Category Archives: Diabetes

“Scope of Practice” Minefields

“. . . my clinical practice as a women’s health NP began in the mid-1970s.  My colleagues who had gone on to academic careers questioned my commitment to nursing and to nursing values.  A common question was ‘Are you a nurse, or are you a mini-doc?’  My answer was, is, and will always be:  ‘I am a nurse with primary care skills.  I take care of my patients within a nursing framework. . . . my values lie in nursing, not in the medical model.  I care for my patients as a fully prepared, primary care provider of women.” – Judith A. Berg & Mary Ellen Roberts, “Recognition, Regulation, Scope of Practice:  Nurse Practitioners’ Growing Pains” (2012)[1]

“We agree certified nurse practitioners can provide many core primary care services, but it is important that this not be misunderstood as suggesting that nurses are interchangeable with physicians in providing the full depth and breadth of services that primary care physicians provide.  The two professions are complementary but not equivalent.  For diagnostic evaluation of clinical presentations that are not straightforward and for the ongoing management of complex or interacting medical problems, the most appropriate clinician is the physician.” – J. F. Ralston & S. E. Weinberger, “Nurses’ Scope of Practice” (2011)[2]

Entering the debate on the “scope of practice” between nurse practitioners (NPs) and physicians is like parachuting onto a battlefield strewn with semantic landmines and decaying verbiage, while overhead the whistle of incoming word-tipped artillery fire grows louder.  For the opposing forces, the NPs and the MDs, negotiation about the scope of NPs’ provider activities has given way to incendiary propaganda and explosive metaphors.  It is all a matter of logistics, planning, grand strategy, tactical advance and retreat.

When the nursing historian Julie Fairman and her colleagues argue that “physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services,”[3]  they leave unexamined the meaning of basic.  Someone, after all, has to do the defining, and in so doing, to differentiate basic services from services that, in given circumstances, are not so basic.  Someone also has to stipulate how exactly “quality” is being assessed, qualitatively and quantitatively, in both the short- and long-term.

It is fine to make the commonsensical point that nurse practitioners should be permitted to practice “to the fullest extent of their skills and knowledge,” as recommended by the authors of the Institute of Medicine report of 2010, The Future of Nursing.[4]  But who decides what “fullest extent” actually means in relation to specific clinical contingencies and management challenges?  Is there even consensus on the meaning of NP “knowledge and competence” in contradistinction to the “knowledge and competence” of those who receive medical training?  Literally, then, what are Fairman and her colleagues talking about?

NP advocates make tactical use of the word “partnership” in framing debates about NP expansion.  And yes, certainly we need NPs and physicians to be collaborative partners in providing quality health care.  But the notion of “partnership,” as used by NPs, also subserves polemics.  Partnership, after all, does not entail parity among partners.  In law and business, for example, there are senior partners and junior partners, name partners and equity partners, voting partners and nonvoting partners.  In medicine, there are any number of  procedures (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy) that fall within the domain of adult primary care, but that many primary care physicians no longer perform, even if they are competent to do so, owing to issues of liability and lack of third party coverage.  This does not mean that primary care physicians, gynecologists, gastroenterologists, and ENTs are not “partners” in care, but rather that “partnership” does not abrogate the need for a division of labor, with the differing responsibilities, obligations, and entitlements that such  division entails.

Physician groups threatened by the legislative incursions of nonmedical providers like NPs are no better and even worse.  The Physicians Foundation is a nonprofit organization of medical groups formed to push back the nonmedical invaders, especially nurse practitioners.  Their report of November, 2012, Accept No Substitute: A Report on Scope of Practice, brims with military metaphors.  The authors, Stephen Isaacs and Paul Jellinek, write of “holding the line” on “expansionary forays” and summarize bulletins “fresh from the front lines.”  “What is the score so far?” they ask.  “Who is winning these scope of practice battles?”  And the military metaphors segue into sports metaphors, with the authors’ dour acknowledgment that physicians “are usually playing defense on scope of practice” brightened by occasional successes in eliminating nonphysician licensing.  In the latter cases, they exult, physicians “are in fact able to move the ball up the field.”[5]

What is one to make of such sophomoric posturing in the face of a serious and growing shortage of primary care physicians?  Where will we find the 51,880 additional primary care physicians that, according to recent published projections, we will need by 2025?[6]  It is easy to appreciate the exasperation of primary care NPs who face such opposition in the face of well-established facts.  To wit:   Only 20% of today’s medical students will choose a primary care specialty; NPs provide more cost-effective care than their physician counterparts; patient surveys reveal satisfaction with the care provided by NPs; and half of all physicians in office practice already work with NPs, certified nurse midwives, and/or physician assistants.  All such facts, be it noted, are ceded by the authors of The Physicians Foundation report.[7]

It is time for physicians to accept not only the reality, but also the socioethical desirability of nonphysician providers.  By the same token, it is time for nurse practitioners to accept the reasonableness of practice limits.  An expanded scope of practice is not a limitless scope of practice.  And, yes, self-evidently, the limits to which NPs are subject will not be identical to the limits imposed on physicians. There are indications for which physician consultation and supervision should be mandatory; there will be procedures that only physicians, including primary care physicians, are trained and legally authorized to perform. Establishing boundaries will always be shaped by power politics and economic self-interest, but it need not be deformed by them.  The process can be elevated by concern for public safety and prudent good sense.  By way of identifying two areas in need of further dialogue informed by complementary needs for patient access and patient safety, consider the topics of chronic disease management and prescriptive authority.

Nurse practitioner advocates tout the important role of NPs in managing chronic disease, and type 2 diabetes is typically given as a case in point.[8]  Certainly NPs can manage diabetics whose glucose levels must be monitored and insulin dosages adjusted.  There is also evidence that specialized NPs are highly effective in collaborative practice with primary care physicians, where they serve as diabetic care coordinators.[9]  What then is the problem?  It arises from the fact that management of chronic disease, especially among the elderly, is rarely a matter of managing a  stable disease entity.  In later life, diabetes, however well monitored and managed, typically leads to neuropathy, retinopathy, and/or kidney disease.

Are NPs trained to manage chronic diseases as independent providers when management ipso facto entails a plethora of intersystemic complications?  Consider another example.  Perhaps an NP-nephrologist can manage end-stage renal disease (ESRD), a chronic disease that can be stabilized for long periods with dialysis.  But what happens when such management, and the prolongation of life it entails, leads to diabetes and heart disease, as it often does?  Is such management still within the “knowledge and competence” of NPs?  As I wrote in “The Costs of  Medical Progress”:

Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

Well-trained NPs no doubt bring much-needed talent to managing intercurrent disease in certain respects.  I am no expert here, but I am open to the possibility that independent management of chronic disease, particularly among the elderly, may not be commensurate with the discrete “skill set” that NPs acquire, even as this “set” is enlarged by the medley of nonmedical skills inculcated by “nursing education and its particular ideology and professional identity.”[10]  Management of chronic disease, that is, often entails complexity of a distinctly medical sort.  Scope of practice debates should be informed by the fact that diabetes, to keep to the example, is no longer a disease with a stable natural history.[11]  The same can be said of kidney disease and heart disease and many types of cancer.  So the question of what NPs can and cannot do needs to be fleshed out in a more clinically realistic manner:  We need to know whether NP-generalists are as capable as primary care physicians of managing chronic illness in the context of life span issues and specific dimensions of patient care.  Are they as capable as primary care physicians, for example, of prioritizing interventions among older patients with multiple chronic diseases?[12]

Another “fullest extent” problematic concerns prescribing privileges.  NPs and APRNs (advanced practice registered nurses) demand the same authorization to prescribe medications as physicians.  This insistence, globally formulated, masks the fact that prescriptive authority is always qualified in various ways. Perhaps physicians, NPs and APRNs, and legislatures should set the all-or-nothing rhetoric aside and wrestle with the real-world issue of “prescriptive authority of various levels” that gets codified in state law.[13]  Is it within the NP’s scope of practice, for example, to change antibiotics without physician consultation for a child who comes to the pediatrician with fever, sore throat, and pain, and whose symptoms have not abated with first-line antibiotics prescribed by the NP?[14]  To begin to get a handle on this kind of issue, one must at present read the law on NP “scope of practice” in a particular state, as NPs have in fact been enjoined to do.[15]

Here is the point: primary care NPs in all states deserve – and now have – “prescriptive authority,” but reasonable people may differ on the breadth of this authority.  Here is an issue that can be subject to empirical research and meaningful negotiation among all the stakeholders, including the public. To wit, what kinds of drugs are NPs trained to prescribe and, based on survey data, what kinds of drugs do they actually prescribe?  Several studies from the 1980s showed “that NPs prescribe a very limited number of relatively simple medications to predominantly healthy populations.”[16]  Perhaps these studies are badly dated and superseded by  recent studies attesting to the broadened range of drugs now prescribed by primary care NPs. Well and good.  Then the “prescriptive authority” granted to NPs by legislatures should be broader rather than narrower.

But, normatively speaking, should it be equivalent to the prescriptive authority of primary care physicians?  Should NPs be granted authority to prescribe controlled substances without collaborative arrangements with physicians and without limiting stipulations as to dosage and duration of use?  Here is another issue ripe for further negotiation informed by empirical research and considerations of patient safety.  I bring no special expertise to the table beyond noting that NPs, however great their knowledge and competence, do not receive the extensive training in physiology, pathophysiology, and pharmacology that physicians do. I do not find it unreasonable that NP-issued scripts should require some degree of physician involvement, as is now the case in 32 states.[17]

The power differential between organized medicine and organized nursing, including medical specialty societies and NP/ACRP societies, has made matters worse for highly trained nurse practitioners seeking to practice to the fullest extent of their knowledge and competence.  But it has also led some NP representatives to demonize medical groups that seek any drawing of lines, since the very act of drawing a line can only derive from the economic imperative to “hold the line” on NP rights.  Consider the reaction of the editor of Policy Politics Nursing Practice in 2006 to the insistence of medical groups that the difference between nurse practitioners with doctorates and physicians be clarified for the benefit of patients. “Does anyone,” he wrote, “seriously see it as part of a conspiracy to mislead patients by having APRNs refer to themselves as doctor? And are physical therapists (who are moving toward a requirement for doctoral-level education), psychologists, and pharmacists in on the conspiracy, too?”[18]

Well, no, hardly.  But the issue here, shorn of polarizing rhetoric, isn’t about willful misleading; it’s about the cultural valence of the title “doctor” and the everyday meanings people impute to it in connection with healthcare.  A patient who seeks treatment from a licensed primary care provider who is referred to and addressed as “doctor” will, absent some kind of a priori clarification, likely assume the “doctor” in question is a physician.  It is not unreasonable to suggest reasonable efforts at patient education to clarify the different roles and orientations of different kinds of providers.  And what prevents NP groups from adopting their own strategy of patient education?  What prevents them from developing and publicizing endorsements of the “doctor of nursing practice” degree that play to the latter’s  “doctoring” strengths in contradistinction to those of physicians?

If there is a conspiracy out there, it is one perpetrated on the public by both physicians and NPs.  It is a conspiracy of partial explanations.  It is the conspiracy among physicians who refuse to cede that nurse practitioners have arrived, that they are licensed clinical providers who are perfectly capable of providing a great deal of what has traditionally been the province of medicine, especially primary care medicine.  But it is also the conspiracy among NP advocates whose rhetoric masks important distinctions, viz., that “fullest extent” of NP/APRN practice is not coextensive with the typically full extent of care that primary care physicians are trained to provide.  This follows from various considerations, not least of which is that family physicians train a total of 21,000 hours whereas NPs train between 3,500 and 6,000 hours.[19]  There, I’ve done it again.  I’ve made a a series of claims that strike me as reasonable and will win me no friends in either warring camp.

__________________________

[1] J. A. Berg & M. E. Roberts, “Recognition, regulation, scope of practice:  nurse practitioners’ growing pains,” J. Amer. Acad. Nurse Pract., 24:121-123, 2012, at 121.

[2] J. F. Ralston & S. E. Weinberger, “Nurses’ scope of practice,” Correspondence, New Engl. J. Med., 364:281.

[3] J. A. Fairman, et al., “Broadening the scope of nursing practice,” New Engl. J. Med., 364:193-96, at 193.

[4] As quoted in J. A. Fairman & S. M. Okoye, “Nursing for the future, from the past: two reports on nursing from the Institute of Medicine,” J. Nurs. Ed., 50:305-311, 2011, at 309.

[5] S. Isaacs & P. Jellinek, Accept No Substitute:  A Report on Scope of Practice. White Paper for The Physicians Foundation, November, 2012 (http://www.khi.org/documents/2014/aug/26/accept-no-substitute-report-scope-practice/), pp. 1, 2, 3, 6.

[6] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[7] Issacs & Jellinek, Accept No Substitute, pp. 8-13.

[8] G. C. Richardson, et al., “Nurse practitioner management of type 2 diabetes,” Permanente Journal, 18:e134-140, 2014;  M. J. Goolsby, “2006 American Academy of Nurse Practitioners diabetes management survey,” J. Amer. Acad. Nurse Pract., 19:496-98, 2007; Fairman, et al.,  “Broadening the scope of nursing practice,” p. 193.

[9] Richardson, “Nurse practitioner management of type 2 diabetes,” op cit.; K. G. Shojania, et al., “Effects of quality improvement strategies for type 2 diabetes on glycemic control:  a meta-regression analysis,” JAMA, 296:427-40, 2006; S. Ingersoll, et al., Nurse care coordination for diabetes:  a literature review and synthesis,” J. Nurs. Care Qual., 20:208-14, 2005.

[10] On the notion of clinical competence as acquisition of a “skill set,” see, e.g., J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY: Springer Pub., 2002),  pp. 311-12 and J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick: Rutgers, 2008), pp. 187, 190.

[11] Chris Feudtner terms it a “cyclical transmuted disease” in Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: North Carolina, 2003), p. 36.

[12] For exemplary instances of how clinical judgment – and not a clinical “skill set” – enters into the prioritizing of treatment interventions among concurrent chronic diseases, see K. C. Stange, et al., “The value of a family physician,” J. Fam. Pract., 46:363-69, 1998; K. C. Stange, “The generalist approach,” Ann. Fam. Med., 7:198-203, 2009, and E. J. Cassell, Doctoring: The Nature of Primary Care Medicine (NY: Oxford University Press, 1997).

[13] Of course, the issue of  levels of prescriptive authority pertains not only to physicians and NPs, but also to physician assistants, dentists, optometrists, osteopaths, and podiatrists. For the concrete manner in which the state of Florida spells out prescriptive levels for each of these professions, see http://www.thehealthlawfirm.com/resources/health-law-articles-and-documents/prescribing-in-florida.html).

[14] M. Crane, “Malpractice risks with NPs and PAs in your practice,” Medscape, Jan 3, 2013 (http://www.medscape.com/viewarticle/775746).

[15] E.g., C. Buppert, “Scope of practice,” J. Nurse Pract., 1:11-13, 2005.

[16] C. D. DeAngelis, “Nurse practitioner redux,” JAMA, 271:868-71, 1994.  The studies  DeAngelis cites are:  P. Repicky, et al., “Professional activities of nurse practitioners in adult ambulatory care settings,” Nurse Pract., 4:27-40, 1980; D. Munroe, et al., “Prescribing patterns of nurse practitioners,” Am. J. Nurs., 82:1538-40, 1982; J. Resenaur, “Prescribing behavior of primary care nurse practitioners,” Am. J. Public Health., 74:10-13, 1984.

[17] “Nurse Practitioner Prescribing Authority and Physician Supervision Requirements for Diagnosis and Treatment” (http://kff.org/other/state-indicator/nurse-practitioner-autonomy/).

[18] D. M. Keepnews, “Scope of practice redux?,” Policy, Politics & Nurs. Prac., 7:84-86, 2006, at 84.

[19] D. Marbury, “Scope of practice debate,” Med. Econ., September 10, 2013, 26-30, at 27 (http://medicaleconomics.modernmedicine.com/medical-economics/news/scope-practice-debate?page=full).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

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Injections and the Personal Touch

“Fear of the needle is usually acquired in childhood.  The psychic trauma to millions of the population produced in this way undoubtedly creates obstacles to good doctor-patient relationships, essential diagnostic procedures, and even life-saving therapy.”  Janet Travell, “Factors Affecting Pain of Injection” (1955)[1]

It was during the 1950s that the administration of hypodermic injections became a fraught enterprise and a topic of medical discussion.  With World War II over and American psychoanalysis suffusing postwar culture, including the cultures of medicine and psychiatry, it is unsurprising that physicians should look with new eyes at needle penetration and the fears it provoked.

In the nineteenth century, it had been all about pain relieved, sometimes miraculously, by injection of opioids.  Alongside the pain relieved, the pain of the injection was quite tolerable, even minor, a mere afterthought.  But in the mid-twentieth century pain per se took a back seat.  It was no longer about the painful condition that prompted injection.  Nor, really, was it about the pain of injection per se.  Psychodynamic thinking trumped both kinds of pain.  Increasingly, the issue before physicians, especially pediatricians, was about two things:  the anxiety attendant to injection pain and the lasting psychological damage that was all too often the legacy of needle pain.  Elimination of injection pain mattered, certainly, but it became the means to a psychological end.  Relieve the pain, they reasoned, and you eliminate the apprehension that exacerbates the pain and leaves deep psychic scars.

And so physicians were put on notice.  They were enjoined to experiment with numbing agents, coolant sprays, and various counterirritants to minimize the pain that children (and a good many adults) dreaded.  They were urged to keep their needles sharp and their patients’ skin surfaces dry.  Coolant sprays and antiseptic solutions that left a wet film, after all, could be carried into the skin as irritants.  For the muscular pain attendant to deeper injections, still stronger anesthetics, such as procaine, might be called for.  Physicians were also encouraged to reduce injection pain through new technologies, to use, for example, hyposprays and spring-loaded presto injectors.  Injection “technique” was a topic of discussion, especially for intramuscular injections of new wonder drugs such as streptomycin.  To be sure, new technologies and refined technique often failed to eliminate injection pain, especially when a large volume of solution was injected.  But, then again, pain relief was only a secondary goal. The point of the recommendations was primarily psychological, viz., to eliminate “the psychological reaction to piercing the skin.”[2]  It was anticipation of pain and the fear it engendered that jeopardized the doctor-patient relationship.

Psychoanalysts themselves, far removed from the everyday concerns of pediatricians, family physicians, and internists, had little to say on the topic.  They were content to call attention now and again to needle symbolism – invariably phallic in nature – in dreams and childhood memories.  In 1954, the child analyst Selma Fraiberg recalled “The theory of a two-and-a-half-year-old girl who developed a serious neurosis following an observation of coitus.  The child maintained that ‘the man made the hole,’ that the penis was forcibly thrust into the woman’s body like the hypodermic needle which had been thrust into her by the doctor when she was ill.”   Pity this two and a half year old.

Inferences about male sadism and castration anxiety were integral to this train of thought.  In 50s-era psychoanalysis, needle injection could symbolize not only “painful penetration,” but also the sadistic mutilation of a little girl by a male doctor.[3]  One wants to say that such strained psychoanalytic renderings are long dead and buried, but the fact is they still find their way into the literature from time to time, usually in the context of dream interpretations.  Here is one from 1994:

Recently Ms. K mentioned a dream in which she was diabetic and had little packets of desiccated insulin which were also like condoms.  All she needed now was a hypodermic syringe and a needle.  I pointed out the sexual nature of the dream with its theme of penetration; she then remembered that in the dream a woman friend had lifted her skirt and Ms. K had ‘whammed the needle right in’.[4]

Psychoanalytic interpretive priorities change over time, whether or not in therapeutically helpful ways being a perennial subject of debate.  By the 1990s, there was belated recognition that children’s needle phobias really didn’t call for analytic unraveling; they derived from the simple developmental fact that “children are exposed to hypodermic needles prior to their ability to understand what is going on,” and, as such, were more amenable to behavioral intervention than psychoanalytic treatment.  In the hospital setting, in particular, children needed simple strategies to reduce fear, not psychoanalytic interpretations.[5]

In 1950s medicine, psychoanalysis was at its best when its influence was subtle and indirect.  Samuel Sterns’s thoughtful consideration of the “emotional aspects” of treating patients with diabetes, published in the New England Journal of Medicine in 1953, is one such example.  Sterns worked out of the Abraham Rudy Diabetic Clinic of Boston’s Beth Israel Hospital, and he expressed indebtedness to the psychiatrist-psychoanalyst Grete Bibring and other members of her department for “many discussions” on the topic.

For most diabetics, of course, daily injections, self-administered whenever possible, were an absolute necessity.  And resistance to the injections, then as now, undercut treatment and resulted in poor glycemic control.[6]  How then to cope with the diabetic’s resistance to the needle, especially when “the injection of insulin is sometimes associated with a degree of anxiety, revulsion or fear that cannot be explained by the slight amount of pain involved.”[7]

Psychoanalysis provided a framework for overcoming the resistance.  It was not a matter of “simple reassurance” about insulin injections, Sterns observed, but – and it is Bibring’s voice we hear –

Recognition that apparently trivial and unfounded complaints about insulin injections may be based on deeply rooted anxiety for which the patient finds superficial rationalizations enables the physician to be more realistic and tolerant, and more successful in dealing with the problem.

Realism, tolerance, acceptance – this was the psychoanalytic path to overcoming the problem.  Physicians had to accept that diabetics’ anxiety about injections arose from “individual personalities,” and that each diabetic had his or her own adaptively necessary defenses.  Exhortation, criticism, direct confrontation – these responses had to be jettisoned on behalf of the kindness and understanding that would lead to a “positive interpersonal relation.”  This entailed an understanding of the patient’s transference to the physician:

It is particularly apparent that most of the reactions of juvenile diabetic patients to discipline, authoritativeness or criticism by the physician are really identical with their reactions to similar situations involving their parents.

And it included a  like-minded willingness to wrestle with the countertransference as an obstacle to treatment:

Even the occasional display of an untherapeutic attitude by the physician is enough to interfere with the development of a relation that will enable him to obtain maximal cooperation from the patient.  If the physician cultivates awareness of his own reactions to a difficult patient, he will be less easily drawn into retaliation or other negative behavior.[8]

The point of the analytic approach was to lay the groundwork for a “positive interpersonal relation” that would enlist the patient’s cooperation, and “not through anxiety or fear of the disease or the physician, but rather through the wish to be well and to gain the physician’s approval.”[9]  Sympathetic acceptance of the patient’s fears, of the defenses against those fears, of the life circumstances that led to the defenses – this was the ticket to the kind of positive transference relationship that the physician could use to his and the patient’s advantage.

_______________

Sterns’s paper of 1953 remains helpful to this day; it exemplifies the application of general psychoanalytic concepts to real-world medical problems that, as I suggested in the final chapter of Psychoanalysis at the Margins (2009), may breathe new life into a beleaguered profession.  The reasonableness of Sterns’s recommendations stands in contrast to the insular irrelevance of  George Moran’s “Psychoanalytic Treatment of Diabetic Children” (1984), where poor glycemic control among children becomes a “metaphorical expression[s] of psychological disturbance” — framed in terms of “entrenched defensive structures” and “drive derivatives” – that calls for psychoanalytic treatment, sometimes via “prolonged stays” of up to several months in pediatric wards.[10]  And yet, there is something missing from Sterns’s commentary.  Like other writers of his time, he was concerned lest needle anxiety become an obstacle to a good doctor-patient relationship.  Cultivate the relationship through sympathetic insight into the problem, he reasoned, and  the obstacle would diminish, perhaps even disappear.  What he ignored – indeed, what all these hospital- and clinic-based writers of the time ignored – is the manner in which a preexisting “good doctor-patient relationship” can defuse needle anxiety in the first place.

Nineteen fifty three, the year Sterns’s paper was published, was also the year my father, William Stepansky, opened his general practice at 16 East First Avenue, Trappe, Pennsylvania.  My father, as I have written, was a Compleat Physician in whom wide-ranging procedural competence commingled with a psychiatric temperament and deeply caring sensibility.  In the world of 1950s general practice, his office was, as Winnicott would say, a holding environment.  His patients loved him and relied on him to provide care.  If injections were part of the care, then ipso facto, they were caring interventions, whatever the momentary discomfort they entailed.

The forty years of my father’s practice spanned the first 40 years of my life, and, from the time I was around 13, we engaged in ongoing conversations about his patients and work.  Never do I recall his remarking on a case of needle anxiety, which is not to deny that any number of patients, child and adult, became anxious when injection time arrived.  My point is that he contained and managed their anxiety so that it never became clinically significant or worthy of mention.  At the opposite end of the spectrum, I know of elderly patients who welcomed him into their homes several times a week for injections – sometimes just vitamin B-12 shots – that amplified the human support he provided.

Before administering an injection, my father firmly but gently grasped the underside of the patient’s upper arm, and the patient felt held, often in just those ways in which he or she needed holding.  When one’s personal physician gives an injection, it may become, in some manner and to some extent, a personal injection.  And personal injections never hurt as much as injections impersonally given.  This simple truth gets lost in the contemporary literature that treats needle phobia as a psychiatric condition in need of focal treatment.   A primary care physician remarked to me recently that she relieved a patient’s severe anxiety about getting an injection simply by putting the injection on hold and sitting down and talking to the patient for five minutes.  In effect, she reframed the meaning of the injection by absorbing it into a newly established human connection. Would that all our doctors would sit down with us for five minutes and talk to us as friendly human beings, as fellow sufferers, before getting down to procedural business.

I myself am more fortunate than most.  For me the very anticipation of an injection has a positive valence.  It conjures up the sights and smells and tactile sensations of my father’s treatment room.  Now in my 60s, I still have in my nostrils the bracing scent of the alcohol he used to clean the injection site, and I still feel the firm, paternal grasp of his hand on my arm at the point of injection.  I once remarked to a physician that she could never administer an injection that would bother me,  because at the moment of penetration, her hand became my father’s.

Psychoanalysts who adopt the perspective of object relations theory speak of “transitional objects,” those special inanimate things that, especially in early life, stand in for our parents and help calm us in their absence.  Such objects become vested with soothing human properties; this is what imparts their “transitional” status.  In a paper of 2002, the analyst Julie Miller ventured the improbable view, based on a single case, that the needle of the heroin addict represents a “transitional object” that fosters a maternal connection the addict never experienced in early life.[11]  For me, I suppose, the needle is also a transitional object, albeit one that intersects with actual lived experience of a far more inspiriting nature.  To wit, when I receive an injection it is always with my father’s hand, life-affirming and healing.  It is the needle that attests to a paternal connection realized, in early life and in life thereafter.  It is an injection that stirs loving memories of my father’s medicine.   So how much can it hurt?

_______________

[1] J. Travell, “Factors affecting pain of injection,” JAMA, 58:368-371, 1955, at p. 368.

[2] J. Travell, “Factors affecting pain of injection,” op. cit.; L. C. Miller, “Control of pain of injection,” Bull Parenteral Drug A., 7:9-13,1953; E. P. MacKenzie, “Painless injections in pediatric practice,” J. Pediatr., 44:421, 1954; O. F. Thomas & G. Penrhyn Jones, “A note on injection pain with streptomycin,” Tubercle, 36:157-59, 1955; F. H. J. Figge & V. M. Gelhaus, “A new injector designed to minimize pain and apprehension of parenteral therapy,” JAMA, 160:1308-10, 1956.  There were also needle innovations in the realm of intravenous therapy, e.g., L. I. Gardner & J. T. Murphy, “New needle for pediatric scalp vein infusions,” Amer. J. Dis. Child., 80:303-04, 1950.

[3] S. Fraiberg, “A critical neurosis in a two-and-a-half-year girl,” Psychoanal. Study Child, 7:173-215, 1952, at p. 180; S. Fraiberg, “Tales of the discovery of the secret treasure,” Psychoanal. Study Child, 9:218-41, 1954, at p. 236.

[4] I. D. Buckingham, “The effect of hysterectomy on the subjective experience of orgasm,” J. Clin. Psychoanal., 3:607-12, 1994.

[5] D. Weston, “Response,” Int. J. Psychoanal., 78:1218-19, 1997, at p. 1219; C. Troupp, “Clinical commentary,” J. Child Psychother., 36:179-82, 2010.

[6] There is ample documentation of needle anxiety among present-day diabetics, e.g., A. Zambanini, et al., “Injection related anxiety in insulin-treated diabetes,” Diabetes Res. Clin. Prac., 46:239-46, 1999 and A. B. Hauber, et al., “Risking health to avoid injections: preferences of Canadians with type 2 diabetes,” Diabetes Care, 28:2243-45, 2005.

[7]S. Stearns, “Some emotional aspects of the treatment of diabetes mellitus and the role of the physician,” NEJM, 249:471-76, 1953, at p. 473.

[8] Ibid., p. 474.

[9] Ibid.

[10]P. E. Stepansky, Psychoanalysis at the Margins (NY: Other Press, 2009), pp. 287-313; G. S. Moran, “Psychoanalytic treatment of diabetic children,” Psychoanal. Study Child, 39:407-447, at pp. 413, 440. 

[11]J. Miller, “Heroin addiction: the needle as transitional object,” J. Amer. Acad. Psychoanal., 30:293-304, 20.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

The Costs of Medical Progress

When historians of medicine introduce students to the transformation of acute, life-threatening, often terminal illness into long-term, manageable, chronic illness – a major aspect of 20th-century medicine – they immediately turn to diabetes.  There is Diabetes B.I. (diabetes before insulin) and diabetes in the Common Era, i.e., Diabetes A.I. (diabetes after insulin).  Before Frederick Banting, who knew next to nothing about the complex pathophysiology of diabetes, isolated insulin in his Toronto laboratory in 1922, juvenile diabetes was a death sentence; its young victims were consigned to starvation diets and early deaths.  Now, in the Common Era, young diabetics grow into mature diabetics and type II diabetics live to become old diabetics.  Life-long management of what has become a chronic disease will take them through a dizzying array of testing supplies, meters, pumps, and short- and long-term insulins.  It will also put them at risk for the onerous sequelae of long-term diabetes:  kidney failure, neuropathy, retinopathy, and amputation of lower extremities.  Of course all the associated conditions of adult diabetes can be managed more or less well, with their own technologically driven treatments (e.g., hemodialysis for kidney failure) and long-term medications.

The chronicity of diabetes is both a blessing and curse.  Chris Feudtner, the author of the outstanding study of its transformation, characterizes it as a “cyclical transmuted disease” that no longer has a stable “natural” history. “Defying any simple synopsis,” he writes, “the metamorphosis of diabetes wrought by insulin, like a Greek myth of rebirth turned ironic and macabre, has led patients to fates both blessed and baleful.”[1]  He simply means that what he terms the “miraculous therapy” of insulin only prolongs life at the expense of serious long-term problems that did not exist, that could not exist, before the availability of insulin.  So depending on the patient, insulin signifies a partial victory or a foredoomed victory, but even in the best of cases, to borrow the title of Feudtner’s book, a victory that is “bittersweet.”

It is the same story whenever new technologies and new medications override an otherwise grim prognosis.  Beginning in the early 1930s, we put polio patients (many of whom were kids) with paralyzed intercostal muscles of the diaphragm into the newly invented Iron Lung.[2]  The machine’s electrically driven blowers created negative pressure inside the tank that made the kids breathe.  They could relax and stop struggling for air, though they required intensive, around-the-clock nursing care.[3]  Many survived but spent months or years, occasionally even lifetimes, in Iron Lungs.  Most regained enough lung capacity to leave their steel tombs (or were they nurturing wombs?) and graduated to a panoply of mechanical polio aids: wheelchairs, braces, and crutches galore.  An industry of rehab facilities (like FDR’s fabled Warm Springs Resort in Georgia) sprouted up to help patients regain as much function as possible.

Beginning in 1941, the National Foundation for Infantile Paralysis (NFIP), founded by FDR and his friend Basil O’Connor in 1937, footed the bill for the manufacture of Iron Lungs and then distributed them via regional centers to communities where they were needed.   The Lungs, it turned out, were foundation-affordable devices, and it was unseemly, even Un-American, to worry about the cost of hospitalization and nursing care for the predominantly young, middle-class white patients who temporarily resided in them, still less about the costs of post-Iron Lung mechanical appliances and rehab personnel that helped get them back on their feet.[4]  To be sure, African American polio victims were unwelcome at tony resort-like facilities like Warm Springs, but the NFIP, awash in largesse, made a grant of $161,350 to Tuskegee Institute’s Hospital so that it could build and equip its own 35-bed “infantile paralysis center for Negroes.”[5]

Things got financially dicey for the NFIP only when Iron Lung success stories, disseminated through print media, led to overuse.  Parents read the stories and implored doctors to give their stricken children the benefit of this life-saving invention – even when their children had a form of polio (usually bulbar polio) in the face of which the mechanical marvel was useless.  And what pediatrician, moved by the desperation of loving parents beholding a child gasping for breath, would deny them the small peace afforded by use of the machine and the around-the-clock nursing care it entailed?

The cost of medical progress is rarely the cost of this or that technology for this or that disease.  No, the cost corresponds to cascading “chronicities” that pull multiple technologies and treatment regimens into one gigantic flow.  We see this development clearly in the development and refinement of hemodialysis for kidney failure.  Dialysis machines only became life-extenders in 1960, when Belding Scribner, working at the University of Washington Medical School, perfected the design of a surgically implanted Teflon cannula and  shunt through which the machine’s tubing could be attached, week after week, month after month, year after year.  But throughout the 60s, dialysis machines were in such short supply that treatment had to be rationed:  Local medical societies and medical centers formed “Who Shall Live” committees to decide who would receive dialysis and who not.  Public uproar followed, fanned by the newly formed National Association of Patients on Hemodialysis, most of whose members, be it noted, were white, educated, professional men.

In 1972, Congress responded to the pressure and decided to fund all treatment for end-stage renal disease (ESRD) through Section 2991 of the Social Security Act.  Dialysis, after all, was envisioned as long-term treatment for only a handful of appropriate patients, and in 1973 only 10,000 people received the treatment at a government cost of $229 million.  But things did not go as planned.  In 1990, the 10,000 had grown to 150,000 and their treatment cost the government $3 billion.  And in 2011, the 150,000 had grown to 400,000 people and drained the Social Security Fund of $20 billion.

What happened?  Medical progress happened.  Dialysis technology was not static; it was refined and became available to sicker, more debilitated patients who encompassed an ever-broadening socioeconomic swath of the population with ESRD.  Improved cardiac care, drawing on its own innovative technologies, enabled cardiac patients to live long enough to go into kidney failure and receive dialysis.  Ditto for diabetes, where improved long-term management extended the diabetic lifespan to the stage of kidney failure and dialysis.  The result:  Dialysis became mainstream and its costs  spiraled onward and upward.  A second booster engine propelled dialysis-related healthcare costs still higher, as ESRD patients now lived long enough to become cardiac patients and/or insulin-dependent diabetics, with the costs attendant to managing those chronic conditions.

With the shift to chronic disease, the historian Charles Rosenberg has observed, “we no longer die of old age but of a chronic disease that has been managed for years or decades and runs its course.”[6] To which I add a critical proviso:  Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

This claim does not minimize the inordinate impact – physical, emotional, and financial – of a single disease.  Look at AIDS/HIV, a “single” entity that brings into its orbit all the derivative illnesses associated with “wasting disease.”  But the larger historical dynamic is at work even with AIDS.  If you live with the retrovirus, you are at much greater risk of contracting TB, since the very immune cells destroyed by the virus enable the body to fight the TB bacterium.  So we behold a resurgence of TB, especially in developing nations, because of HIV infection.[7]  And because AIDS/HIV is increasingly a chronic condition, we need to treat disproportionate numbers of HIV-infected patients for TB.  They have become AIDS/HIV patients and TB patients.  Worldwide, TB is the leading cause of death among persons with HIV infection.

Here in microcosm is one aspect of our health care crisis.  Viewed historically, it is a crisis of success that corresponds to a superabundance of long-term multi-disease management tools and ever-increasing clinical skill in devising and implementing complicated multidrug regimens.  We cannot escape the crisis brought on by these developments, nor should we want to.  The crisis, after all, is the financial result of a century and a half of life-extending medical progress.  We cannot go backwards.  How then do we go forward?  The key rests in the qualifier one aspect.  American health care is organismic; it is  a huge octopus with specialized tentacles that simultaneously sustain and toxify different levels of the system.  To remediate the financial crisis we must range across these levels in search of more radical systemic solutions.


[1]C. Feudtner, Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: University of North Carolina Press, 2003), p. 36.

[2] My remarks on the development and impact of the Iron Lung and homodialysis, respectively, lean on D. J. Rothman, Beginnings Count: The Technological Imperative in American Health Care (NY: Oxford University Press, 1997). For an unsettling account of the historical circumstances and market forces that have undermined the promise of dialysis in America, see Robin Fields, “’God help you. You’re on dialysis’,” The Atlantic, 306:82-92, December, 2010. The article is online at   http://www.theatlantic.com/magazine/archive/2010/12/-8220-god-help-you-you-39-re-on-dialysis-8221/8308/.

[3] L. M. Dunphy, “’The Steel Cocoon’: Tales of the Nurses and Patients of the Iron Lung, 1929-1955,” Nursing History Review, 9:3-33, 2001.

[4] D. J. Wilson, “Braces, Wheelchairs, and Iron Lungs: The Paralyzed Body and the Machinery of Rehabilitation in the Polio Epidemics,” Journal of Medical Humanities, 26:173-190, 2005.

[5] See S. E. Mawdsley, “’Dancing on Eggs’: Charles H. Bynum, Racial Politics, and the National Foundation for Infantile Paralysis, 1938-1954,” Bull. Hist. Med., 84:217-247, 2010.

[6] C. Rosenberg, “The Art of Medicine: Managed Fear,” Lancet, 373:802-803, 2009.  Quoted at p. 803.

[7] F. Ryan, The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost  (Boston:  Little, Brown, 1992), pp. 395-398, 401, 417.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.