Archive for August 2010

Patient-Empowered Communication   Leave a comment

I’ve uploaded two articles for next week’s discussion on patient-empowered communications: Inger Holmstrӧm and Marta Rӧing, “The Relation Between Patient-Centeredness and Patient Empowerment: A Discussion On Concepts,” and Nancy Tomes, “Patient Empowerment and the Dilemmas of Late-Modern Medicalisation.”

Holmstrom_ScienceDirect_27Aug10

medicalization–tomes

Posted August 31, 2010 by MGalbreath in Uncategorized

Vanity Fair Article: Topic of Cancer (Christopher Hitchens)   1 comment

Topic of Cancer, an article recently published in Vanity Fair is especially interesting if you know Christopher Hitchens’ work (most notably his 2007 book God Is Not Great: How Religion Poisons Everything). He captures his experience so poigniantly with such raw humor that I was transfixed. The article is a GREAT read, written in first person by Hitchens about his experience with cancer (being an atheist nonetheless).

One of my favorite lines, as he talks about his journey to the other side, as a “new citizen of the sick culture”: “The new land is quite welcoming in its way. Everybody smiles encouragingly and there appears to be absolutely no racism.” Ain’t that the truth.

Posted August 31, 2010 by Lela in Uncategorized

Quick Video-From the Science Perspective   Leave a comment

So I came across this quick video last night while I was searching youtube for something to listen to as I go to sleep.

Yes, I listen to physics lectures as I drift off. Please don’t judge me 😦

Anyway, I thought this video seemed surpisingly relevant (at least it did at 12:30 last night) because it talks how medicine and the science that goes into medicine are related but not the same thing. It’s just two minutes, but I thought it helped to illustrate the variety of deciplines and ways of thinking that help develop our medical system.

Posted August 31, 2010 by kathryndunlap in Uncategorized

Kathryn’s Response of Montgomery   1 comment

I very much enjoyed the way that Montgomery tackled the issue of public perception of medicine as a science and doctors as scientists, which is of course not the full picture. The way that doctors themselves, even those from more social science backgrounds, maintained a concept of medicine as a science even if they were not 100% scientists but rather practitioners of something that was part science part art.

As a composition instructor, like Montgomery addressed in chapter 3, I think that not only the narratives of the patients are important, but what is practiced and valued in medical writing. On page 49 Montgomery says “the clinical case history not only provides a means of working out and remember what is best to do for a give patient, but also captures experience and presents it to its audience. As a result, case narrative is the primary, vicarious means of shaping clinical judgment for new learners and experienced practitioners alike.” What this calls attention to is how clearly narrative experience is tied into the practice of scholarly medical publishing that furthers the development of medicine. Even tests and publications of new drugs or procedures are only put in a clinical, medical setting very late in the game. And while this is partly about getting a wider sample of results before the start of general distribution, it is also about getting to understand the experimental treatment in context with a more diverse swath of patients.

At least it should be. This is what doctors want from a clinical trial, while companies are more interested in reproducing the lab results to build support and confidence in their product. I suspect that we might be more skeptical of our science mingling too closely with our medicine, but speculations like that could be a whole post in itself.

The ideal behind clinical judgment, as developed over a long apprenticeship, makes me feel a little more confident about medicine in general, but as Montgomery is often pointing out, this bears far more resemblance to a social science then the universally reproducible results of physics, to paraphrase from page 71. So like the story of the boy building the card tower, medicine is rigorous and rational, but it is not possible to isolate the individual factors that go into a medical condition.

Because I’m a child of the electronic generation, I tend to like to have the tv on as I do work. This Saturday, while cleaning, I had on a House marathon. I do try to catch the episodes when they’re on, but I’d always considered them ridiculously inaccurate. I still believe that, but now for slightly different reasons. The odd, intuitive causalities that the titular character pulls from seemingly nowhere, I thought were the ridiculous. That, as Montgomery is getting at, is an important part of medicine, though one that is not fully celebrated among the public or the medical community. Montgomery mentions Sherlock Homes and deduction at the start of chapter 6, indicating that doctors have taken deduction as a descriptor of what they do. That the main character of House is based of Sherlock Holmes seems to be an interesting connection. One that might indicate that the absurd seeming medical show may have a bit more to do with medical thinking then I initially though.

Posted August 31, 2010 by kathryndunlap in Uncategorized

Walking Tightropes: Response to Montgomery   1 comment

“When the results are normal, we go back to normal too. We are reimmersed in our ordinary lives and their more immediate concerns” (14). And when they are not, everything changes.

The introduction and first chapter of How Doctors Think elucidates how prevalent medicine is in our lives and how forcefully we can be thrust into its uncertainty. Montgomery’s first chapter starts with a story that I know well, as my sister had a lump in her breast removed just months before my mother was diagnosed with stage three follicular Lymphoma. We had barely gotten over my sister’s “scare” (her lump was benign) when my mom felt lumps in her neck. Montgomery’s opening resonated for me and I realized the timing of this class is both opportune and intense. It was hard to read chapter one being so fresh from my mom’s chemo. I met many women with breast cancer, along with others battling its cousins: melanoma, leukemia, throat cancer, prostate, bladder, lung, brain…the stories circulating during those twelve-hour days at the hospital made me feel lucky that my mother’s prognosis was good. I felt guilty being grateful that she was usually much better off than her roommates, but I couldn’t help it. It was hell nonetheless and Montgomery captures the experience effectively. She speaks with the voice of a mother and a professor and researcher critical of the very practices that will save her daughter’s life—a nuanced, unique, and appropriately biased perspective.

Montgomery’s discussion about chemotherapy is important because chemo is both hard science and application or practice. It is the chemistry of life and death and must be administered with skill and compassion. The treatment process can be confusing for patients. Montgomery writes, “If consensus has been reached about who needs chemotherapy, there are nevertheless bewildering choices among chemotherapeutic agents and regimens” (19). It is overwhelming to be faced with such a grave and pressing set of options, particularly for a scared patient still processing a diagnosis.  The language of chemo (Bendumustine, Rituxin, chop), the tools (mints, distraction, that one comfort food to quell nausea), the time passers (crosswords, puzzles, knitting), the accessories (lime/pink/blue bracelets, cups, ribbons)—this was not a language I expected to learn. Those who work in oncology, and as Montgomery asserts, all fields of medicine, must strike a careful balance between the factual/scientific/concrete and the emotional/compassionate/uncertainty that cancer treatment demands. One of my pharmacist friends jokes that she wanted to be a doctor but did not like working with the people as much as the drugs. Oncologists must be the pharmacist and the nurse, the counselor and the medical expert, the scientist and the practitioner.

Montgomery’s discussions consistently relate back to a persistent distinction between science/objectivity (as if science is objective) and art/practice/subjectivity, reiterating our culture’s love affair with binaries. She asks why “clinical judgment [is] not celebrated” (34). Is it because we feel more comfortable putting our lives in the hands of objectivity rather than the conjecture of one single subjective individual? Relying on the comforting assumption that science and thus medicine is objective, factual, fixed, and reliable makes us feel better. Of course that “singular” opinion is the result of countless case studies, much research, and many other opinions (objective and subjective), and while that might be a better bet than prayer, the holistic nature of medicine involves mind, body, and spirit—or at least it should. We are whole beings and should be treated as such. The same goes for medicine, which requires combination of science and humanity, case studies and kindness.

My question is for discussion is one Montgomery poses on page 79 (since she spends most of the book entertaining the question of misdescription, I wonder what you think): “Does the misdescription of medicine matter?” To elaborate, if medicine is actually practicing what Montgomery preaches by being a science and art of medical application, does it matter if it is categorized as a science? Or does it impact the practice of medicine more than we realize? After reading Groopman, I’m not so sure.

Posted August 31, 2010 by Lela in Uncategorized

Jen’s Montgomery Response   3 comments

Montgomery asserts that “Patients see the person who is the physician but respond to the archetype; they evoke physicianly performance by the power of their need” (200). Thus the reciprocal relationship in which doctors or any professional are perceived to “perform” in accordance with their constituents’ “expectations” is made clear.

When I am less prepared than I would like to teach a class, I remind myself that at least I know more than my students do about “x.” This allows me to feel more confident (fake it until you make it!). While this can be comforting at times, I never want to rely on this dynamic. Because my credentials create certain expectations, most students are willing to abdicate their own better judgment in favor of my perceived expertise. I have to constantly fight against this apathy/passivity by empowering students and helping them to understand what they already understand; I strive to wake up their intuition and critical thinking.

Though I can clearly relate to this professional experience, I never thought of the extent to which medical doctors act under the same auspices. However, as Montgomery points out, doctors often prefer the comfort and insulation that is implicit in the “physicianly performance.” They may prefer patients who abdicate their responsibility to participate effectively in their own care because they are less trouble.

However, a teacher’s job is to insist on this participation. While students long for reassurance—you are smart; you will graduate and get a good job; etc., they have a lifetime of school and social experiences to inform their judgment about their skills and potential. All of these highly variant experiences inform their academic experience.

Patients (especially those with catastrophic illnesses), on the other hand, are usually at a loss. The experience that informs them is former/formative interactions with doctors that which is so informed by their “need” and the fulfillment of this need that magical, modern medicine prescribes, as well as our cultural conventions (our elevation of those whom we perceive as experts). This lulls patients into a false sense of security. Patients tend to believe in the science of medicine rather than the practice of medicine, as Montgomery explores throughout the text because it is reassuring.

What can we learn about the doctor/patient dynamic performance by comparing it to the teacher/student dynamic performance? In what ways might we consider the doctor both the teacher and student?

Posted August 31, 2010 by jenwojton in Uncategorized

Concetta’s Response to Montgomery   1 comment

Last time in class we focused on the concept of narrative as a way in which doctors could avoid misdiagnosis by looking at the symptoms and letting them tell the story. However, after this week’s reading, I am beginning to wonder if narrative may be the problem, not the solution.

What makes a doctor more like the one that treated Daniel Pink’s patient 2 and less like the one that let patient 1 die (as mentioned in Elle’s Montgomery response)? Coming from a field as self-reflective as teaching, I find it shocking that medicine isn’t more conscious of its shortcomings, especially since there are so many instances of misdiagnosis and clinical error that as “scientists” they should be able to recognize some flaw in not being self-conscious. I also find it extremely horrifying that Montgomery implies that doctors only adopt the idea of medicine as art and science purely for the authority it grants and that they would sacrifice reliability and logic for a false sense of security. I can, however, see why they feel compelled to do so.

Doctors often demand horrible things of their patients by way of treatment, especially when the disease is fatal and the science uncertain. Rather than go through the loss of her breasts and the pain of cancer treatment, my aunt, like thousands of others, turned to herbal and non-invasive treatments to cure her cancer; she did not last a year after diagnosis. Some might dismiss her decision as ignorant (and for the record, I do) but when the narrative that doctors put forth is that of the infallible doctor of Science with a capital “S”, and then patients face the reality of a treatment with an uncertain success rate, it destroys the doctor’s credibility. Yet this fear of losing credibility is exactly why doctors perpetuate this narrative; if a doctor fails to convince someone that the treatment, though painful, will save their life, that patient will most likely die.

Even doctors who doubt this narrative of certainty will fall back on it; when proposing her solutions to this problem of authority, Montgomery needs to frame them in the form of a narrative:

As for (authority), it arises more strongly from human need in time

of illness than from science. A widespread appreciation of clinical judgment

would provide physicians a human and fallible but still trustworthy authority.

Montgomery 39

It cannot be a matter of finding statistics on what methods are best; Montgomery needs to reassure doctors by preserving this narrative of authority. Even her colleague, who equally expresses doubt about medicine’s certainty, became authoritative when telling her that her daughter “would not die”, not that there is a slim chance that she will die or giving her the national statistics (190). In that moment he became an authority solely to reassure Montgomery, not to adequately prepare her or to dispel the myths of medicine’s certainty.

This becomes even more troubling when Montgomery states that “Physicians …have been trained to expect of themselves a perfection of effort” but that “people with chronic diseases know better” (191). One thing I noticed was missing from the curriculum at UCF’s medical center is a class on basic problem solving skills. Do they expect new doctors to just pick it up as they go? A new physician who has not had or know someone with a chronic disease will more than likely buy into this narrative at first, seeing the more experienced doctor as simply being better at being “perfect”. Even once that narrative has been dispelled for the new doctors, they might find themselves using it to their advantage when faced with a patient that refuses treatment. What gets lost here is the ability to admit error, to admit that a patient might have had terrible things done to them for no reason, from something as simple as undressing in front of hospital staff, as was the case with the cancer patient in last week’s reading, to having a double mastectomy only to have the cancer return.

If doctors cannot admit fallibility, than perhaps it isn’t just society that thinks too highly of doctors. It may seem counterintuitive to say this in a profession where lives are at stake, but there has to be room for error and doubt. If not, misdiagnosis can lead to more harm than loss of credibility.

Posted August 31, 2010 by capochetta in Uncategorized