word “clinician” is “klinikos”( the bed). Clinician is so called because he/she works at the patient’s bedside. It stands to logic that clinical teaching has to be at the bedside. All senior clinicians know that clinical skills have deteriorated over the past several decades and agree that bed-side teaching of medical students and house-staff is essential. Medical students look forward to clinical teaching with hands-on experience. After all, that is what they expected and entered medical education for. Patients know that the society needs future physicians trained in clinical skills. Patients have repeatedly stated that being part of clinical teaching is valuable and important to them. Most seem to enjoy the experience. If so, what is the problem?

Efforts are under way to improve the situation. Some medical schools have started bed-side teaching starting in the first year and continuing through the entire 4 years. Supervised physical examination followed by immediate feedback is part of the requirement for students in their senior year in some schools. But some basic problems remain such as inadequate number of clinical role-models as teachers, time constraints on clinical teachers (between their RVU’s and teaching schedule) and the related issue of who pays for teaching-time.

I have always felt most comfortable teaching at the bedside by modeling my behavior. It was challenging to balance the needs and expectations of the child and the parent and the needs and expectations of the learners. If we are to re-invigorate bed-side teaching, we need to know what the expectations, fears and hopes of patients are and what they like and do not like about bed-side teaching. Some will not like it at all, and we have to be sensitive even if they do not voice their objection.

Incidentally, one of the most intriguing things I have done during bedside rounds is to let the mother do the teaching, when appropriate. This was most effective when caring for children with uncommon conditions and syndromes. The mothers knew more than me anyway. They enjoyed teaching. The students learnt not only medicine but also what it is to live with a child suffering from a complicated chronic disease. I learnt a whole lot in the process!

There are a few studies on the patients’ perspective on bed-side interactions. The one I wish to comment on is by Drs. Fletcher, Furney and Stern (Patients speak: what's really important about bedside interactions with physician teams. Teaching and Learning in Medicine 19: 120-127, 2007). This is a study based on a theory of qualitative research, called Grounded Theory in which a model is created based on analysis of actual data. Selected patients were interviewed to voice their opinions on the perceived benefits and concerns related to bed-side rounds. These audio-taped interviews were analyzed to generate a model in which items of importance to patients were categorized. The final model contained two major components: 1.Patient-team interaction and 2.Team characteristics.

Category 1 (Patient – team interactions) included items related to information exchange, evidence of caring, involvement in teaching, knowing the team and bedside manner. Category 2 (Team characteristics) included items related to team attributes and team collaboration and communication. Patients had lots to say about all these areas – not surprisingly. As pointed out by Walker Percy, “if you listen, patients will tell you not only what is wrong with them, but also with you”.

You may wish to read the article for details. But the items I looked for relates to the “bed-side manner”. What do patients think it is made of? Here are some ideas: “showing interest in patient via nonverbal cues, establishing personal connection, acknowledging patient’s affect” and “non patronizing” attitude, using humor (Caution: It has to be proper and appropriate), using language they can understand and not allowing more than one person examining at the same time”.

Most patients were positive about their experience. But I was surprised that many patients did not feel they contributed much to the learning of students.

All these observations are intuitive to expert clinicians. But it is good to have science behind it so we can teach the junior faculty and students. It is interesting that the Bill and Melinda Gates Foundation is spending millions of dollars to study the characteristics of good teachers in public schools. We need to know what makes for a good teacher in a medical school at the bedside.

More thoughts on Thinking Skills

2011-01-11T16:37:00.000-08:00

I came across two letters from my correspondence with an insurance investigator. This blog is based on those letters.

In 1979, I was fortunate to sit next to a gentleman in an international flight. During our discussion, I learnt that he was an investigator for an insurance company. He was an expert in investigating fires and figuring out what started the fire, where it started and how it spread etc. His logical thinking was amazing and it was very similar to the way good clinicians think during the process of differential diagnosis. We discussed these similarities and recognized that the process is similar whether you are investigating how a fire started or how a disease I started. I suggested that he write a book on how one should think in a logical fashion to solve problems.

I wrote to him in July of 1979. In September I heard from him, from his sick-bed. He said: “The joy of having a fit body and a keen mind has all but gone”. I felt so sad to read that sentence. I learned a lot about how one feels when sick. He was brutal about the way physicians treated him. He called them “tight-lipped” and how they wanted him to accept serious treatment without explaining the reasons.

He went on to say why he does not think he will write a book. But two remarks from his letter are worth quoting: “ …….most of my decisions and inspirations are invariably involuntary but at the same time they stem, not from the loftiest thought process but from basic reasoning, imagination and common sense”. He then went on to say that he knows that text books are necessary but “in the young person they trap the mind; thinking is relegated simply to remembering”.

I never heard from him again. But I will never forget him as one of the people who stimulated me to think logically and to emphasize thinking skills in learning and education.

Do no harm

2010-12-16T09:26:00.000-08:00

A recent CPC in the New Englad Journal of Medicine (November 11, 2010) on wrong-site surgery (wrist instead of one finger) and wrong procedure (carpal tunnel release instead of trigger-finger release) has an excellent discussion on causes of human error, disclosure of errors and caring for the caregivers. True to the tradition of the series, there is an excellent list of references on these topics. I would like to draw attention to two of those articles.

The discussion in the NEJM points out how error can occur due to breakdown in skill-based behavior or rule-based behavior or knowledge-based behavior. Skill-based behaviors involve routine tasks. Rule-based behaviors involve algorithms and check-lists. Knowledge based behaviors require “conscious problem solving and application of standardized knowledge to novel and unexpected situations”. Obviously the causes will be different for each of these areas of skill.

The first reference article reviews these causes and models of human error (Reason J. Human error: models and management BMJ 2000; 320: 768-770). This excellent review points out how one of the commonest responses to an error is to blame the involved individual. This is the Person approach model of error of causation and we all know that “blaming individuals is emotionally more satisfying than targeting institutions”.

In the System Approach, we concede the fact that humans are fallible. “We cannot change the human condition” but “we can change the conditions under which humans work”. The emphasis is not who made the mistake but asking whether steps were taken to minimize errors and if so where and how they broke down.

We are told that in plane accidents, the pilot is not singled out except when he/she was under the influence of mind-altering substances or knowingly violated the safety protocol. Based on studies conducted in US Navy Nuclear aircraft carriers, Nuclear Power plants and air traffic control centers with heavy work-loads and demanding activities but with low adverse incident rates, the system approach lays emphasis on defenses, barriers and safeguards. Even with these safeguards, errors can and do occur because of unfortunate alignment of errors in different areas. This is called the “swiss cheese model” of harm creation.

The second, more theoretical article on “The role of error in organizing behavior” by Rasmussen appeared in Ergonomics in 1990 (Ergonomics 1990; 33: 1185-1199). I found it a difficult read. However, Table 1 is very useful to understand the concept of “interaction between different levels of cognitive control”, namely knowledge-based domain, rule-based domain and skill-based domain”.

Shared decision making

2010-11-30T11:27:00.000-08:00

In my Handbook of Clinical Skills, I discussed decision making by the physicians on diagnostic and treatment strategies and also discussed some ideas on how to help patients with their decision (shared decision making).

What does “shared decision-making” mean? How can a patient with limited understanding make a meaningful decision, particularly in the midst of a personal crisis? Is it even fair to ask them to do so? How can a physician respect the “autonomy” of the patient, provide appropriate information in an understandable manner and make the patient truly a partner in the decision-making?

Communication skill is the key. The first step in communication is compassionate, deep listening. Without listening we cannot understand the patient’s fears, hopes, predicaments and values. The next step is the ability to present complex information in an understandable way. Of course, there has to be a trusting relationship.

Good clinicians have been performing these tasks admirably even before terminologies such as “patient-centered care” and “shared decision making” were coined. Two articles in JAMA dealing with this topic will be of great use, particularly to students, trainees and young practitioners.

The first one by Epstein and Peters (Beyond Information – Exploring patient preferences JAMA 302:195-197, 2009) deals with how physicians can help patients understand cognitive, emotional and relationship factors that influence their preferences.

The other paper by Alexander Kon (JAMA 304:903-904, 2010) is a broader discussion of shared decision-making. Dr.Kon suggests that this be viewed as a continuum, which it is. He provides a diagrammatic description of this continuum at five levels: fully driven by patient (or patient’s agent), strong physician recommendation (in which he clearly states his preference with supporting reasons), equal partnership in which the patient values play a significant part, informed non-dissent (in which the patient does not veto the physician’s recommendation) and completely physician-driven.

When a physician has long-standing relationship with a patient and knows him/her well and there is mutual trust and open lines of communication both ways, there are very few problems. But, in several situations such as decisions in the critical care unit, during end-of-life care, emergency care and complicated chronic illness where there are differences of opinion, shared decision making becomes a delicate task.

Patient perspective

2010-11-16T02:38:00.000-08:00

Diseases are recognized by their symptoms and signs and confirmed with several laboratory and imaging studies. Ideally, treatment is aimed at stopping and reversing the pathology and thus controlling the symptoms and signs. Reversal of pathology as shown by relief of symptoms and normalization of laboratory and radiological changes are easier to document in acute diseases.

Things are not so easy in chronic diseases. For example, rheumatic diseases are notoriously difficult to diagnose and manage. They evolve over years. They are multisystem diseases. Their clinical features overlap. Fortunately, management of rheumatic diseases has improved dramatically in the past two decades. Several new drugs have been introduced in the management of rheumatoid arthritis, systemic lupus etc. During the development and testing of these diseases it became clear that we needed objective and quantifiable criteria to diagnose and document acuity, chronicity, damage to organs, improvement on therapy, flare and remission. Several tools have been developed for these purposes for each of these diseases. Initially, all the tools included objective and quantifiable criteria. However, it has become obvious that many of the drugs we use may relieve the symptoms or normalize laboratory values, but do not make the patient feel better subjectively. Therefore, there is recent emphasis on including items of importance to the patients (subjective data) in measurement tools.

For example, in one study, in-depth interview with 23 patients generated 63 items of importance in outcome. This list was similar to those already in use by physicians. However, the priorities were different. For example, participants in a survey ranked the following items high on the list: less pain, doing everyday thing, more mobility, less fatigue, more independence and doing things they want to do. This should be no surprise at all.

Hopefully, future outcome measures will include items of importance to patients (subjective) in addition to the traditional items that measure control of the basic disease (objective).

On becoming an effective teacher

2010-10-16T08:17:00.000-07:00

I am scheduled to give a seminar to young physicians who plan to make teaching as their career. The topic is “On becoming an effective teacher”. I have been reading and reflecting on ancient and modern teachers in preparation for this seminar. I was greatly impressed by what I read in some of the ancient Sanskrit literature from India. In those days the tradition was oral transmission and not writing. Reading what those wise men said was inspiring to the teacher in me. (Incidentally, the word Guru was intended to refer to these masters) These master teachers showed humility about their knowledge. They showed respect for their students and appeared to have had a good grasp of psychology of teaching and learning. This essay is to support this observation.

Almost all the Upanishads (sacred texts of Hinduism) and epics were written as answers to questions by ardent seekers. Bhagvat Gita came into being in answer to a question by Arjuna, a warrior. In Bhagavata Purana there are sections consisting entirely of questions.

Bhagavat Gita is a sacred text of the Hindu tradition. In this text, Lord Krishna answers all of Arjuna’s metaphysical and mundane questions in detail. At the end of this text, after expounding the entire essence of the relationship between the Supreme, the individual and the cosmos, Lord Krishna tells Arjuna: Ithi thay gnanam aakyaatham guhyat guhyataharam mayaa vimrushya ethath ashesheyna yatha icchasi tathaa kuru” (Chapter 18, stanza 63). The meaning is: “I have declared to you the secrets of secrets. Reflect on it fully and act as you like”. He did not say: “This is what you should do”.

In the other classic, Yoga Vasishta, the sage Vyasa is teaching young Raama, the hero of Ramayana. At the end of Chapter 21, Vasishta says: “shruthva vichaarya cha iva anthah yath yuktham thath samaachara” , which means “Having heard and examined it within yourself, do what is proper”.

There is one Upanishad called Prasna Upanishad. Prasna means questions! Obviously this is the “Questions Upanishad”. Four students approach a learned man by name Pippalada with their questions. Each chapter starts with a question by one of the students followed by the teacher’s answers. It is amazing to read the 2nd stanza which is a statement by the teacher. He says: “Come with faith and mental preparedness and ask your questions. I will explain, whatever I know”. (yadi vignayasyaamah vo vakshyaamyah)

In another Upanishad called Brhadaaranyaka Upanishad there is a dialogue between King Janaka and the sage Yaagnyavalkya (Chapter 4, Section1). When Janaka asks a question, the sage answers by saying: “Let me hear what anyone may have told you”. Starting where the student is at his state of knowledge is an extremely important point in teaching.

Another master teacher is Adi Sankara who lived several centuries back. His period is disputed but generally assigned to the late 8th century (788-820?). One specific sentence he wrote attracted me to him. This is: “na hi prathyakshavirodhey shruthey praamaanyam” meaning that sacred texts cannot be an authority as against observable facts! He follows this sentence by saying that even if hundred vedic (sacred) texts say fire is cold and devoid of light, it is not so. I understand this statement to mean: “Don’t just swallow whatever is written or told to you; Think”.

The attitude of the ancient masters (guru) shows their respect for the students as individuals and their trust in the student’s capacity to grow. This is good psychology of learning and of teaching.

Effectiveness and Efficiency

2010-09-21T15:02:00.000-07:00

I mentioned Comparative Effectiveness Research in the previous essay, without elaboration. Now, you can learn more about it in the Medical News and Perspective section of the JAMA ( September 8, 2010. Pages 1058-59). NICE (National Institute for Health and Clinical Excellence) has been performing this function in UK for about a decade. If you wish to learn more about how this Center works in UK, please read this interview with Dr.Kalipso Chalkidou, the Director of the International Program at NICE.

Effectiveness and Efficiency

2010-09-18T04:18:00.000-07:00

Effectiveness and Efficiency is the title of a monograph written by the famous Doctor Cochrane of the UK. This was published in 1972 by the Nuffield Provincial Hospital Trust. I was fortunate enough to come across this publication in the 1970’s and was impressed with so many of his observations. I tried to remember his remarks whenever I was ordering new laboratory tests or deciding about newer forms of treatment. They helped me understand the deficiencies in the way we practice medicine. So many of the remarks he made in his concluding remarks still hold good, after 40 years.

I read the monograph again recently and was so impressed that I decided to quote a few of his remarks.

“If we are ever going to get the ‘optimum’ results from our national expenditure on the NHS we must finally be able to express the results in the form of the benefit and the cost to the population of a particular type of activity, and the increased benefit that could be obtained if more money were made available.”

“…In particular, I believe that cure is rare while the need for care is widespread, and the pursuit of cure at all costs may restrict the supply of care, but the bias has at least been stated.”

He points out the need to “use science to control this inflation” and acknowledges the probability of decrease in clinical administrative freedom.

Prof. Cochrane was probably the first to emphasize “outcome research” to establish the utility of scores of tests and medical devices which enter into medical practice every year. This will also include comparative effectiveness research. We all know that the current trend just cannot go on unabated without bankrupting the entire national budget.

Doctor Cochrane concludes the monograph with a poem by Eliot and says: I hope clinicians in the future will abandon the pursuit of the “margin of the impossible” and settle for “reasonable probability”.

I wish more of our young physicians and politicians will read this classic monograph.

Franz Kafka on Being a Doctor

2010-08-25T14:57:00.000-07:00

“Filling prescriptions is easy, but getting on with people is harder”

quote from A Country Doctor, in Metamorphosis and other stories by Franz Kafka,
Translated by Michael Hoffman. Modern Classic Series. Penguin Books, London. 2007. Page 188

Informed Consent

2010-07-29T16:46:00.000-07:00

In my book on Handbook of Clinical Skills, I did not discuss Informed Consent adequately. Recently I saw several articles and books on the subject.

Ethics demands that physicians obtain informed consent from the patient before initiating treatment, except in emergencies. It is also required by law. In certain situations, this becomes a difficult issue. When the affected individual is not capable of giving informed consent as in pediatrics and geriatrics, what should one do? What should one do when dealing with adults who have mental illness or under the influence of drugs or alcohol?

We all know that informed consent implies “understanding, voluntariness and authorization” on the part of the person who gives consent. Things are not that simple however.

Understanding on the part of the patient depends on the ability of the “information-giver, the clinical setting, patient’s socio-economic status and educational level, patient’s mental state and values. The physician’s focus is on the welfare of the patient and he has to be able to know the facts, ability to apply those facts to the patient’s special condition and also on patient’s values. He has to be able to present the facts and alternatives in a language understandable by the patient. And then it is the patient who has to analyze the risks and benefits of the alternatives and make the decision and be able to communicate it to the physician.

Informed consent requires that the physician explains the facts about proposed treatment and its alternatives in a clear, understandable fashion. It requires that the pros and cons of the suggested treatment and of the alternatives are laid out clearly. It also requires that the patient’s mental and emotional conditions are such that he/she can understand the facts and their implications. It also requires that the patient has the needed educational and intellectual skills and ability to reason out the differences between the alternatives. It further requires that the patient is truly free to make the choice and has the necessary socioeconomic background to go through with the decision.

Informed consent requires competence on the part of the patient. How does one assess competence? Is it a legal definition or a clinical definition when physicians say that a particular patient is competent or incompetent to make a decision? Doctor Applebaum who has written both books and articles on this subject points out the difficulties in this area of definition and the lack of distinction between the words “competence” (legal) and “capacity” (clinical).

There are several tools for systematic assessment of patient’s capacity to make decision. These are based on an understanding of the subcomponents of the entire process. They are: 1. Ability of the patient to communicate his/her preferred treatment option. 2. assessment of the patient’s understanding of the information provided by the physician. 3. Assessment of the patient’s understanding of the consequences of the proposed treatment and lack of treatment and 4. Reasons why the patient chose the treatment he decided on (or refusal of treatment).

There are specific questions one can ask to assess each of these four steps. Several of these questions are listed in a table in one of the articles by Doctor Applebaum (Assessment of Patient’s Competence to Consent toTreatment. N Eng J Med 2007: 357; 1834). He also refers to other formal tools such as the MacArthur Competence Assessment Tool.

In a recent piece on this topic Doctor Zaldy Tan points out how things are not so simple in a clinical setting (The Right to Fall – A Piece of My Mind. JAMA. 2010; 303:2333). There are other factors particularly “values”, a nebulous, subjective term influenced greatly by cultural and religious beliefs. Then there are the language barriers in understanding what is presented and expressing the decision.

One recent book by Franklin G.Miller and Alan Wertheimer on The Ethics of Consent: Theory and Practice (Oxford University Press, 2010) is about consent in general. A review of this book by Robert Veatch (JAMA 303: 2531-32, 2010) is worth reading.
Reading Doctor Veatch’s review, I learned that the current concept of consent is considered to be “autonomous authorization” and that an alternate concept is “fair transaction”.

There are situation when it will be acceptable and is indeed accepted that physicians act without “autonomous authorization”. There are situation where autonomous authorization is absolutely imperative. Indeed it may be illegal not to do so.

Uncertainty

2010-07-10T03:02:00.000-07:00

In my Handbook of Clinical Skills, I wrote about the art of making decisions under uncertain conditions. Since then, I came across a quote by William Osler which says: “Medicine is a science of uncertainty and an art of probability”. There is an editorial and essay on this topic in a recent issue of the Lancet (Lancet May 15, 2010. Pages 1666, 1686-87) Both point out how in spite of all the statistics and probability theories, uncertainty is a central problem in the practice of medicine and is likely to be so always. How can this problem be approached by physicians?

In an earlier issue of Lancet (April 11, 2009, pages 1244-1245), Dr. deMelo-Martin points out how Rene Descartes’ quest for certainty as the standard of knowledge based on scientific inquiry has benefited humanity immensely. However, in the process of inquiry, “the knowable has been reduced to the measurable”. Areas that are ambiguous and not measurable get out of sight. Still these are the areas that need to be explored when physicians want to help patients under uncertain conditions.

How can physicians help patients cope with uncertainty and make meaningful decisions with serious consequences? How can physicians gain more insight into “values, meanings and priorities” of patients? This will take time and patience. Careful, compassionate and deep listening and dialogue with patients exploring alternative avenues acceptable to their value system will help.

Practical and Productive Thinking

2010-06-23T17:24:00.000-07:00

I was reading a book by Mortimer Adler on Aristotle. The chapter on Productive thinking and Practical thinking was stimulating to read. Productive thinking requires knowledge and know-how. Practical thinking requires an idea of the ends and the means to get there. We need more practical thinkers, as defined by Aristotle.

We do have such thinkers, if only they are listened to. One such is Doctor George C.Halvorsen. His book on “Health care will not reform itself” (CRC Press, 2009)is full of practical ideas with data to back them up. He considers the current status of health care in US as “ the epitome of a non-system”.

It is very clear that when you wish to solve a problem, you need practical thinking. You have to identify the problem and set a goal first. Then you collect data, analyze them and look at various methods to reach the goal.

But, what have we seen so far in solving the health care crisis? An ideology or a specific tool has been touted as the solution to the problem. In other words, the goal has to fit in with the means!! If you have already decided on the means, how can there be a discussion or meaningful solution to the problem?

Some quotes from Doctor Halovorsen’s book are such contrasts to the closed minded thinking of politicians and technology experts:
“We need goals – and then we need strategies to achieve those goals”.
“Work backwards from the goal to the strategy”.
“We need clear goals, a strategy to achieve each strategy, and the tools necessary to achieve each strategy. Tools make huge sense when we have a strategy”.

Healthcare viewed as a commodity

2010-05-08T03:19:00.000-07:00

Soon after I posted the earlier blog on medicine as a commodity, I came across another concept. This is about how a member of a society is viewed. Is he/she viewed as a citizen? Or is he/she viewed as a consumer?

For a citizen, health care is a necessity, if not a right. If the citizen is viewed as a consumer, health care can become a commodity. But, it need not, if we reject the definition of “commodification” as applied to health care.

This dichotomous thinking is artificial since an individual is both a citizen and a consumer.

Is Medical care a commodity?

2010-04-13T09:46:00.000-07:00

Recently, I came across three concepts on commercialization. I wondered about the relevance of these concepts to the practice of medicine.

The first is a definition of the word “commercialization”. According to one definition it is “Commodification or stripping an object of all other values, except its value for sale to someone else, and marketing” . Just by the nature of it, medical care is laden with several values including the values of life itself, compassion for the suffering, equality of human beings among many other values. I find it difficult to imagine how it is possible to strip all these out of care of the sick.

The second is a statement by a professor at a business school. I have forgotten his name and the exact quote. But the essence of his statement is that any manager of a business organization, who worries about the social responsibility of the organization, does not belong in that position. In other words, his/her responsibility is to the bottom-line of the organization, to the Board and to the shareholders and not to the society they are part of.

Since I quote the above statement from memory, I may not be accurate. But I know it is not too far off the base. Indeed, an executive friend of mine confirmed that this is true of what is taught. He also pointed out how when companies support social causes it is only for greater visibility and goodwill. It has nothing to do with social responsibility. When conditions get tough within the organization, these social programs will be the ones to be cut out.

From the organization point of view, it makes sense. However, it amazes me to think that managers will be taught not to concern themselves with social responsibility.

The third is an essay by a member of the Rajya Sabha (one of the two houses of the parliament) in India. In an article he had written in a local paper, he says that “capitalism” reduces all public utilities into commodities for sale and “profit”. He goes on to say: “Capitalism had little need for commodities like health, education, sanitation etc which have an irreplaceable “use value” determining the quality of life of human beings”………… and how these are converted into commodities with “exchange values” that generate “profit”. Of course, he is using emotionally charged words to influence our thinking. If we listen without judgment, we realize that this is similar to the definition of commercialization (Point 1, above).

If we can go past words that generate “heat” such as capitalism, socialism, commercialization and profit, these three concepts, taken together, do shed some “light” on the dilemma we face in delivering health care to people who need them. We need to stop pretending as if medical care is a commodity and start thinking fresh on basic human needs, quality of life, “use values”, “exchange values” and profit as applied to health care.

Compartmental View

2010-03-10T05:06:00.000-08:00

Oriental philosophy, particularly the Buddhist philosophy emphasizes how perceptions are not reliable even when the organs of perception are working well. They point out how perceptions do not reveal objects of perception as they are, but modified by our “mind-consciousness”. All of us know this. Our point of view, our bias and our mental blocks can and often do alter perception.

Good clinicians know this too. In our communication with patients it is not what we say that matters; but it is how our message is heard, interpreted and acted upon. What we as physicians think is important, may not be important to the patient. Conversely, when patients tell us some of their concerns, they may not even register in our psyche. We look at things from different points of view because we tend to live in different compartments. “Compartments can profoundly affect the context within which we view reality”, as pointed out by Doctor Steven R. Feldman from the Center for Dermatology research at the Wake Forest University in his Clarence S. Livingston Lecture (Dermatology Online 13 (4): 20, 2006).

Using clinical examples, Doctor Feldman points out how we fail to see things that are happening in the “patient’s compartment” and how we cannot trust even things we see in the "physician compartment" because of built-in bias, selection-bias etc. He also extends these concepts to other public arenas and has even published a book on this topic. Without getting into the controversies, I have to agree with him when he says that “most of the time there is no pure good and there is no pure evil; there are simply perceptions of reality that are colored by context”. Therefore, it is important “that each side consider and understand how the other views the issue” from their compartmentalized context. This is important in all human relations - personal, professional and political.

Physician - Patient Relationship

2010-02-21T07:37:00.000-08:00

Patients' view of characteristics of outstanding physicians

All of us have worked with outstanding physicians during our learning years and most of us have modeled after them. If someone asks you to describe specific aspects of their actions leading to your impression, what will they be? You will include in this list items such as excellent knowledge, great bed-side manner etc. That is from your point of view as a physician and that is fine. But, what qualities do patients think are important in a physician to be designated as an outstanding clinician?

If you do not know already, there is a free, public website (www.drscore.com) which collects satisfaction ratings of U.S. physicians by patients. This is done anonymously. Roger Anderson, Angela Barbar and Steven Feldman (http://www.drscore.com/press/releases/7traits.pdf) used this data to describe the qualities of medical practitioners that patients value most.

Patients noted 24 specific traits which fall under seven major domains. The seven domains are: 1. Access to care. 2.Good communication. 3.Personality of the provider. 4.Quality of care. 5. Continuity of care. 6. Quality of the facility in which care was provided and 7. Office staff.

What are the components in each of these domains which create an impression of excellence in the recipient of care? In the domain on Access to care, what patients want most are relatively short waiting time to get an appointment, relatively short waiting time once they are in the office or clinic and the ability of the physician to get back to the patient over the phone reliably and quickly after a visit. Common comments include: “Extremely sensitive to phone calls”, “I can call him anytime” and “always timely”.

In the area of communication skills, patients identified the physician’s ability to give personal attention, to listen seriously, to treat patients as partners in decision-making and to give information in an understandable and understanding way as important. Typical comments include: “He truly listens and does not shrug off what you are feeling”, “you can open up to him” and “He explains to me everything so that I can understand it”.

What do patients mean by “Outstanding personality and demeanor”? Patients want to know and feel that the physician recognizes the visit as highly personal and not a business transaction. They expect warm personal qualities in the physician such as friendliness, a caring attitude and humaneness, and understanding. They want to feel that the physician understands their concerns, shows empathy, takes the patient’s interest first and is knowledgeable, so that they can develop trust.

Patients obviously value competence in their physician as an extremely important requirement. However, what the medical profession defines as competence and how it tests for competence is only one portion of what patients consider as competence. The other components are patient advocacy (the sense that the doctor has patient’s interest first), perceived thoroughness in taking history and physical examination and the way the physician looks at issues related to medicines he prescribes. Patients tend to favor physicians who are cautious in the use of medicines, open to alternative approaches, keeping the cost of medicines manageable and explaining the good and bad points of medicine.

Patients definitely value continuity of care and follow up on details as shown by comments such as “If he is doubtful about his decision, he asks for second opinion”, “ He follows through with everything” and “very good about follow-up with other doctors involved”.

Professional, friendly staff who make patients welcome and who are helpful make a big difference in the perception of patients. As I have said always: “The person who answers phones in a doctor’s office is the most important person in starting the relationship on solid grounds”. For the same reason, I am against automatic answering machines, although I know it is cost effective!

Of course, clean, modern and patient-friendly office atmosphere is important. Patients also will feel more confident when the office is well-organized and not chaotic.

Finally, the authors make an important statement in their discussion.It is: “…..while patients value technical expertise, their overall health care experience is driven largely by other factors”. This includes areas such as accessibility, clean safe facilities and personal attention.

Good clinicians know what excellence in medical care is. They teach this by acting as role-models. However, when we teach future physicians, they need to know what excellence is not only from physician’s point of view and but also from the patients point of view. They do differ because we live in two different compartments. We have to know what is in the other compartment. This will be the subject of my next blog.

Mentor

2010-02-08T16:27:00.000-08:00

We hear the word “mentor” often. It feels good when someone says that you are his mentor. We all have read the story of Odesseus and his son Telemachus. We also generally understand that mentor is a wise counselor. However, this word is often used when a more appropriate word would be teacher, tutor, advisor, preceptor or counselor. What does the word truly mean?

In a fine essay, Drs. Sambunjak and Marusic of Croatia define the structural, interactional and temporal features of mentoring. (Mentoring. What is in a Name? Sambunjak D and Marusic A. JAMA 302:2591-92, 2009) Structurally, it is a relationship between a more experienced or senior person (mentor) and a less experienced or junior person (mentee). The functions of the mentor include “sponsorship, protection and promotion of visibility”. This means that the mentor has an educational role (helping the mentee acquire and integrate new knowledge), personal role in helping the mentee to become increasingly self- sufficient and a professional role in making sure that the mentee reaches his full potential. It is interesting to note that the mentor does not play the role of an evaluator. Finally mentoring can continue over an extended time but must change over time before it becomes dysfunctional.

What is Clinical Competence?

2009-06-23T18:06:00.000-07:00

Initially I chose “Clinical Skills” as the title for my book. Later I decided on “Clinical Competency Skills” at the suggestion of an editor. I know what the word “competence” means. As usual, a common word takes a special meaning when it enters the lexicon of a profession or a trade. In medicine, competence is defined as “ the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served”. I prefer the simple definition, which is “capacity equal to requirement”.

There are several components to competency. The first requirement is that the physician is able to relate to people in distress and make them comfortable. In other words, he has human relationship skills. Knowledge is of paramount importance without which human relation skills are of no use, and may even be dangerous. The physician needs listening and communication skills. He needs procedural skills and clinical reasoning skills. Above all, he has to be able to reflect on daily experiences and keep improving all his skills all the time.

It is easy to enumerate the components of competency. How does one teach competency? How does one assess competency? A recent article on Assessment in Medical Education summarizes some of the domains within the realm of competency and methods of evaluation. I found Table 1 in this article very useful to think about competency in general and the difficulties in assessing competency.

Epstein RM. Assessment in Medical Education. N Engl J Med 2007; 356:387-96. www.nejm.org
Klass D. Assessing Doctors at Work – Progress and Challenges. N Engl J Med. 2007; 356:414-15. www.nejm.org

Communication Skills and Patient Safety

2009-06-23T17:58:00.000-07:00

Recently I attended a talk by Mr. Bill Taggart of University of Texas (at Austin). The topic was “ Lessons learned from Aviation – Practical skills that actually work”. The talk was excellent. If you wish to arrange for Mr.Taggart to give grand rounds at your Hospital, you may wish to reach him at the Human Factors Research Project at the University of Texas at Austin. (e mail address: BTaggart@aol.com) Mr.Taggart is the developer of Crew Resources Management Program that is used routinely by major airlines in US and abroad. More recently, he has started applying lessons learned in aviation industry to patient safety issues.

The topic is very important and timely. There are two additional reasons I am writing about this topic. 1.In my Handbook of Clinical Skills, I talk about learning from other professions. Here is an excellent example of learning from the aviation industry. 2. In his talk Mr.Taggart presented data collected between 1995-2005 by the JCAH on the root causes of sentinel events, surgery at wrong sites and perinatal injuries and deaths. In all of them, communication failure is on the top of the list.

When I condensed Mr.Taggart’s entertaining talk to a few “sound bites” with focus on communication (he talked about other topics too), here is what I got:

Focus has to be on the patient, But
Physician must know the big picture
Pay close attention to what the patients (and parents in pediatrics) have to say
Describe what you see (not impressions and interpretations)
Be clear and precise with the words you use to describe (no euphemisms, vague remarks)
Use the correct words to show the urgency of the situation

Communication Skills and Listening

2009-06-23T02:32:00.000-07:00

Common sense observation tells me that “listening” is a good thing particularly when you are helping someone who is grieving. I do not need “science” to prove that listening is good. But, it is easier to convince others with actual observations and scientific data.

In a recent article on this subject, investigators from France report on a prospective, controlled trial in which 126 family members of patients dying in ICU’s were randomly assigned to a formal intervention group or routine care group. The intervention group received care according to detailed guidelines developed specifically for end-of-life care. Outcomes were defined and appropriate statistical tools were used for analysis. The authors conclude that “using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement”.

There is an accompanying editorial that points out “A key skill is listening more and talking less”. It is the same as what Plutarch said several centuries back: “We have two ears and one tongue so we may listen twice as long as we talk”!

Most of us learn how to communicate with patients and how to comfort those in distress by just observing a few sensitive clinicians. It is definitely important to develop tools that help young physicians learn some of the principles of communication under different circumstances. The authors of the above-quoted study give a mnemonic to remember the steps in this process of bereavement-counseling. It is: VALUE.

Valuing and appreciating what the family members have to say
Acknowledging the emotions expressed by the family members
LISTENing
Understanding who the patient was as a person, by listening to family members
Eliciting questions from the family members.

References:
Lautrette A et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007: 356: 469-78.
Lilly C, Daly BJ. The healing power of listening in the ICU. N Engl J Med 2007; 356: 513-15.
Curtis JR et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med 2001; 29: suppl 2: N26-N33.

Humor- When and How to use

2009-06-23T02:22:00.000-07:00

I learnt recently that the word humor is etymologically related to the word humility. Good humor is kind and compassionate. It makes us laugh at human follies. The word seems to have another connection – with the humors of Hippocrates. According to his theory, when humors “flow” normally, one is in good health. Irregular flow of humors leads to ill health (or ill humor).

A sense of humor is essential in life – particularly in a physician’s life. Humor and laughter are helpful for patients in their recovery. However, physician’s work is serious. Good clinicians know when to use humor and when not to. Inappropriate jokes and bad timing can land you in trouble. I believe that patients do not worry as much about your sense of humor as about your knowledge and expertise. They may not like physicians who are too serious or morose. But I do not think they want a clown either.

I am a serious person by nature, and like to use humor sparingly. However, I love good jokes. In fact, I have been collecting medical jokes and have a whole file on them. Hope to share some with you periodically.

Here is a start. This one is by Art Buchwald in an essay on humor in JAMA (252:3014,1984). “If laughter is such good medicine, why won’t Medicare and Medicaid pay for it?”.

Here is another one from Henny Youngman who was famous for his one-liners. This is about a hotel room he was staying in. “ My room is so small, the mice are hunch-backed”.

Humor - Art Buchwald

2009-06-23T02:21:00.000-07:00

I am sad that Art Buchwald is no more with us. Only recently I completed reading his last book with the title “Too soon to say goodbye”. He says: “Doctors gave me three weeks to live. I never knew dying could be so much fun”. What an attitude to death! Or, Is it attitude to life?

It is amazing to read about his refusal to go through dialysis, accepting a life in a Hospice, having fun meeting people and writing this book and even organizing his own funeral.

There are quotable remarks all though the book. Here are a few about his stay at the Hospice:

“How long they allow me to stay is another problem. But in case you are wondering, I am having the best time of my life.”
“Dying isn’t hard. Getting paid by Medicare is”.
“Being 80 is a matter of life or death. I chose life. It is much better position to be in, and it is easier on your back.”
“At a certain time in life, actually right now, the two questions that become uppermost in my mind are: What am I doing here? And where am I going? The first one is a narcissistic one. I was put in this world to make people laugh. The second one is much harder – I have no idea where I’m going, and no one else either”.

Art, thanks for making us laugh.

Clinical Measurements

2009-06-23T02:13:00.000-07:00

Recently, I was reviewing the literature for articles on measurements of height, weight, BMI etc infants and children. I was amazed to note that there are at least 3 different methods for measurement of chest circumference. Fortunately, the articles describe the method clearly. That is how I know they are different. However, textbooks assume you know which method to use, when they refer to normal chest circumference.

I found the same situation when reviewing articles on waist to hip ratio as a mark of obesity. I reviewed three articles and found three different methods. The more recent ones are consistent with each other. How does one establish an acceptable method?

We insist on the accuracy, reliability, and reproducibility of laboratory values. Why not insist on these characteristics for clinically important measurements?

Listening Skills

2009-06-22T03:17:00.000-07:00

Listening to parents (and patients)

During my residency days, I saw a 20 months old child who was brought in by his mother with the chief complaint of “ my child weighs heavy”. There was no other complaint. Physical examination was normal. It is possible that I missed minimal edema during physical examination. But I did not ignore her complaint, because in pediatric practice the dictum should be “Trust what mother says, until proven otherwise”. On examination of the urine I noticed significant proteinuria. Subsequently we found that the child was in the early stages of acute glomerulonephritis.

The example outlined in the first paragraph is about listening to parents and doing something about their concerns. How do we know what the concerns of parents are? An essay on “Listen to the parents – They may know best” (BMJ 313: 954, 1996) refers to an article on the information needs and experience of parents of children with a recent acute viral illness. The parents needed information on the following items: How can I gauge the severity of illness?
How do I know when to seek advice?
What is virus illness? (What do you mean by virus? Where does it come from? In other words, could I have done something to prevent it? In other words, was I a bad mother?)
How do antibiotics work?
What is the experience of other mothers?

Some interesting quotes were: “ The doctor said it was a virus and needed no treatment and then a few days later the other doctor gave the antibiotics”. “You just get palmed off……you sort of feel let down….disheartened… sometimes you feel as though may be they are not listening to what you are saying”.

Here is an important point. It is not adequate that you think you are truly listening. It is how the parents perceive that counts. Their perception depends on your body-language and listening habits. It also depends on what you do with what you heard. If you do not address their concerns specifically, they go away thinking that you did not listen.

It is obvious that parents need information developed to suit their needs and abilities. We cannot know what their needs and abilities and constraints are unless we LISTEN carefully.

Genug Syndrome

2009-06-21T14:32:00.000-07:00

Dr.Jennifer M. Soyke talks about "Genug Syndrome" in a recent issue of JAMA (Vol 299: page 2606, 2008). This is an interesting essay about the need for writing a cause of death in death certificates, a legal requirement. When people just die of old age, what “diagnosis” can a physician give as the cause of death? Why desecrate death with medical diagnosis? Therefore, when a courageous old lady who had led a remarkable life died of just old age, her daughter devised the name of Genug syndrome. It appears that the meaning of this word is “Enough”. Another family had coined the word “Zahl Kam Rauf”, meaning “number came up”. Coming to think of it, my mother, who lived up to almost 100 years used to say: “I have the ticket. The train has’nt arrived”.

"Medicalisation"

2009-06-21T14:30:00.000-07:00

All of us know how many day-to-day conditions are given the name of a disease and treated unnecessarily. Why is fatigue not respectable enough for attention unless it is part of the chronic fatigue syndrome? Why do TV commercials equate fatigue with anemia? Why are naturally shy people given the label of a psychological syndrome? Are they real or are they over-dramatized categories erected by non-scientists and made into a reality by media specialists?

"Medicalisation" is the term applied to the “ process by which certain events characteristic of everyday life become medical issues”. This process has definitely benefited a few and has brought in some new knowledge. But there is a cost to the society. A few non-medical scholars have started questioning the wisdom of explaining every day events using disease models. Some of them have even started discussing what the limits of medicine should be!

If you are interested in this topic you may want to look through several articles published in The Lancet (Vol 369: Number 9562: February 24-March 2, 2007). These articles are based on a conference of non-medical scholars who met recently to discuss how the interactions between medicine, culture, politics and drug industry lead to the “medicalisation” of events in everyday life. I found the articles on “Medicalisation and Race” and “Medicalisation and HIV treatment” particularly informative.

Physicians and Pharmaceutical Industry

2009-06-21T14:23:00.000-07:00

In 2000, the pharmaceutical industry spent almost 5 million dollars on one-to-one promotion of drugs through their drug representatives. No one will spend that much money for no gains. The goal of the representatives is to increase the market share for the specific drug they are promoting.

The pharmaceutical companies are not just throwing the representatives on to the streets without preparation. They are taught specific strategies to be used for specific personalities of physicians. For example, "reps" make strong personal connection with “high-prescribers” and may reward them with unrestricted “educational” grant. Friendly “thought-leaders” are groomed for the speaking circuit. These and other techniques used to influence prescribing behavior of physicians is outlined in an article written by a pharmacist and former drug "rep" and a physician who studies pharmaceutical marketing practices. (Following the Script: How drug reps make friends and influence doctors. Fugh-Berman A, Ahari S. PloS Medicine April 2007; 4 (4): e 150 ) www.polsmedicine.org .

This paper is worth reading since the public, the medical profession and the pharmaceutical industry are all concerned about the advantages and disadvantages of physician-industry relationships. It is also worth remembering the last sentence of this paper: “ Physicians must rely on information on drugs from unconflicted sources, and seek friends among those who are not paid to be friends”.

Another article in the New England Journal of Medicine documents how commonly physicians and industry maintain close relationships in the form of receiving food in the work-place, receiving drug samples and receiving reimbursement for attending professional meetings or for CME. This is happening even after the introduction of a new code of conduct by the Pharmaceutical Research and Manufacturers of America and codes of conducts recommended by the AMA and ACP. (A national survey of physician-industry relationship. Campbell EC, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. N Engl J Med 2007: 356: 1742-50)

Healthy Habits

2009-06-21T14:20:00.000-07:00

A recent study from England examined the effects of four specific health related behaviors – moderation in drinking, not smoking, regular exercise and plenty of fruits and vegetables in the diet. These health behaviors added 14 more years to the life span of the individuals.

An editorial accompanying this article asked how results of such research efforts can be implemented and turned into “actual public health outcomes” and identified four factors that need to be addressed:
1. Results need to be disseminated
2. Individuals need to want and make changes in their life-style
3. In order for this to happen, the information has to be presented to the public in an accessible and balanced manner
4. Most important is a suitable environment that enables such a change in life-style

This in turn requires involvement of the society and its government and implementation of policies and procedures to promote healthy behavior.
Ref: PLoS Med 5(1): e15,2008 and PLoS Med 5(1): e12, 2008

Electronic Medical Records

2009-06-21T14:18:00.000-07:00

We all know the advantages of electronic medical record(EMR). It certainly makes medical records easily available, all in one place and all at the click of a “mouse” and easily portable. However, anything new and technically feasible has to be implemented with caution and with concern for potential disadvantages. “Before blindly embracing electronic records, we should consider their current limitations and potential downsides” as pointed out by Drs.Pamela Hartzband and Jerome Groopman (N Engl J Med 358: 1656-1658, 2008).

Some of the concerns raised in this article are:
The habit of cutting and pasting passages from other physician’s notes, instead of taking one’s own history, may lead to errors in diagnosis and management.
Notes written on templates may be insufficient to document some of the unique features of individual patients and may interfere with critical thinking.
Automatic reproduction of ALL laboratory results may lead to errors and delay in identifying critically important data.
New developments in the condition of the patient and sequences in change of status get buried in the mass of data.
Physicians keep looking at the computer screen when the patient is talking thus missing important non-verbal cues.
Filling in boxes may help obtain and record important and critical data consistently, but does not allow entry of free texts on observations other than what the “pigeon-holes” require. (This is not the problem of the computer).

I wish to add one more item that relates to entry of data in the examining room of teaching hospitals. I notice that the trainee is working with the computer when the teaching attending is interviewing the patient and examining the patient, thus missing a great opportunity to learn.

Communication Skills

2009-06-21T14:13:00.000-07:00

Medical terminology and Confusion in Communication

Avoidance of medical errors has taken center stage in the practice of medicine. Errors in communication between health care professionals and between health care professionals and patients are amenable to analysis and corrective steps, as has already been shown. The Institute of Safe Medical Practices and other institutions have helped identify and correct abbreviations (eg: qod and qid and qd) that are prone to cause errors and “sound-alike” names of drugs. One other area that needs attention is a list of Latin and Greek medical terms which were coined centuries back. All of us remember trying to pronounce clearly AB-duction and AD-duction of the hip and trying to figure out the definitions of genu varum and genu valgum. Did you know that at one time, these terms were defined in exactly the opposite way?

“You go to the doctor with your complaints in your mother tongue; he/she will tell you what you have in Latin and Greek” is a quote I remember. In the past, when physicians had little to offer other than naming the symptom and holding the patient’s hands, these old terminologies were useful. Besides, they increased the aura around the role of the physician who knew all these Latin and Greek names. In this era of internet when patients have access to information as much as we do, when the need for reducing errors is urgent, why not simplify medical terms? If the clergy can offer prayers in the local language so the commoner can understand what he/she is saying, why not do the same with medical communication?

“For the sake of clinicians and patients alike, removal of archaic, risk prone terms to simplify the language of medicine is a necessary step” says Melinda Lyons in an editorial in a recent issue of the Lancet (371: 1321-1322, 2008).

Complementary and Alternative Medicine

2009-06-21T14:07:00.000-07:00

The Task Force on Complementary and Alternative Medicine of the American Academy of Pediatrics came out with a report recently (Pediatrics Dec 2008). It is timely because there seems to be an increase in the use of alternative and complimentary medicine both among adults and children. In addition, a Professor of Complementary Medicine and his colleague have also recently come out with a book summarizing all available studies in some of these modalities (Trick or Treatment published by WW Norton in 2008). The Committee report is bland and seems to endorse these modalities, whereas the book points out that there is no or very little evidence to support the use of at least three of these modalities, namely acupuncture, homeopathy and chiropractic.

The report states in its first paragraph that the Complementary and Alternative Medicine (CAM) as a group , its practices and products “ ……. are not presently considered to be part of conventional Western medicine”. The emphasis should not have been on Western or Eastern medicine, or conventional and non-conventional, but on the lack of scientific principles behind these therapies and the lack of evidence to support their claims.

In the next paragraph of the Committee report, the first sentence states that many of these practices have undergone rigorous research and have been integrated into mainstream care. The second part of the statement is true. But it is not because rigorous research showed that these forms of therapy work. Indeed, the truth is the opposite, as documented in the book on “Trick or Treatment” by Ernst and Singh.
Doctor Edzard Ernst , Professor of Complementary Medicine at the University of Exeter in UK , and Simon Singh came to a different conclusion in their book. These authors critically reviewed all available publications on several alternative forms of therapy and concluded as follows: “Having sought to be both open-minded and skeptical, and having relied on all best available evidence, our broad conclusion is fairly straightforward. Most forms of alternate medicine for most conditions remain either unproven or are demonstrably ineffective, and several alternative therapies put patients at risk of harm”(page 280). They point out how patients who venture towards alternative medicine are at risk of being exploited and even damaging their health due directly to some forms of therapy such as megavitamins and cervical manipulation and also by delaying proper care.

After reviewing the data on acupuncture these authors concluded that it does not work for a whole range of conditions, except as a placebo and that there is only marginal and unconvincing evidence in support of its usefulness for the control of pain and nausea. They did not find any evidence for the use of homeopathy for the treatment of any ailment.

Then, of course, there is a famous paper by a sixth grade student based on a well-planned study she conducted on Therapeutic Touch and the so-called “energy fields”. She showed how several practitioners of this form of therapy could not detect the energy field of this young lady under experimental conditions (A close look at Therapeutic Touch JAMA 279 (13): 1005-1010, 1998).

In spite of lack of consistent demonstrable evidence, the Taskforce report seems to be bland when it says that pediatricians should provide evidence-based information about relevant therapies and that pediatricians should make CAM providers part of care-coordination activities.

It is ironical and astounding that in this era of explosive developments in science, there is so much “blind faith”. At one time doctors were paternalistic and played “God”. Now, they are running to the other extreme and promote unscientific claims in the name of honoring the autonomy of patients and the importance of “individual experience”.

We want our practitioners to practice evidence-based medicine on the one side. Then, we ask them to use whatever seems to “work” or go along with the flow.

Then there is the cost of care. Third party payers will not pay for investigations and treatment not backed by evidence for their usefulness, even within conventional medicine. How can we support alternative therapies that have not been shown to work when rigorously tested?

Yes. Parents and patients do use and will continue to use all these forms of treatment whether physicians approve or not. That is the reality. We have to accept it. We should be sympathetic to the plight of the parents and their good intentions. But we do not have to go along. It is our duty to point out without being confrontational, that there is no basis for the claims.

What is even more important is to look at the reasons for so much currency for these ideas among the public and answer them. We have to address the issues that drive patients to unproven remedies. For example, the CAM practitioners clearly spend more time with patients and listen to them. The so-called conventional system does not support this simple step. CAM practitioners are more easily accessible. Western medicine practitioners are not. These and other reasons for the popularity of CAM are well-explained in the book by Ernst and Singh. We should encourage all physicians to read that book!

Some of the following points may help; I tried them. They did not always work. But, parents knew that I understood their intentions and their need to try anything that may help, but I am not in support of unproven remedies.
1. Be open and non-critical of parents and patients so they will inform you of all other forms of therapy they are using.
2. Tell them that you understand their need to do everything they can to get better. At the same time tell them that your duty is to protect them from false hopes and extra expenditure on treatments not proven to be beneficial or shown to be harmful.
3. Find out about the exact items they are using and warn them if they are using mega-doses of Vitamins A and D, manipulations of the neck, unknown formulations with contaminants.
4. Show them the book by Drs. Ernst and Singh and the paper by the sixth grader and inform them about the lack of evidence for these forms of therapy.
5. Educate the parents, media and the public about how scientific treatments are developed, tested and regulated and how alternate forms of therapies are not.

Lifelong Learning

2009-06-21T05:58:00.000-07:00

Whenever I read books by good writers, I am always looking for great descriptions of complex ideas. You will be amazed at what you can find. Here are a few examples:

1. To understand the behavior of people who are ill, read Tolstoy’s “ The Death of Ivan Ilyich”.
2. To understand grief at the loss of a close person, read CS Lewis’s “A grief observed”.
3. To understand the subject of classification and taxonomy, read Colin Tudge’s book on “The Tree”.
4. To look at the cosmos through the innocent eyes of a child, read “The Little Prince” by Antoine de Saint Exupery.
5. To understand the mystery of the atoms, molecules and how they morph into life forms, read Bill Bryson’s book on “A Short History of Nearly Everything”.
6. To learn about genetic codes, read “The Frameshift” by Robert J.Sawyer.

Incidentally, is this not what we call lifelong learning?

Adherence and Compliance

2009-06-21T05:52:00.000-07:00

I came across an article on a well-designed study on elderly patients who were taking multiple medications and therefore at risk for poor adherence. The study was part of a pharmacy care program and included a period of observation followed by a randomized trial of a comprehensive program with educational (counseling by a pharmacist) and structural (blister packing of the daily dosage) components. The program was found to be effective in improving compliance and resulted in objective improvement in the primary conditions. (LeeJK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure and low density lipoprotein cholesterol: a randomized controlled trial. JAMA 2006; 296: 2563-2571. http://jama.ama-assn.org/)

In an accompanying editorial, Ross Simpson reviews the “Challenges for improving medication adherence”. (JAMA 2006; 296: 2614-2616). Some of the factors that lead to poor adherence as listed in paragraph 2 of this Editorial are:

Patient characteristics: advanced age, cognitive impairment, depression, attitudes and beliefs about the importance of medications, the disease being treated and the potential for adverse effects.

Barriers related to the medication: adverse effects, poly-pharmacy, frequent dosing and high cost.

System and Clinician related barriers: insufficient access to physicians, lack of trust between clinician and patient, physician’s negative attitude to the value of guideline-recommended care.

Physician-Patient Communication

2009-06-21T02:36:00.000-07:00

What do parents want to hear after a child’s death?

I have dealt extensively with this topic (giving bad news) in my Handbook of Clinical Skills. Good sensitive clinicians know intuitively what to say and how and when to say it. A good way to find out what the parents want to hear about the circumstances surrounding the death of a child is to ask the bereaved parents themselves. This is a delicate task. According to a recent study in which bereaved parents took part, most parents expressed a desire to meet with their physician and a willingness to come back to the hospital for such a meeting (Meert et al . J Pediatr 2007; 151: 50-55).

Major reasons given by bereaved parents for such a meeting were:
1. To gain information about the admission to the ICU and cause of death, results of autopsy, withdrawal of life support, genetic risk, bereavement support and what to tell other family members.
2. To provide feedback to the staff on communication styles, conflicting information, and administrative issues.
3. To express gratitude
4. To obtain emotional support including reassurance that everyone, including the parents did what they could (and not feel abandoned).

2009-06-21T02:05:00.000-07:00

Educating patients on Risks and Benefits of treatment options

In this essay I summarize a study that evaluated the usefulness of a general education primer on the ability of patients to interpret medical data and understand risk. (The effectiveness of a primer to help people understand risk: The randomized trials in distinct populations. Wolosin S, Schwartz LM, Gilbert Welch H. Ann Intern Med 2007; 146: 256-265. www.annals.org) The investigators tested this primer on two populations, a high socioeconomic group and a low socioeconomic group. The authors showed that the booklet improved the ability of both groups of people to interpret medical data.

The authors outlined some key concepts from the primer in a tabular form. Although this was a research study and although the booklet is not for routine use, the questions listed in this table will be of great use to clinicians when they educate their patients on understanding risks. Therefore, I recommend this article strongly, particularly the table on Page 260. It is called Figure 2, although it is a Table. This entire table is reproduced with permission in my Handbook on Clinical Skills. The following is a summary.

The questions are grouped under 4 headings:

1.Questions on Risk
Risk of what (new symptom, organ damage,death, disability)?
How serious is the risk? What is the probability of the occurrence?
Can the doctor explain the risk in a user-friendly format?

2.Questions on interpreting benefit
How effective compared to doing nothing or compared to some other treatment?
What are the side-effects? How common and how serious are they?

3.How applicable are these data to your specific situation considering your age, sex, other conditions etc?

4.What is the source of information?

Communication Skills

2009-06-21T01:59:00.000-07:00

Disclosing medical errors to patients

External pressures and internal changes within the medical profession have facilitated the development of standards for disclosing medical errors to patients. The Joint Commission has issued a nationwide disclosure standard. Some key elements in this disclosure are:
Provide facts about the event
Express regret and give formal apology (if appropriate)
Establish disclosure coaching methods and support system
Provide emotional support for health care workers, patients and families
Track and enhance disclosure methods

For more detailed discussion, please read Disclosing Harmful medical errors to patients by Gallagher TH, Studdert D, Levinson W. N Engl J Med 356: 2713-2719, 2007.

Humor

2009-06-20T16:17:00.000-07:00

Mr. Ambrose Bierce

I read about Mr. Ambrose Bierce in a recent issue of the Economist and learned more about him from books available at the University of Delaware Library. Mr.Bierce lived during the later part of the 19th century and the early part of the 20th (1842-1914). His writing skills were extraordinary. He is known as a supreme satirist. But, I find him more of a cynic than a satirist.

Here are a few pithy definitions from his book on “The Devil’s Dictionary”.

Childhood: “The period of human life intermediate between the idiocy of infancy and the folly of youth”.
Consult: “To seek another’s approval of a course already decided on”.
Diagnosis: “A physician’s forecast of a disease by the patient’s pulse and purse”.
Religion: “ A daughter of Hope and Fear, explaining to Ignorance the nature of the Unknowable”.
Peace: “In international affair, a period of cheating between two periods of fighting”.
Patience: “ A minor form of despair disguised as a virtue”.

Diagnostic errors in medicine

2009-06-20T16:13:00.000-07:00

I recently came across two articles. The first was published in 1998 (Medical student errors in medical diagnosis. Academic Medicine 73: (10) Supplement; October 1998). The summary of the article is that we emphasize identification of physical findings in medical education. But we do not emphasize their clinical significance and how to use these findings in clinical reasoning. Consequently, even after recognizing abnormalities in physical examination, wrong conclusions are reached.

The other paper was published in 2005 (Diagnostic error in internal medicine Arch Intern Med 165: 1493-1499, 2005). The authors identified 100 cases of diagnostic errors through voluntary reports, quality assurance activities and autopsy discrepancies. When they reviewed the records and identified the causes, 65% of the causes were system related (eg., faulty test instruments, failure or delay in communication, inefficient processes etc). Cognitive factors contributed to 74% of errors. Faulty or inadequate knowledge was only a minor problem (11/ 272).

The most common problems were related to faulty processing of available information. The single most common error was “premature closure”. In other words, physicians failed to consider other reasonable alternatives once their minds latched on to the “initial diagnosis”.

I deal with this problem of “closed mind”in detail in the chapter on Problem Solving skills in my book on Handbook of Clinical Skills. Our mind tries to find an explanation for everything. That is its strength. But it tends to “shut down” as soon as it finds “an” answer, “any” answer! That is its weakness.

Diagnostic Skill

2009-06-20T14:52:00.000-07:00

First Impressions

Experienced clinicians make a short list of differential diagnosis within the first few minutes of history-taking. This list becomes the base from which they generate questions to ask. Experienced clinicians also know that the first impression may be wrong. They know how to keep an open mind even as they proceed with physical examination and collect laboratory and imaging data.

One of the biggest weaknesses I have found with medical students and residents is that they tend to run with the first impression without questioning, until they face a big obstacle. In an article on "Diagnostic errors in internal medicine" (Mark L. Graber, MD; Nancy Franklin, PhD; Ruthanna Gordon, PhD. Arch Intern Med. 2005;165:1493-1499),the authors pointed out that the most common errors were related to faulty processing of available information. Among these, the single most common error was “premature closure”. In other words, physicians failed to consider other reasonable alternatives once their minds latched on to the “initial diagnosis”.”

In a recent exercise in Clinical Problem Solving in the New England Journal of Medicine, the authors show how the initial impression can be wrong. In this article the authors report a patient with vertebral osteomyelitis and epidural abscess who was initially thought to have TB and was also treated for it; but actually this patient turned out to have meliodosis. The authors cautioned “Beware of First Impressions”. They are correct.

In addition, there is another clinical dictum that is always useful. Whenever you are making a differential diagnosis for any symptom, think of the commonest cause and think of the worst or the most serious cause. With that rule, one could have considered meliodisis earlier in this patient with diabetes.

Also, there is a book entitled Blink which overemphasizes the importance of first impressions. I respectfully disagree, particularly in clinical medicine.

Listening Skills

2009-06-19T11:38:00.000-07:00

“If only there were one person you could call on…”

I wrote briefly about a monograph entitled “They get this training but they don’t really know how you feel” in an earlier essay. Doctor Mervyn Fox of Institute of Child Health in London wrote this. After working as a Hospital Doctor with handicapped children and their families and after having read the available literature at that time (1970) he wondered, “ What is it like to be the parent of a handicapped child?” Therefore, he organized a study to answer just that question. The project was conducted on scientific lines with review of the literature, standardized questionnaire, rating scales, statistical analysis etc.

Dr.Fox interviewed the families in their own homes. The parents knew that this was a research project, but they did not know that Dr.Fox was a physician until after the interview. This allowed parents to express their opinions without inhibitions. The study resulted in the preparation of a thesis and several scientific publications by Dr.Fox .

One important publication was the actual transcripts of the interviews with the
title: “They get this training but they don’t know how you feel”. In this monograph, we hear the actual “voices” of the parents who live 24 hours a day, 365 days a year with a handicapped child. They are unedited and unfiltered. Many of the comments are the same as what I have heard from parents of severely handicapped children in US and India. They are so real, so poignant and so touching; I quote a few of them here:

“They get this training but they don’t know how you feel”
“There will never be a time when I am young and free”
“You can see them humoring you – it is no good, sympathy without action”
“You always get the feeling you are not doing enough, there is something more you should be doing”
“Nobody tells you about YOUR child”
“We would like to see our children die before we do”
“He used to say Come back next month, it is something you have got to live with, got to accept. But what I had to live with I just did not know”
“They speak as though they know more than me … about my child”
“The biggest need of all is a home where the child can go to give parents a break….”
“And when you get to the Hospital, you never see the same doctor, always a junior…”
“Little things, little problems. You do not know who to turn to”
“ If not, someone who is trained in kindness…”
“If only there were one person you could call on, who had a bit of experience with these children….”
“We need one person, someone who could come to us, or we could go to him, and he would have time to talk to us…”

The last two statements were the driving force behind my efforts to establish a Nurse as the coordinator in our Rheumatology clinic. She was the one person the families turned to for help. Every one of the nurses who worked, performed admirably and here is my chance to publicly thank all of them for providing the support and the help they provided the children and their families in a timely fashion and with deep compassion.

Systems of Delivery of Medical Care

2009-06-19T11:25:00.000-07:00

Clinicians know that one of the major determinants of patient satisfaction and satisfactory physician – patient relationship is continuity of care. Several developments in the systems of care in the past few decades have interfered with this physician-patient dyad.

Almost 30 years ago, Doctor A. Mervyn Fox of U.K. interviewed parents of children with severe disabilities and wrote a monograph entitled “They get this training but they don’t really know how you feel”. One of the major points made by parents was the need for continuity of care. The other was the need for one stable and specific person the family can call with their questions and concerns. I was fortunate enough to read this entire monograph and the comments made by British parents were almost the same as those I heard from parents here in USA. The needs of parents expressed in these comments influenced the organization of our Rheumatology clinic at the Children’s Seashore House and the Children’s Hospital of Philadelphia with a Nurse Coordinator as the link between the families and the clinic. (Regionalized Arthritis Resources: Status report on Pediatric Arthritis Initiative. Athreya B, Tourtellote C, Salmon JW Arthritis Rheum 20: (suppl 2): 604-606, 1977)

Principles of care so well tested in chronic care are making a comeback as part of improving Quality of care. Although the value of Patient-centered, community -based coordinated care (Brewer EJ, McPherson M,Magrab PR, Hutchins VL. Family-centered, Community-based, Coordinated care for Children with special health care needs. Pediatrics 83:1055-1060, 1989) was recognized, these principles were not implemented adequately or consistently in the era of managed care, cost containment and bottom-line. Fortunately, the need for patient participation in medical decision-making and care is getting the attention it deserves. Agencies responsible for medical education and licensing are emphasizing the importance of human relation skills, communication skills and patient satisfaction.

Education of future physicians in principles of patient centered care alone is not adequate when the Systems of delivery of care are so unfriendly to these concepts. With this in mind, Drs Beeson and Dean suggest four general ideas to change the current system of medical care. (A System based approach to Patient-centered Care JAMA 296: 2848, 2006). These suggestions are based on successful chronic care models with proven benefits and well-known common sense concepts such as continuity of care and one person for the patient to relate to. Also included are ideas such as templates for patients to make an agenda for their clinic visits in which they can write their specific concerns and internet-based tools for self-management.

Society and Medicine

2009-06-19T11:15:00.000-07:00

In response to competing pressures faced by medical professionals and the declining public trust, the American Board of Internal Medicine Foundation, American College of Physicians Foundation, and the European Federation of Internal Medicine collaborated on a project on “Medical professionalism in the new millennium: a physician charter” in 2002 and published a report. Whereas the motivation is laudable, the altruistic principles outlined in the Charter cannot be viewed in isolation. Physicians practice in a society and within a system of medical care. Physicians cannot apply their altruistic principles without support from the public and the policy makers. With this in mind, another conference was held in 2005 to discuss the ramification of the Physician Charter which resulted in a recent publication(JAMA 298: 670-673, 2007). The main points of this publication are:

Ensure that all members of society have access to a basic set of preventive and medical services.
Provide the infrastructure necessary to foster improvement in the quality and safety of health care services.
Construct and maintain a medical liability system that encourages wide dissemination of lessons learned from medical errors.
Align payment system with professional values and performance.
Provide adequate support for the education and training of physicians.
Provide adequate support for medical and health sciences research.
Recognize and minimize opportunities for conflicts of interest.
Finally, all of this requires an effective medical-societal alliance.

(P.S. I am not aware of any forum set up to implement these ideas. If any of the readers know of such a forum, please write a comment. Thank you.)

Communication Skills - Patient education

2009-06-19T03:06:00.000-07:00

Healthy Habits

A recent study from England examined the effects of four specific health related behaviors – moderation in drinking, not smoking, regular exercise and plenty of fruits and vegetables in the diet. These health behaviors added 14 more years to the life span of the individuals.

An editorial accompanying this article asked how results of such research efforts can be implemented and turned into “actual public health outcomes” and identified four factors that need to be addressed:
1. Results need to be disseminated
2. Individuals need to want and make changes in their life-style
3. In order for this to happen, the information has to be presented to the public in an accessible and balanced manner
4. Most important is a suitable environment that enables such a change in life-style

This in turn requires involvement of the society and its government and implementation of policies and procedures to promote healthy behavior.

Delivery of Medical Care

2009-06-19T02:50:00.000-07:00

In my book and other postings I have discussed how “disgruntled doctors cannot be expected to provide outstanding medical care”. One of the reasons for the dissatisfaction among physicians is the application of business models to clinical encounters. As pointed out by Drs. Pamela Hartzband and Jerome Koopman in the New England Journal of Medicine (NEJM 2009; 360 (2): 101-103), the current business models apply “price tags” to every aspect of a doctor’s day and the “quality of care” is counted in numbers and not in real quality of human relations. They also point out that research in behavioral economics and psychology suggests that there may be unintended consequences to application of the mindset of the market-place to medicine.

Psychologists use the word "interactions" for all human encounters. It is obviously a more suitable, objective word in scientific work. In reality, is it not “relationship” also? Be that as it may, psychologists point out that there are two types of interactions – one is “social” or “communal”. The other is “market” or “exchange”.

In the communal relationship, one “helps” the other because there is a need. There is an expectation and an obligation. We are expected to help, out of compassion, for the sake of the “group”, not for name , fame or money. Ideally, we should not even expect anything in return. It is part of being human.

In the market relationship, we expect money or some other barter of good of similar value in turn for the service provided.

Dr.Hartzband and Dr.Koopman point out how medicine is not strictly a market place. Medicine has both a communal and a market place component. This is the most important point of this timely editorial.

None of us will deny that money plays a big part in medical practice. Without money there can be no service. But does money have to be the “primary” driving force? It should not be. Can it be the only drive force? No, since there is the communal element in this relationship. Physicians know this. When will the several other players in the delivery of medical care, many of them primarily in profit-making industries exert their “social” responsibility and restore the balance?

As if to confirm this concern of mine, Dr.Victor Fuchs, the noted health care economist writes an editorial on Health Care Reform with the title: Why so much talk and so little action? (NEJM 360 (3); 208-209, 2009). He cites four major reasons. The first is that “many organizations and individuals prefer the status quo”. You can guess who makes this list. They are not the majority; but have disproportionate clout. The second reason is that it is generally difficult to bring about “change”. Third, our political system has several “choke points” that offer opportunity to the motivated few to stifle efforts to change the status quo. Finally, although there are many who want reform, they are not united behind a single approach. Amen.

2009-06-19T02:40:00.000-07:00

Physician-Patient Communication

Educating patients on risks and benefits is a formidable task. The patients have to understand not only available options, but also the risks and benefits of those options. How can we educate them on risk stratification, data interpretation and statistical analysis? What are some of the major issues in this patient education process?

I came across an interesting article on this topic recently. (Communication of risk: choice, consent and trust Lancet 2002; 360: 166-68). According to the author of this article, the most important issues to be aware of are: 1. Provide the individual with sufficient information using appropriate language so that he/she can understand the risks involved. The “framing” of the risk is an important step in this process. 2. Being truthful and realistic given the uncertainties and the unknowns. 3. Even after getting and understanding all the information, the patient has to trust his physician before giving a truly informed consent.

This article has a small section on trust and lists the following requirements to develop a trusting relationship:
Truth-telling
Openness
Respect for the view of others
Accepting the rights of others to make decisions
Doing your best in the best interest of the patient
Not doing harm
Keeping promises.

Cultural aspects and Medical Anthropology

2009-06-18T02:45:00.000-07:00

Social medicine, Cultural competency and Ethnography

All of us know that Rudolf Virchow is one of the founders of modern medicine. But few of us know that he was the first to pioneer the concepts of social medicine. After studying an epidemic of typhus, he concluded that poverty and living conditions were the root causes of that epidemic and that both social and medical measures were needed to combat diseases and promote health. That was almost 150 years back!

The idea of social medicine, what it is, how it evolved and where it is now are covered in a series of articles in a recent issue of the electronic journal PLoS Medicine (October 2006; Volume 3;Issue 10) (www.plosmedicine.org)
Two articles are particularly worth reading: 1. Porter D. How did social medicne evolve and where is it heading? Pages 1667-1672.
2. Kleinman A,Benson P. Anthropology in the clinic: The problem of cultural competency and how to fix it. Pages 1673 -1676.

The second article emphasizes ethnography which is a description of ” what life is like in a “local world”, a specific setting in a society”. Some of the questions to ask in order to get a personal description of how a disease or an illness is experienced by the patient are listed in Box 2 - page 1764. They are: “What do you believe is the cause of this problem?”, “What do you think this problem does inside your body?”, “what do you fear most about this condition?” and ” what do you fear most about the treatment?”.

Cultural aspects

2009-06-18T02:42:00.000-07:00

Medicalisation

All of us know how many day-to-day conditions are given the name of a disease and treated unnecessarily. Why is fatigue not respectable enough for attention unless it is part of the chronic fatigue syndrome? Why do TV commercials equate fatigue with anemia? Why are naturally shy people given the label of a psychological syndrome? Are they real or are they over-dramatized categories erected by non-scientists and made into a reality by media specialists?

Medicalisation is the term applied to the “ process by which certain events characteristic of everyday life become medical issues”. This process has definitely benefited a few and has brought in some new knowledge. But there is a cost to the society. A few have started questioning the wisdom of explaining every day events using disease models. A few have even started discussing what the limits of medicine should be!

If you are interested in this topic you may want to look through several articles published in The Lancet (Vol 369: Number 9562: February 24-March 2, 2007). These articles are based on a conference of non-medical scholars who met recently to discuss how the interactions between medicine, culture, politics and drug industry lead to the medicalisation of events in everyday life. I found the articles on “Medicalisation and race” and “Medicalisation and HIV treatment” particularly informative.

Cultural Aspects of Human Behavior

2009-06-18T02:39:00.000-07:00

Help - seeking behavior

When someone is not feeling well, what will he/she do? Will she ask for help at once? How long will she wait? Who will she consult first? Why? All of these questions lead to discussions on illness behavior, help-seeking behavior etc. This is a complex issue even in adults. In children, it is even more complicated for obvious reasons. There are cultural differences too in how individuals respond to stresses in life.

In an article I came across recently, the authors describe one aspect of help-seeking behavior. This is a qualitative study of parents of children who call doctors over the phone after office hours are over. This “listening” study unearthed some of the reasons for this aspect of help-seeking behavior. One parent said that she had taken the child to the doctor that morning. But that doctor was looking at the watch during the entire visit giving the impression that he was in a hurry. Therefore, the mother did not have any confidence in his assessment. When the symptoms persisted throughout the day, she became anxious and called the doctor on call.

Another parent said that the doctor who examined her child that morning “looked like someone who should be retired”. Other reasons mentioned were concerns about specific illness, previous bad experience in managing similar problems, and previous poor experience with the specific health-care facility.

Hopton J, Hogg J, McKee I. Patient’s accounts of calling the doctor after hours: qualitative study in one general practice. Brit M J 1996; 313: 991-994.

Communication Skills

2009-06-17T03:09:00.000-07:00

Curb-side Consultation

2009-06-17T03:07:00.000-07:00

As physicians we are often asked for curb-side consults. This happens most often in family and social gatherings. We can be sympathetic and be general with our recommendations, unless it is an emergency. Even then, there are ethical and legal responsibilities.

What about a situation in which the physician encounters an individual in a casual setting or in a public place and suspects a medical disorder? Does he give unsolicited advice to a stranger? Does he express his concern to the individual and face the possibility of a wrong diagnosis and creating unnecessary anxiety? Or, does he not communicate his suspicion knowing that the individual may face a serious medical problem in the future?

In his essay on “The ethics of passer-by diagnosis”, Doctor Edward Mitchell gives a few guidelines. He suggests that we take into account the following factors: prior relationship between the physician and the subject, urgency of the situation, accuracy of the diagnosis and the risks of harm likely to be caused by the diagnosis. For details, I refer the reader to the Lancet 371:85-87,2008.

Communication Skills

2009-06-17T03:03:00.000-07:00

Medical terminology and Confusion in Communication

Avoidance of medical errors has taken center stage in the practice of medicine. Errors in communication between health care professionals and between health care professionals and patients are amenable to analysis and corrective steps, as has already been shown. The Institute of Safe Medical Practices and other institutions have helped identify and correct abbreviations (eg: qod and qid and qd) that are prone to cause errors and “sound-alike” names of drugs.

One other area that needs attention is a list of Latin and Greek medical terms which were coined centuries back. All of us remember trying to pronounce clearly AB-duction and AD-duction of the hip and trying to figure out the definitions of genu varum and genu valgum. Did you know that at one time, these terms were defined in exactly the opposite way?

“You go to the doctor with your complaints in your mother tongue; he/she will tell you what you have in Latin and Greek” is a famous quote. In the past, when physicians had little to offer other than naming the symptom and holding the patient’s hands, these old terminologies were useful. Besides, they increased the aura around the role of the physician who knew all these Latin and Greek names. In this era of internet when patients have access to information as much as we do, when the need for reducing errors is urgent, why not simplify medical terms? If the clergy can offer prayers in the local language so the commoner can understand what he is saying, why not do the same with medical communication?

“For the sake of clinicians and patients alike, removal of archaic, risk prone terms to simplify the language of medicine is a necessary step” says Melinda Lyons in an editorial in a recent issue of the Lancet (371: 1321-1322, 2008). Amen!

Human Relation Skills

2009-06-17T03:00:00.000-07:00

In a superbly philosophical Sanskrit book called Yoga Vasishta, the main character says: “Life is as transient as the drop of water at the sharp corner of a blade of grass” (1: 30-31). Later he says: “Calamities occur in a moment; so does good fortune. At one moment it is birth and at another moment it is death. What indeed is not momentary?” (1:63).

The same idea is expressed in simple English by Joan Didion in her book on “The Year of Magical Thinking” (Alfred A.Knopf, New York, 2005) as follows: “Life changes fast. Life changes in the instant. You sit down to dinner and life as you know it ends”.

Grief and suffering are so very personal. Each one of us experience and exhibit these feelings differently. How do we feel when a member of our family becomes seriously ill or dies? How do we cope? How do we console and comfort someone who has lost a child, a parent or a spouse?

We physicians, deal with loss, death and grief in our patients everyday. How do we learn about the feelings of people diagnosed with a catastrophic illness or have lost a loved one? How and where do we learn to help them? I have relied heavily on the writings of sensitive literary figures to understand human behavior under stress. My all-time favorites are Leo Tolstoy (specifically The Death of Ivan Ilyich) and William Carlos Williams (several articles and poems). To this list I have to add two more.

The first is Joan Didion. Following the sudden loss of her husband and a series of life-threatening illnesses in her daughter, Ms.Didion has recorded her mental state honestly and powerfully in the book on “The Year of Magical Thinking”. She shares with us how her mind wanted her to believe that her husband will return back, which in turn led her to behave in certain ways. Her descriptions of grief and mourning are powerful. Her descriptions of the hours following her husband’s death weaving society’s expectations and her personal needs are lessons for those who want to help on such occasions. She has also done enough research to quote from medical and psychiatric journals about death, grief and mourning.

The second author is Randy Pausch. He was a Professor at the Carnegie-Mellon Institute. At age 46 he was diagnosed with Pancreatic cancer and was given only a year to live. When he was asked to give a talk in the tradition of The Last lecture, he “did not have to imagine it”. He knew that it will be his last lecture. The book was not about death; it was about living. Since “time is all you have….and you may find one day that you have less than you think”, he summarized all of his core beliefs for the talk. This became such a success, that this one hour lecture was expanded into a book (The Last Lecture, Hyperion Book, New York, 2008).

For those of us who wish to learn how people who have experienced major losses in their lives feel and behave, these are two great books.

Human Relation Skills

2009-06-17T02:47:00.000-07:00

Judging oneself;Judging others

We tend to judge ourselves better than others do. We tend to think that we do not get biased whereas others do. We believe that we are not likely to get sick because we are wise and follow good habits. We believe that our own perceptions are closer to truth than that of others. All of these seem to happen because we are aware of our own feelings, emotions and intentions and our perception of ourselves is based on this awareness. This inner state is not available to others and they judge us based on our actions.

Since we do not have access to the inner thoughts of others,our perception of others is based entirely on what we can observe visually. Therefore our judgment of others is not kind. This “asymmetry” in judging others by what we see and ourselves by what we feel and think lead to several problems in human relations. There are several studies to document all these problems and are well summarized in an article by Emily Pronin in Science (How we see ourselves; How we see others. Science 320:1177-1180, 2008). These insights have great relevance to our role as clinicians when we are communicating with patients.

All of us think that we are good listeners, whereas others may think otherwise. This is called Positive Illusion. This is a problem among physicians who often think they are better listeners than they actually are. Rarely do patients agree with this assessment.

People overestimate their ability to learn about the personality of others after brief encounters. Look at the way we conduct job interviews! Look at the way we judge patients after the very first encounter. On the other hand we accuse others of having made a snap judgment about us! We think we know others better than they know us!! That is because we perceive their actions and attribute motives; but when we are dealing with our actions, we want others to know our intentions. This leads to misunderstanding and miscommunication between individuals and groups.

We can correct this problem by asking the other person to give us their perceptions. As CS Lewis said in his book on Screwtape Letters, if you want to know what your weaknesses are, do not think; just ask your spouse! However, we tend not to trust the perception of others. We tend to think that others perceptions and judgments are biased while denying its influence on our own thinking. We know how it is easy to succumb to conflicts of interest due to unintentional bias. (Everyone is a little bit biased: Even physicians. Cain DM and Detsky AS. JAMA 299:2893-2895;2008)

This asymmetry of judging oneself by one’s intentions and others on their not-so-good behavior, is not necessarily all bad. It has survival advantages. It allows us to predict what others might do. It is certainly safer to rely on one’s own perception than that of others. What is important is to realize that just as we judge ourselves by our intentions and others by their actions, the others are doing the same. It is wise to give others benefit of the doubt at times of conflicts and misunderstanding. When others do something bad, it may not be wanton or malicious but due to their circumstances or misperceptions.

The conclusions of Emily Pronin are worth quoting: Applying the same standards of judgment to others as to oneself is “not only socially charitable - it would also be scientifically informed”.

Ref: Pronin, Emily. How we see ourselves; How we see others. Science 320:1177-1180, 2008

Patient Care

2009-06-16T10:17:00.000-07:00

ABCD of Care of Patients

Almost 100 years back, Francis Peabody said that “………the secret of the care of the patient is in caring for the patients”. How can one make this concept practical? How can we remind ourselves about the core values of compassion, respect and dignity of the individual inherent in caring for others? How can medical teachers impart these values to students and trainees?

Professor Chochinov of Manitoba, Canada has developed a framework to guide healthcare practitioners and this framework can be applied to teaching and to clinical practice and across all medical specialties. Physicians and all allied health professionals will find this useful. Prof.Chochinov calls it the “ABCD of dignity conserving care”.
“A” stands for “Attitude”
“B” stands for “Behaviour”
“C” stands for “Compassion”
“D” stands for “Dialogue”

If you wish to learn more about the details of each of these steps, please read an excellent essay by Prof.Harvey Chochinov in BMJ 335: 184-187, 2007. (http://www.bmj.com/archive/)

Physician – Patient Communication

2009-06-16T10:12:00.000-07:00

e mail communication

Physicians have always had several lines of communication with patients. Now we have to add one more, namely on-line or electronic communication. Like any innovation, it is a good thing, when used appropriately. It can be a major source of problem, when done without some forethought and guidelines. Although patients have been ready to use the e mail to ask some simple questions or to make appointments, the health-care system has not been ready because of concerns about privacy and legal liabilities. Besides, no one was paying for the time spent by the physicians on this task. Now, things are changing.

The Federal Government has set a goal of establishing Electronic Health Records for most Americans by 2014. The public has expressed a strong interest in using tools of internet technology to communicate with their doctors and some are even willing to pay for some of the services. Insurance companies have also started covering some of the services. However, there are a few hurdles to clear before communication with patients through e mail is fully accepted by physicians and the health care system.

During e mail communication, there is no direct connection or contact with the patient. Therefore, the physician can not make clinical judgments based on personal observations and physical examination. The patient is not on the phone.Therefore,the physician cannot listen to variations in the voice and discern the concerns. The patient is using words to express his questions and concerns. This may not pose a problem in e communication if it is for appointments or requests for refill. But, words may not express the problem accurately or adequately with more serious questions. The physician will still have to decide whether to answer or insist on talking with the patient on the phone or seeing the patient before answering the question. If he decides to answer, he has to be more careful with the choice of words.

In short, the ability to communicate effectively becomes even more important in the era of internet communication.

(Stone JH. Communication between physicians and patients in the era of e-medicine N Engl J Med 356: 2451-2454, 2007)

Doctor-Patient Relationship

2009-06-16T10:08:00.000-07:00

Patient’s expectations

In order to be a good doctor, we need to know ourselves first. We also have to know what patients expect of their doctors. The following items are listed by Drs. GL Ginder and K.Sexton under “What parents want from their doctor” in their Chapter on Patient-Physician Relationship in Pediatric Primary Care – A Problem-oriented Approach (Mosby, 1997) edited by Dr.William Schwartz and his colleagues.
Technical competence
Compassion
Information sharing (includes timing and style of delivery)
Being treated with respect
Being allowed to participate in decision making
Responsiveness to questions, concerns and fears

Clinical Skills

2009-06-16T10:03:00.000-07:00

Diagnostic Skill – First Impressions

Experienced clinicians make a short list of differential diagnosis within the first few minutes of history-taking. This list becomes the base from which they generate questions to ask. Experienced clinicians also know that the first impression may be wrong. They know how to keep an open mind even as they proceed with physical examination and collect laboratory and imaging data.

One of the biggest weaknesses I have found with medical students and residents is that they tend to run with the first impression without questioning, until they face a big obstacle. I have pointed out in my blog on Diagnostic errors in internal medicine that “the most common problems were related to faulty processing of available information. The single most common cause was “premature closure”. In other words, physicians often fail to consider other reasonable alternatives once their minds latches on to an “initial diagnosis”.”

In a recent exercise in Clinical Problem Solving in the New England Journal of Medicine, the authors show how the initial impression can be wrong. In this article the authors report a patient with vertebral osteomyelitis and epidural abscess who was treated for TB; but actually turned out to have meliodosis. The authors cautioned “Beware of First Impressions”. They are correct.

One has to keep an open mind. In addition, there is another clinical dictum that is always useful. Whenever you are making a differential diagnosis for any symptom, think of the commonest cause and think of the worst or the most serious cause. With that rule, one could have considered meliodisos earlier in this patient with diabetes.

Also, there is a book entitled Blink which overemphasizes the importance of first impressions. I respectfully disagree, particularly in clinical medicine.

Clinical Skills

2009-06-15T17:39:00.000-07:00

How to learn? How to teach?

The word Clinical has its root in the Greek word Klinikos meaning the bed. Therefore, clinical medicine is bedside medicine and clinical skills should include all the skills required of a clinician at the bedside. In my view,the list should include: listening skills, observation skills, diagnostic skills, caring skills, problem solving skills, communication skills, human relation skills and negotiation skills.

All of us know that these skills are important. But how do you teach them? At present, medical students learn these skills mostly by observing master clinicians who act as role-models. There are not adequate numbers of such role models in medical schools. Only recently have medical schools come to recognize the importance of master clinicians in their academic ranks. Even when such masters are available, learning by observing is a passive method.

How can one teach clinical skills using active, practical methods? One method is to observe students interact with patients directly or through a video and then discussing the techniques. Another method is to use seminars and workshops developed by industries in listening skills, communication skills, negotiation skills and problem solving skills. Some such programs are available in medical field also.

It will be best if medical schools organize specific courses or seminars on each of the skills required at the bedside. These can be conducted by one of the staff members using materials available from variety of sources. Alternately, a specialist can be invited to conduct these courses.

I have found that organizing a seminar lasting 2 to 3 hours is a practical way to introduce students to some of the techniques in each of these skills.Using well-known principles of adult-learning, I divide my session into 4 segments. The first segment is for Introduction of the participants and of the topic. This should last for about 20 to 30 minutes. I often ask the participants what each of the participants hopes to learn in the session. I then summarize my plans and align their expectations with what is planned for the session. The second segment is to provide Information. I give a talk summarizing what is known about that topic. This talk lasts for about 20 minutes. The third segment is for Integration. This consists of one or more exercises to explore the main topic. Students are divided into groups of 3 or 4 and asked to think about a particular topic or problem. This should last for about 30 minutes. This is followed by a group session lasting about 15 minutes when the students present their ideas and recommendations. The final segment is for Implementation of ideas generated. At this session, students spend a few minutes individually or as groups, writing down how they plan to implement the ideas they learnt.

If a follow-up session can be planned to find out how well the ideas were implemented, what the blocks to implementation were and what the outcomes were, the students will benefit even more.

(My book on Handbok of Clinical Skills - A Practical Manual has a chapter on how to organize a course on Clinical Skills)

Communication Skills

2009-06-15T17:33:00.000-07:00

Physician to physician communication

In my book on Clinical Competency Skills there is a chapter on communication skills. The focus is primarily on communication between patient and physician. There is a small section on Consultation where I deal with physician to physician communication. But it is not a comprehensive discussion. In a recent issue of JAMA, Doctor Michael D. Stillman deals with this topic with great examples. (Physicians behaving badly. JAMA 300 (1); 21-22, 2008)

All of us know that it is disrespectful to alter a patient’s medical regime without discussing with the primary physician. It may even be dangerous sometimes. More important, we may be able to learn some very important facts about the patient’s illness and personal predicaments by talking with the primary physician. We also know how embarrassing it is for the primary physician to hear about the death of a patient from the family instead of from the consultant.

Poor communication between physicians is unfortunately still common. Doctor Stillman gives examples from his practice. One example is that of a patient whose medications were changed to a more expensive formulation with inconvenient dosing schedule during a hospital admission by physicians who did not know her. There was a patient from his practice who was admitted to a hospital for surgery and he met her accidentally. Another patient’s death was not reported to him by the consultants at the hospital.

These problems are not only between hospital physicians and community physicians. This is a problem between physicians in general.

Fortunately, there are physicians who do communicate with the referring physician and the family physician. Doctor Stillman gives an example of a trainee who e mailed him every week to report on the progress of the patient and a discharge summary.

As pointed out by Doctor Stillman, “ we miss critical pieces of histories and thus either perform redundant workups or fail to address important medical issues “ by not discussing with other physicians involved in the care of a patient, particularly the primary physician.

Clinical competency - Thinking Skills

2009-06-11T05:19:00.000-07:00

Clinical experiences early in my medical career convinced me that the medical school packed facts into my brain, but did not teach me how to think and use that information at the bed-side. I observed some great clinicians at work, thinking about a diagnosis or management strategy. But that was the classic method of “monkey see, monkey do”.

The emphasis at the medical school was on the hard science of biology and medicine and scientific method. This included analytical thinking, deductive retrospective reasoning ( called retrospective prophecy by Sir William Osler), statistics and algorithms. It failed to show me in a formal way the importance of my perceptions and emotions and those of patients in decisions making. It failed to show that context matters in patient care.

Formal training did not emphasize adequately the importance of reflection on one’s own thinking and learning from experience. One of my earliest experiences with learning from reflecting on an experience was with a 6 year old child undergoing surgery for a bent finger. She carried a diagnosis of Juvenile Rheumatoid (Idiopathic) Arthritis (JRA). When I took a detailed history, two items caught my attention: 1.This child was born with bent finger. 2. Two of this child’s siblings were also born with bent fingers and were diagnosed as having JRA. When I reviewed the details of the past history and laboratory data of this child and her siblings, I did not find any increase in the white cell count in the blood. There was no increase in sedimentation rate. The synovial fluid did not show increase in white cells and the biopsy of the synovium of the siblings did not show any inflammatory cells. In other words, there was no arthritis. How can the diagnosis of Juvenile arthritis be correct when there was no arthritis? This led to my clinical habit of asking Three Questions (Pediatric Physical Diagnosis by Balu Athreya and Benjamin Silverman Appleton Century 1982).

The three questions are: What is it? What is it not? How do you know? Answer to the first question should define the symptom or sign or diagnosis. In the example given in the earlier paragraph, the child was diagnosed as having arthritis. Arthritis is inflammation of the joint. But this child had no systemic or local evidence of inflammation. The child had swelling of the joint. But it was not due to inflammation. Therefore diagnosis of arthritis was wrong. Obviously the diagnosis of JRA was also wrong.

This leads to the next question: what is it not? In other words, what other conditions can look like the condition you are thinking of? What other conditions can mimic the condition under scrutiny? What are the “look-alike” conditions? What are the exclusions? Swelling of the periarticular tissues can look like joint swelling. Swelling of the bone can look like joint swelling. Fluid in the joint other than inflammatory effusion can look like arthritis. For example, blood in the joint or sterile effusion can cause joint swelling.

How do you decide? In other words, how do you confirm what it is? Examination of the joint fluid is the definitive way to prove inflammation although it may not be always necessary or possible. In this patient, there was no increase in the cells in the synovial fluid. In addition, synovial biopsy had been done and did not show any inflammation.

This rule of define (what is it?), exclude (what is it not?) and confirm (how do you know?) can be applied to any clinical situation.

I learnt another important fact about thinking. If it was not arthritis, what was it? The clue was in the history of three siblings born with bent fingers. Until this critical feature is taken into account, the conclusion will be wrong. Indeed this patient was found to have a rare disorder due to a genetic defect.

Subsequently, I found that this idea about critical point is important in many other situations. Let me explain with an example of the mother of a child with head injury. This mother had acquired a reputation for being a most difficult person to manage. She was indeed angry and moody. Given what had happened to her child this is not unreasonable. However, periodically she became particularly difficult to communicate with. It soon became clear to me that she had an obsession with time management. If someone made an appointment to meet with her at a particular time and did not show up on time, she became agitated. Most of us get upset if we are made to wait. But this woman became impossible to deal with even if there was a delay of 2 to 3 minutes by her watch! Once this “critical point” became evident, we planned so that we did not give precise time of appointments, but only a range. Or we made sure we were there ahead of time. This made our communication much easier.

This critical point concept has helped me at home and at work. In any complex situation there is often one special issue that needs attention before a practical decision can be made. Until that special critical factor is addressed, the final solution will never be appropriate and complete.

The third early experience was with a 13 year old girl with scleroderma. The disease had ravaged her legs. The right leg was totally atrophic. One day that young lady asked me whether she can have a new leg. She did not ask for amputation, mind you. I was stunned and was not prepared for this question. I said that it was possible and we started discussions about the pros and cons. Later that day when I wrote out ALL the factors I knew were important from the medical point of view and ALL the other factors in the patient’s life situation, it was clear that amputation of the leg and a prosthesis was possible. But there were dangers. There were also concerns about her family resources. We were able to discuss these issues at a later visit. She did get a prosthesis and she did go dancing like the other girls. She was so happy when she told me about the dancing during one of her visits. I wish I was there when she went on the dance floor for the first time!

The point here is how to factor in non-medical factors during decisions on patient-management. I have seen my mentors make such decisions in the privacy of their office and inside their “brains”. But these were never made explicit.

This is the problem with thinking skills. Everyone knows that thinking is important. Thinking skills are emphasized in clinical training. But most of the emphasis is on analytical thinking using classic tools of science. They are concrete, objective, supposedly quantitative. They are dichotomous yes/no, medicine/surgery as if it is possible to clearly classify “things” neatly falling into one pile or other. It is as if we can stuff all solutions into neat pigeonholes. Sydney Gellis said famously “If you are one of those who like to see every little piece fall into place, you should be in carpentry”.

Major problems with formal courses on teaching and thinking about clinical skills are: there is very little discussion on how our brains work in solving problems; intelligence and knowledge (information) are emphasized and not creative thinking; mental blocks and blind alleys are not discussed; reflective thinking is not emphasized; no time is provided for reflection; and finally specific skills in thinking are not taught or learnt in medical schools. The irony is that such skills have been widely available for several decades. Extensive literature going back to the early 1900’s is available. Industries and businesses have been using them for decades. One of the current world leaders in thinking skills is Edward de Bono, a PHYSICIAN!

I wish to share some skills in thinking that have helped me in my professional work. I do not claim originality to any of these ideas. Let me start with a simple example. When faced with a patient with a new problem, here are the questions that need an answer:
What is the most common cause of this symptom (or sign or disease)?
What is the most urgent condition I need to think about so that it can be taken care of at once? (One with the most serious consequence)
What is the most logical cause of these symptoms and signs?
What is the most important concern and the question from the patient’s point of view?
If this is a problem I have not handled before, who else has? Can I call and get help?

Caring and Communicating

2009-06-09T12:34:00.000-07:00

Recently, two of my family members were seriously ill. Several family members and friends were extremely helpful through this rough period. Being a clinician, I could not help observing the way many of them responded. (I was reflecting on my own behavior too!)
Some just dropped everything and showed up at the doorsteps wanting to help. They were comfortable talking to someone in deep trouble. Their presence was soothing. They just gave themselves freely.
There were a few who were particular about not invading the privacy and they did not call for many days. They genuinely believe in this concept of invasion of privacy. This is a cultural issue, more common in the western cultures. For me with my oriental view, when someone is in trouble I would rather show up and be of help rather than stand on this formality.
There were some who were afraid of their own anxiety and did not know how to respond. They never called for a long time. After several months, it became embarrassing and so they avoided the situation even more! Some used the idea of “wanted you to have privacy” as an excuse for their own inability to face our predicament and their anxiety.
There were some who knew that socially you are expected to call on someone who is seriously ill. They therefore came to visit.It is a formality to get over with.They insisted on coming when it was convenient for them irrespective of the strain it placed on the patient and the family.
It appears that humans become anxious when they face someone with a serious illness. This anxiety leads some to avoid the situation completely and they disappear from the circle of friends, at least for a short time. Others express their anxiety visibly and make the patient even more anxious. A few others know they are anxious and are open about it. A few are calm and patient-centered and make the patient comfortable.
All these points are brought out thoughtfully by a well-known psychologist and family therapist, Doctor Dan Gottlieb in his book on Learning from the Heart (Sterling Books, 2008)

Clinical Competency Skills - A new site

2009-06-07T04:22:00.000-07:00

Friends and Colleagues,

Welcome to this new site for my blogs on clinical competency skills. This move became necessary because the book on Clinical Competency Skills associated with the earlier site will no longer be published by the Booklocker company. The publication has been taken over by the World Scientific Publishers. The second edition of my book will appear under a new title: Handbook of Clinical Skills.

The World Scientific Publishers have established a website associated with the current edition of the book for descriptions,book reviews and sales only. The URL is: http://www.worldscibooks.com/medsci/7330.html.

I have opened this current blog site for publication of essays and updates associated with the new edition of the book. The URL is http://clinicalcompetencyblogspot.com.

You will be able to connect between these sites.

I hope you find the book useful. Please share your suggestions and comments and help me make this book even more useful and practical.

Finally, I thank Angela and Richard of the Booklocker company for their support and help in publishing the first edition and maintaining the website for me.

Balu Athreya M.D.
Wilmington, DE USA