How Doctors Think

My most recent chronic illness/chronic pain support group meeting was on the topic of communication with your doctor.  In today's post and the next one, I will share some highlights of that session. I started with a review of the book HOW DOCTORS THINK, by Dr. Jerome Groopman. 

Dr Groopman stated that medical students these days are taught to diagnose by using decision trees. The trunk of the clinical decision tree is a patient's major symptom or laboratory result, contained within a box. Arrows branch from the first box to other boxes. For example, a common symptom like "sore throat" would begin the tree, followed by a series of branches with "yes" or "no" questions about associated symptoms.

This can be useful for run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example. But they don’t work when a doctor needs to think outside the box. This method of diagnosing ignores the fact that each person is different, shows symptoms differently and reacts differently to treatment.

Dr Groopman concluded that the next generation of doctors was being conditioned to function like well-programmed computers that operate within a strict binary framework.

Doctors are supposed to be emotionally neutral, but this isn’t always the case. The sickest patients are often the least liked by some doctors. The doctor may feel frustrated, and feel a sense of failure with disease that resists treatment. People with chronic pain and chronic illnesses tend to fit this category. It’s important to find doctors who can work with us.

On average doctors tend to interrupt patients within 18 seconds of when they begin telling their story. Doctors end up making thinking errors, by stereotyping, or jumping to conclusions based on assumption. They fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause. Once there is a label, they stop looking, ignoring details that don’t fit.

After surveying the significance of a doctor's words and feelings, the book looks at how different types of doctors think. An ER doctor needs to use a different thinking style than a primary care doctor. For either one, though, sound medical judgments meld together first impressions and deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes. There is a factory mentality w/ managed care.

This book is worth the time to read it.  It will give you insight into how your doctor may be thinking, and that insight can guide how you interact with him/her.  Dr. Groopman gives some suggestions of what we, as patients, can do to help our doctors give us the best care:

• Offer to retell your story-how you felt, when and how it happened/. This can remind the doctor of a clue he had overlooked or forgotten, or prompt him to think in another direction.
• There is a 20-30% error rate in radiology- esp. w/ more sophisticated scans, where there are thousands of images. Ask that scans be re-examined, or even redone.  Radiologists do best if they know why the scan was ordered. If the doctor didn’t specify, you tell them. If other tests were inconclusive, they may also need to be redone.
• Patients can ask questions to guide the doctor off the automatic expected path. “What else could it be?” “Is there anything that doesn’t fit?” “Is it possible I have more than one problem?” “What is the worst thing this could be?” “What body parts are near where I am having symptoms?” If treatment isn’t working or if the doctor suggests something that didn’t work in the past, or you had a bad reaction to, tell him, and ask “What else can I try?”
• Tell your Dr how you feel, what you think, what you fear. Ask questions if you don’t understand. Take notes. Take someone with you if you want, to be an extra set of ears.
• Sometimes a doctor does not want to be asked questions. It is your body; you have a right to be informed, and to get the best care possible.
• If you feel you and your doctor are not communicating well, you can find a new doctor, or bring up the issue with the doctor. Sometimes clarifying expectations can help.
• Dr Groopman concludes that doctors are learning to partner with the patient and family. Patients need to be more educated and informed. Look on the internet (but be picky about what sources you believe.) Talk to other people. Give your doctor info about your illness, etc. The more they understand, the better they will be able to help you.

In my next post I will share a list of other ideas to help you communicate better with your doctor.

Plan Ahead for a Crisis

What do you do when nothing works?  This is one of the biggest dilemmas in medicine.  In a group I was leading (on the hospital psych inpatient unit) the other day on leisure, a couple of patients said they had lost interest in everything, others said they just had no motivation to do anything.  These are typical feelings with depression.  A few months ago, a patient said she knew she could and should pick up the phone and call someone when she is thinking about suicide, but at that point, that was not what she wanted to do.
There are no foolproof answers to these situations. Motivation and interest can't be conjured up if they aren't there, and if someone really feels they are better off dead, why would they call someone to stop them?  Research has shown that usually a combination of medication and talk therapy works best to treat most depression.  When people get to the point of the patients described above, medication is the first line of attack. When they start to feel better, they can better make use of other options.  It takes alot of strength to pull out of real depression without medicine.
The groups I teach are a sort of talk therapy, but I don't see patients on an ongoing basis.  Each group I lead is separate, the patients choose to come or not, and only while they are inpatients on the psych units at our hospital.  With these constraints, I try to make each group have an impact on how the patients think about themselves and/or their illness.
One of the things I talk to my patients about is having a plan in place before a crisis.  Keep phone numbers handy  or on speed dial for close friends or relatives who are supportive, their doctor/therapist/counselor/case manager/sponsor, and the crisis and suicide hotlines.  When a person is depressed, thinking clearly can be very difficult.  Having a clear plan ready can save their life.
I talk to them about getting familiar with their symptoms so they can learn to catch things before they get to the crisis level.   Experiment with a variety of coping techniques to learn what is most helpful in different circumstances, and have the materials readily accessible.  We brainstorm coping techniques they have tried or heard about, including relaxation techniques, distraction, reframing, etc.
These ideas are helpful not only for depression, but for physical illness and pain, as well.  Think about yourself- What triggers a flare for you?  How do you know you are going downhill?  What has helped you in the past?  By planning ahead, you may be able to prevent a crisis, or at least minimize its impact.
  

Ergonomic Gardening

Last year I wrote several posts on gardening, and how I really enjoy my two garden boxes.  They are each about 10 feet by 3 feet, and raised up about a foot off the ground.  Today was the first time this year that I spent much time on them, about 2 hours.  I weeded both gardens, used a claw tool to loosen the soil and mix in some fertilizer, and planted seeds for radishes, beets, lavender, snapdragons and zinnias.  Sounds like I did alot, and though I am not sore, I did have to take a nap afterwards.
While I was gardening, I was thinking.  There are a few things that I might do differently if I were to build new garden boxes.  The way the gardens are set up, they are as little awkward to work in.  I can sit on the brick edging.  This puts my back to the garden, and I have to twist around to work.  Another option is to kneel on the ground.  This puts me facing the garden, but I need to wear knee pads or use some kind of cushion to kneel on.  I could also sit on a low stool, and lean forward.  Its a long reach to the back of the bed.  I did a combination of sitting on the edge and kneeling today.  Keeping myself moving and switching positions often helped decrease any strains on my body. 
An ideal arrangement for gardening is to build a raised box garden. There needs to be about 26-27 inches of clearance under the table so a person can sit in a chair, legs under the table.  This allows the person to get close enough to work in the garden without straining to reach.  The box should be 8-12 inches deep, allowing enough depth of soil for many kinds (but not all kinds) of plants, but not so deep that the sides are too high.  If there is access to the garden from just one side, it should be no more than 2 1/2 feet wide, if there is access from all around, it can be as much as 5 feet wide.  Here is one site I found with instructions for building such a bed.  There were other sites like this as well, I searched for 'raised garden on legs'. 
For easy on the hands garden tools, I like Goodgrips, though there are other brands available.  This site has info on gardening with arthritis, and a variety of ergonomic gardening tools.  They even have a gardening caddy that you can sit on, and it has wheels to move around easily. 

E-Reading

I love to read.  When I am really busy, what I crave the most is to have several hours when I can just sit and read.  My husband and I are both book people (maybe because we are Jewish, sometimes called 'the people of the book'?)  Whenever we travel to other cities, we look for used/rare book stores to browse in, and used to go home with piles of books we knew we would not have time to read.  When we moved from our house into a much smaller apartment, we got rid of close to30 boxes of books, mostly to the public library, some to our Temple library or other places.  We still have 12 bookcases full of books, but we try not to buy more unless they are something we really expect to use.
We seldom buy fiction, because those books we would just read once and be done.   More often, we would jot down the title and author, and look for the book at the library.  Lately we have gone high tech with our reading.  We didn't spend $100 bucks for an Amazon Kindle, or other e-reader, which would then require us to buy the books as well (though there are some free books for Kindle, mostly classics).  Instead we get our books from the library, for free, and read them on our computers.  We both have netbooks, which are smaller and lighter than regular laptops, so we can take them wherever we go.
Our public library is a member of two book consortia, The Ohio E-Book project, and the SEO Consortium.  I am sure there are others online, I have not yet explored this. (If anyone knows of any they would like to let me and my readers know about, please post a comment at the end of this post.)
From the comfort of my living room, sitting on my recliner with my kitty between my knees, I can go online, browse for books to read, check them out, and download them to my netbook.  The library allows me to check out books for 2 weeks, but the SEO Cons. lets me have them for 3 weeks.  After that, they expire, and can no longer be opened.  I check them out using my library card, but I think you can also register on your own to use the consortia.  Thousands of free books at your fingertips, including new releases, all for free.
There are also multiple formats available.  The person who told me about the consortia downloads her books as audiofiles, then she listens to them on her IPod.  My husband and I both download our books as e-books, and read them like a book.  I like the Mobipocket format, my husband usually uses Adobe reader.  On my netbook, I can decide if I want to read in one column or two, how bright the screen is, and what size letters I want.  Lots of ways to adjust it to make reading easier.  Try doing that with a regular print book.
Check it out (pun intended).  Try  your local library's website, or look online for options.  No need to wear shoes, or even clothing to go to the library these days.  You may not find a specific book, but there are plenty of choices. This is a wonderful resource for people who don't feel up to going out, but want to read.  
 

Don't Worry Needlessly

Yesterday a squirrel came up on our front porch and stayed for quite awhile. He was eating something, I have no idea what. Camille, my cat, almost missed him as she walked past the sliding glass door towards her food dish, but saw him move out of the corner of her eye, and turned back to the door. She slowly snuck up to the door, on her stealthy kitty paws.

I expected the squirrel to take off as soon as Camille came into view, but no. The squirrel continued to eat, and to rise up on its haunches from time to time to look around. There they were, the predator and the prey, mere inches apart. The squirrel didn't flinch, even when Camille put her paws on the door. Several times they seemed to stare into each others eyes. Then the squirrel would resume calmly eating, and Camille would resume watching. After awhile, Camille relaxed from her predator pose. She even got bored, went to get something to eat, then came back and lay down at her post in front of the door as if nothing unusual was going on.

The squirrel appeared to understand the solidity of the glass door separating them, and the biological fact that cats don't have hands to open doors. Even with a predator an easy reach away, he didn't worry, because he knew that was as close as the predator could get.

We humans are different. We tend to worry whenever we get the chance, even when worry is not warranted. We worry that a loved one, who is five minutes late, is in a ditch somewhere. We worry that we won't get an 'A' on the test that we took yesterday. We worry that the meal won't be perfect for our in-laws. We worry that our fatigue will just get worse and worse, that our pain will never let up, that we will never be able to do anything again.

Even if the situation we worry about is likely to happen, worry isn't the answer. Worry keeps us stuck and in pain. A true assessment of the facts of the situation is more helpful, looking at what is, and what will likely be, allowing us to think about what actions we can take to prevent the unwanted outcome. If it can't be prevented, we may be able to soften the impact by preparing for it or changing the circumstances in which it will happen.

A true assessment might show us that there is really little or no chance of a problem happening, and therefore nothing to worry about. We can just go on with our plans. Just like the squirrel who saw the cat, but also recognized the protection that the glass door provided him.

Save it for a Rainy Day

Here in Northeast Ohio we have had mostly cool rainy days for the past month. My husband set up our rain barrels this past weekend.  This morning he said "The rain barrels are full.  You need to go water your garden."  I think not.
I have been thinking about the expression "Save it for a rainy day."  Where does it come from and what does it mean?  I did a quick search online, and found no consensus.  Here is my favorite, from 1580 in a book called 'The Bugbears": 'Wold he haue me kepe nothing against a raynye day?'" [From "The Dictionary of Cliches" by James Rogers (Ballantine Books, New York, 1985)]. It generally is used to mean saving money when you have it for times when you have less and really need it. It makes sense in a farming community, where no money is earned on a rainy day. 

So what does it have to do with this blog?  Alot of people with chronic illnesses and pain are affected by the weather. In 1995, Professor Robert Jamison at Brigham and Women's Hospital's Pain Management Center noticed that the waiting room was fuller on damp, humid days than on warm sunny days.  They  handed out hundreds of questionnaires in a variety of cities, and found that most people felt changes in their body before the weather actually changed.  He concluded that it was the barometric pressure that was causing the effect, with low pressure associated with cold, wet weather and an increase in pain, and high pressure associated with clear, dry conditions and decreased pain.  I have not noticed weather affecting how I feel, but it is true that I have had increased pain lately.  I think I should pay attention to this.

So if people tend to have increase pain on rainy days, then maybe 'save it for a rainy day' takes on a new meaning.   You get a new magazine in the mail?  Save it for a rainy day,when you hurt and want to be less active.  A new flavor of tea catches your interest? Save it for a rainy day when you feel the need to treat yourself kindly.  Have a new (or old) movie you have been wanting to see?  Save it or a rainy day when the room is just as dark with the shades open as it is with the shades drawn.  In other words, be nice to yourself.  If pushing yourself when you hurt makes you hurt more, don't do it.  

On the other hand, if pushing yourself when you hurt does not make you hurt worse, a rainy day is a great time to take care of things that have been piling up.  Sort through clothes and get rid of ones that don't fit.  Rearrange the pantry, or clean out the junk drawer.   Make a big pot of soup and invite friends over to watch that movie with you, or to do a craft or jigsaw puzzle together.  Get help if needed for any task.  

The list of ideas for a rainy day can go on and on.  Many people feel a bit down on rainy days.  Do something to get yourself (or keep yourself) out of the dungeon.  Doing something special, or fun, or different or indulgent or interesting or creative or... or... or....