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Injections and the Personal Touch

Posted on April 18, 2014 | Leave a comment

“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.

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The Times They Are a-Changin’: Trends in Medical Education

Posted on October 24, 2013 | Leave a comment

Medical educators certainly have their differences, but one still discerns an emerging consensus about the kind of changes that will improve healthcare delivery and simultaneously re-humanize physician-patient encounters.  Here are a few of the most progressive trends in medical education, along with brief glosses that serve to recapitulate certain themes of previous postings.

Contemporary medical training stresses the importance of teamwork and militates against the traditional narcissistic investment in solo expertise.  Teamwork, which relies on the contributions of nonphysician midlevel providers, works against the legacy of socialization that, for many generations, rendered physicians “unfit” for teamwork.  The trend now is to re-vision training so that the physician becomes fit for a new kind of collaborative endeavor.  It is teamwork, when all is said and done, that “transfers the bulk of our work from the realm of guesswork and conjecture to one in which certainty and exactitude may be at least approached.”  Must group practice militate against personalized care?  Perhaps not. Recently, medical groups large and small have been enjoined to remember that “a considerable proportion of the physician’s work is not the practice of medicine at all.  It consists of counseling, orienting, extricating, encouraging, solacing, sympathizing, understanding.”

Contemporary medical training understands that the patient him- or herself has become, and by rights ought to be, a member of the healthcare team.  Medical educators ceded long ago that patients, in their own best interests, “should know something about the human body.”  Now we have more concrete expressions of this requirement, viz., that  if more adequate teaching of anatomy and physiology were provided in secondary schools, “physicians will profit and patients will prosper.”   “Just because a man is ill,” notes one educator, “is no reason why he should stop using his mind,” especially as he [i.e., the patient] is the important factor in the solution of his problem, not the doctor.”  For many educators the knowledgeable patient is not only a member of the “team,” but the physician’s bonafide collaborator.  They assume, that is, that physician and patient “will be able to work together intelligently.”  Working together intelligently suggests a “frank cooperation” in which physician and patient alike have “free access to all outside sources of help and expert knowledge.”  It also means recognizing, without prejudice or personal affront,  that the patient’s “inalienable right is to consult as many physicians as he chooses.”  Even today, an educator observes, “doctors have too much property interest in their patients,” despite the fact that patients find their pronouncements something less than, shall we say, “oracular.”  Contemporary training inherits the mantle of the patient rights revolution of the 1970s and 80s.  Educators today recognize that “It is the patient who must decide the validity of opinion from consideration of its source and probability.”  Another speaks for many in reiterating that

It is the patient who must decide the validity of opinion from consideration of its source and probability.  If the doctor’s opinion does not seem reasonable, or if the bias of it, due to temperament or personal and professional experience is obvious, then it is well for the patient to get another opinion, and the doctor has no right to be incensed or humiliated by such action.

Contemporary medical training stresses the importance of primary care values that are lineal descendants of old-style general practice.  This trend grows out of the realization that a physician “can take care of a patient without caring for him,” that the man or woman publicly considered a “good doctor” is invariably the doctor who will “find something in a sick person that aroused his sympathy, excited his admiration, or moved his compassion.”  Optimally, commentators suggest,  multispecialty and subspecialty groups would retain their own patient-centered generalists – call them, perhaps, “therapeutists”  — to provide integrative patient care beyond diagnostic problem-solving and even beyond the conventional treatment modalities of the group.  The group-based therapeutist, while trained in the root specialty of his colleagues, would also have specialized knowledge of alternative treatments outside the specialty.  He would, for example, supplement familiarity with mainstream drug therapies with a whole-patient, one might say a “wholesome” distrust of drugs.

Contemporary training finally recognizes the importance of first-hand experience of illness in inculcating the values that make for “good doctoring.”  Indeed, innovative curricula now land medical students in the emergency rooms and clinics with (feigned) symptoms and histories that invite discomfiting and sometimes lengthy interventions.  Why has it taken educators so long to enlarge the curriculum in this humanizing manner?  If, as one educator notes, “It is too much to ask of a physician that he himself should have had an enigmatic illness,” it should still be a guiding heuristic that “any illness makes him a better doctor.”  Another adds:  “It is said that an ill doctor is a pathetic sight; but one who has been ill and has recovered has had an affective experience which he can utilize to the advantage of his patients.”

The affective side of a personal illness experience may entail first-hand experience of medicine’s dehumanizing “hidden curriculum.”  Fortunate the patient whose physician has undergone his or her own medical odyssey, so that life experience vivifies the commonplace reported by one seriously ill provider:  “ I felt I had not been treated like a human being.”  A physician-writer who experienced obscure, long-term infectious illness early in his career and was shunted from consultant to consultant understands far better than healthy colleagues that physicians “are so prone to occupy themselves with the theoretical requirements of a case that they lose sight entirely of the human being and his life story.”  Here is the painful reminiscence of another ill physician of more literary bent:

There had been no inquiry of plans or prospects, no solicitude for ambitious or desires, no interest in the spirit of the man whose engine was signaling for gas and oil.  That day I determined never to sentence a person on sight, for life or to death.

Contemporary medical training increasingly recognizes that all medicine is, to one degree or another, psychiatric medicine.  Clinical opinions, educators remind us, can be truthful but still contoured to the personality, especially the psychological needs, of the patient.  Sad to say, the best clinical educators are those who know colleagues, whatever their specialty, who either “do not appreciate that constituent of personality which psychologists call the affects . . . and the importance of the role which these affects or emotions play in conditioning [the patient’s] destiny, well or ill, or they refuse to be taught by observation and experience.”   This realization segues into the role of psychiatric training in medical education, certainly for physicians engaged in primary care, but really for all physicians.  Among other things, such training “would teach him [or her] that disease cannot be standardized, that the individual must be considered first, then the disease.”  Even among patients with typical illnesses, psychiatric training can help physicians understand idiosyncratic reactions to standard treatment protocols.  It aids comprehension  of the individual “who happens to have a very common disease in his own very personal manner.”

_____________

These trends encapsulate the reflections and recommendations of progressive medical educators responsive to the public demand for more humane and humanizing physicians. The trends are also responsive to the mounting burnout of physicians – especially primary care physicians – who, in the  cost-conscious, productivity-driven, and regulatory climate of our time, find it harder than ever to practice patient-centered medicine.  But are these trends really so contemporary?  I confess to a deception.  The foregoing paraphrases, quotations, and recommendations are not from contemporary educators at all.  They are culled from the popular essays of a single physician, the pioneer neurologist Joseph Collins, all of which were published in Harper’s Monthly between 1924 and 1929.[1]

Collins is a fascinating figure.  An 1888 graduate of New York University Medical College, he attended medical school and began his practice burdened with serious, sometimes debilitating, pulmonary and abdominal symptoms that had him run the gauntlet of consultant diagnoses – pneumonia, pulmonary tuberculosis, “tuberculosis of the kidney,” chronic appendicitis, even brain tumor.  None of these authoritative pronouncements was on the mark, but taken together they left Collins highly critical of his own profession and pushed him in the direction of holistic, collaborative, patient-centered medicine.  After an extended period of general practice, he segued into the emerging specialty of neurology (then termed neuropsychiatry) and, with his colleagues Joseph Fraenkel and Pearce Bailey, founded the New York Neurological Institute in 1909.  Collins’s career as a neurologist never dislodged his commitment to  generalist patient-centered care. Indeed, the neurologist, as he understood the specialty in 1911, was the generalist best suited to treat chronic disease of any sort.[2]

Collin’s colorful, multifaceted career as a popular medical writer and literary critic is beyond the scope of this essay.[3]  I use him here to circle back to a cardinal point of previous writings.  “Patient-centered/relationship-centered care,” humanistic medicine, empathic caregiving, behavioral adjustments to the reality of patients’ rights  – these additives to the medical school curriculum are as old as they are new.  What is new is the relatively recent effort to cultivate such sensibilities through curricular innovations.  Taken together,  public health, preventive medicine, childhood vaccination, and modern antibiotic therapy have (mercifully) cut short the kind of  experiential journey that for Collins secured the humanistic moorings of the biomedical imperative.  Now medical educators rely on communication skills training, empathy-promoting protocols, core-skills workshops, and seminars on “The Healer’s Art” to close the circle, rescue medical students from evidence-based and protocol-driven overkill, and bring them back in line with Collins’s hard-won precepts.

It is not quite right to observe that these precepts apply equally to Collins’s time and our own.  They give expression to the care-giving impulse, to the ancient injunction to cure through caring (the Latin curare) that, in all its ebb and flow, whether as figure or ground, weaves through the fabric of medical history writ large.  Listen to Collins one final time as he expounds his philosophy of practice in 1926:

It would be a wise thing to devote a part of medical education to the mind of the physician himself, especially as it concerns his patients.  For the glories of medical history are the humanized physicians.  Science will always fall short; but compassion covereth all.[4]

[1] Joseph Collins, “The alienist in court,” Harper’s Monthly, 150:280-286, 1924; Joseph Collins, “A doctor looks at doctors,” Harper’s Monthly, 154:348-356, 1926; Joseph Collins, “Should doctors tell the truth?”, Harper’s Monthly, 155:320-326, 1927;  Joseph Collins, “Group practice in medicine,” Harper’s Monthly, 158:165-173, 1928;  Joseph Collins, “The patient’s dilemma,” Harper’s Monthly, 159:505-514, 1929.   I have also consulted two of Collins’s popular collections that make many of the same points:  Letters to a Neurologist, 2nd series (NY: Wood, 1910) and The Way with the Nerves: Letters to a Neurologist on Various Modern Nervous Ailments, Real and Fancied, with Replies Thereto Telling of their Nature and Treatment (NY: Putnam, 1911).

[2] Collins, The Way with Nerves, p. 268.

[3] Collins’s review of James Joyce’s Ulysses, the first by an American, was published  in The New York Times on May 28, 1922.  His volume The Doctor Looks at Literature: Psychological Studies of Life and Literature (NY: Doran, 1923) appeared the following year.

[4] Collins, “A doctor looks at doctors,” p. 356.  Collins’s injunction is exemplified in “The Healer’s Art,” a course developed by Dr. Rachel Naomi Remen over the past 22 years and currently taught annually in 71  American medical colleges as well as medical colleges in seven other countries.  See David Bornstein, “Medicine’s Search for Meaning,” posted for The New York Times/Opinionator on September 18, 2013 (http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/?_r=0).

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

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Posted in Doctor-Patient Communication, General, Medical Education, Psychiatry in Medicine

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Caring Technology

Posted on October 11, 2012 | Leave a comment

The critique of contemporary medical treatment as impersonal, uncaring, and disease-focused usually invokes the dehumanizing perils of high technology.  The problem is that high technology is a moving target.  In the England of the 1730s, obstetrical forceps were the high technology of the day; William Smellie, London’s leading obstetrical physician, opposed their use for more than a decade, despite compelling evidence that the technology revolutionized childbirth by permitting obstructed births to become live births.[1]  For much of the nineteenth century, stethoscopes and sphygmomanometers (blood pressure meters) were considered technological contrivances that distanced the doctor from the patient.  For any number of Victorian patients (and doctors too), the kindly ear against the chest and the trained finger on the wrist helped make the physical examination an essentially human encounter.  Interpose instruments between the physician and the patient and, ipso facto, you distance the one from the other.  In late nineteenth-century Britain, “experimental” or “laboratory” medicine was itself a revolutionary technology, and it elicited  bitter denunciation from antivivisectionists (among whom were physicians) that foreshadows contemporary indictments of the “hypertrophied scientism” of modern medicine.[2]

Nineteenth-century concerns about high technology blossomed in the early twentieth century when technologies (urinalysis, blood studies, x-rays, EKGs) multiplied and their use switched to hospital settings.  Older pediatricians opposed the use of the new-fangled incubators for premature newborns. They  not only had faulty ventilation that deprived infants of fresh air but were a wasteful expenditure, given that preemies of the poor were never brought to the hospital right after birth.[3]   Cautionary words were always at hand for the younger generation given to the latest gadgetry.  At the dedication of Yale’s Sterling Hall of Medicine, the neurosurgeon Harvey Cushing extolled family physicians as exemplars of his gospel of observation and deduction and urged  Yale students to engage in actual “house-to-house practice” without the benefit of “all of the paraphernalia and instruments of precision supposed to be necessary for a diagnosis.”  This was in 1925.[4]

Concerns about the impact of technology on doctor-patient relationships blossomed again in the 1960s and 70s and played a role  in the rebirth of primary care medicine in the guise of the “family practice movement.”  Reading the papers of the recently deceased G. Gayle Stephens, written at the time and collected in his volume The Intellectual Basis of Family Practice (1982), is a strong reminder of the risks attendant to loading high technology with relational meaning.  Stephens, an architect of the new structure of primary care training, saw the “generalist role in medicine” as an aspect of 70s counterculture that questioned an “unconditional faith in science” that extended to medical training, practice, and values.  And so he aligned the family practice movement with other social movements of the 70s that sought to put the breaks on scientism run rampant:  agrarianism, utopianism, humanism, consumerism, and feminism.  With its clinical focus on the whole person and liberal borrowings from psychiatry and the behavioral sciences, family practice set out to liberate medicine from its “captivity” to a flawed view of reality that was mechanistic, protoplasmic, and molecular.[5]

Technology was deeply implicated in Stephens’ critique, even though he failed to stipulate which technologies he had in mind.  His was a global indictment: Medicine’s obsession with its “technological legerdemain” blinded the physician to the rich phenomenology of “dis-ease” and, as such, was anti-Hippocratic.  For Stephens, the “mechanical appurtenances of healing” had to be differentiated from the “essential ingredient” of the healing process, viz., “a physician who really cares about the patient.” “We have reached a point of diminishing returns in the effectiveness of technology to improve the total health of our nation.”  So he opined in 1973, only two years after the first crude CT scanner was demonstrated in London and long before the development of MRIs and PET scans, of angioplasty with stents, and of the broad array of laser- and computer-assisted operations available to contemporary surgeons.[6]  Entire domains of technologically guided intervention – consider technologies of blood and marrow transplantation and medical genetics – barely existed in the early 70s.  Robotics was the stuff of science fiction.

It is easy to sympathize with both Stephens’ critique and his mounting skepticism about the family practice movement’s ability to realize its goals. [7]  He placed the movement on an ideological battleground in which the combatants were of unequal strength and numbers.  There was the family practice counterculture, with the guiding belief that “something genuine and vital occurs in the meeting of doctor and patient” and the pedagogical correlate that  “A preoccupation with a disease instead of a person is detrimental to good medicine.”  And then there were the forces of organized medicine, of medical schools, of turf-protecting internists and surgeons, of hospitals with their “business-industrial models” of healthcare delivery, of specialization and of technology – all bound together by a cultural commitment to science and its  “reductionist hypothesis about the nature of reality.”[8]

Perceptive and humane as Stephen’s critique was, it fell back on the very sort of reductionism he imputed to the opponents of family practice.  Again and again, he juxtaposed “high technology,” in all its allure (and allegedly diminishing returns) with the humanistic goals of patient care.  But are technology and humane patient care really so antipodal?  Technology in and of itself has no ontological status within medicine.  It promotes neither a mechanistic worldview that precludes holistic understanding of patients as people nor a humanizing of the doctor-patient encounter.  In fact, technology is utterly neutral with respect to the values that inform medical practice and shape individual doctor-patient relationships.  Technology does not make (or unmake) the doctor.  It no doubt affects the physician’s choice of specialty, pulling those who lack doctoring instincts or people skills in problem-solving directions (think diagnostic radiology or pathology). But this is hardly a bad thing.

For Stephens, who struggled to formulate an “intellectual” defense of family practice as a new medical discipline, technology was an easy target.  Infusing the nascent behavioral medicine of his day with a liberal dose of sociology and psychoanalysis, he envisioned the family practice movement as a vehicle for recapturing “diseases of the self” through dialogue.[9]  To the extent that technology – whose very existence all but guaranteed its overuse – supplanted  the sensibility (and associated communicational skills) that enabled such dialogue, it was ipso facto part of the problem.

Now there is no question that overreliance on technology, teamed with epistemic assurance that technology invariably determines what is best, can make a mess of things, interpersonally speaking.  But is the problem with the technology or with the human beings who use it?  Technology, however “high” or “low,” is an instrument of diagnosis and treatment, not a signpost of treatment well- or ill-rendered.  Physicians who are not patient-centered will assuredly not find themselves pulled toward doctor-patient dialogue through the tools of their specialty.  But neither will they become less patient-centered on account of these tools.  Physicians who are patient-centered, who enjoy their patients as people, and who comprehend their physicianly responsibilities in broader Hippocratic terms – these physicians will not be rendered less human, less caring, less dialogic, because of the technology they rely on.  On the contrary, their caregiving values, if deeply held, will suffuse the technology and humanize its deployment in patient-centered ways.

When my retinologist examines the back of my eyes with the high-tech tools of his specialty – a retinal camera, a slit lamp, an optical coherence tomography machine – I do not feel that my connection with him is depersonalized or objectified through the instrumentation.  Not in the least.  On the contrary, I perceive the technology as an extension of his person.  I am his patient, I have retinal pathology, and I need his regular reassurance that my condition remains stable and that I can continue with my work.  He is responsive to my anxiety and sees me whenever I need to see him.  The high technology he deploys in evaluating the back of my eye does not come between us; it is a mechanical extension of his physicianly gaze that fortifies his judgment and amplifies the reassurance he is able to provide.  Because he cares for me, his technology cares for me.  It is caring technology because he is a caring physician.

Modern retinology is something of a technological tour de force, but it is no different in kind from other specialties that employ colposcopes, cytoscopes, gastroscopes, proctoscopes, rhinoscopes, and the like to investigate symptoms and make diagnoses.  If the physician who employs the technology is caring, then all such technological invasions, however unpleasant, are caring interventions.  The cardiologist who recommends an invasive procedure like cardiac catheterization is no less caring on that account; such high technology does not distance him from the patient, though it may well enable him to maintain the distance that already exists.  It is a matter of personality, not technology.

I extend this claim to advanced imaging studies as well.  When the need for an MRI is explained in a caring and comprehensible manner, when the explanation is enveloped in a trusting doctor-patient relationship, then the technology, however discomfiting, becomes the physician’s collaborator in care-giving.  This is altogether different from the patient who demands an MRI or the physician who, in the throes of defensive medicine, remarks off-handedly, “Well, we better get an MRI” or simply, “I’m going to order an MRI.”

Medical technology, at its best, is the problem-solving equivalent of a prosthetic limb.  It is an inanimate extender of the physician’s mental “grasp” of the problem at hand. To the extent that technology remains tethered to the physician’s caring sensibility, to his understanding that his diagnostic or treatment-related problem is our existential problem – and that, per Kierkegaard, we are often fraught with fear and trembling on account of it – then we may welcome the embrace of high technology, just as polio patients of the 1930s and 40s with paralyzed intercostal muscles welcomed the literal embrace of the iron lung, which enabled them to breath fully and deeply and without pain.

No doubt, many physicians fail to comprehend their use of technology in this fuzzy, humanistic way – and we are probably the worse for it.  Technology does not structure interpersonal relationships; it is simply there for the using or abusing.  The problem is not that we have too much of it, but that we impute a kind of relational valence to it, as if otherwise caring doctors are pulled away from patient care because technology gets between them and their patients.  With some doctors, this may indeed be the case.  But it is not the press of technology per se that reduces physicians to, in a word Stephens disparagingly uses, “technologists.”  The problem is not in their tools but in themselves.

[1] A. Wilson, The Making of Man-Midwifery: Childbirth in England, 1660-1770 (Cambridge: Harvard, 1995), pp. 97-98, 127-128.

[2] R. D. French, Antivivisection and Medical Science in Victorian Society (Princeton:  Princeton University Press, 1975), p. 411.

[3] J. P. Baker, “The Incubator Controversy: Pediatricians and the Origins of Premature Infant Technology in the United States, 1890 to 1910,” Pediatrics, 87:654-662, 1991.

[4] E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (NY: Schuman, 1950), pp. 244-45.

[5] G. G. Stephens, The Intellectual Basis of Family Practice (Kansas City: Winter, 1982), pp. 62, 56, 83-85, 135-39.

[6] Stephens, Intellectual Basis of Family Practice, pp. 84, 191, 64, 39, 28.

[7] E.g., Stephens, Intellectual Basis of Family Practice, pp. 96, 194.  Cf. his comment on the American College of Surgeon’s effort to keep FPs out of the hospital: “There are issues of political hegemony masquerading as quality of patient care, medicolegal issues disguised as professional qualifications, and economic wolves in the sheepskins of guardians of the public safety” (p. 69).

[8] Stephens, Intellectual Basis of Family Practice, pp. 23, 38, 22.  In 1978, he spoke of the incursion of family practice  into the medical school curriculum of the early 70s as an assault on an entrenched power base:  “The medical education establishment has proved to be a tough opponent, with weapons we never dreamed of. . . .We had to deal with strong emotions, hostility, anger, humiliation. Our very existence was a judgment on the schools, much in the same way that civil rights demonstrators were a judgment on the establishment.  We identified ourselves with all the natural critics of the schools – students, underserved segments of the public, and their elected representatives – to bring pressure to bear on the schools to create academic units devoted to family practice” (pp. 184, 187).

[9] Stephens, Intellectual Basis of Family Practice, pp. 94, 105, 120-23, 192.

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

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Naming the Pain

Posted on August 29, 2012 | 1 comment

I always begin my “Medicine and Society” seminar by asking the students to identify as many of the following terms as they can and then to tell me what they have in common: nostalgie; railway spine; soldier’s heart (aka effort syndrome or Da Costa’s syndrome); puerperal insanity; neurasthenia; hyperkinetic syndrome; irritable bowel syndrome; ADHD; chronic fatigue syndrome; and fibromyalgia.

The answer, of course, is that they are not diseases at all but broadly descriptive syndromes based on self-reports. In each and every case, physicians listen to what patients (or, in the case of children, parents or teachers) tell them, and then give a diseaselike name to a cluster of symptoms for which there is no apparent biomedical explanation.

The fact that such conditions have existed throughout history and the appreciable symptomatic overlap among them surprise some students but not others.  I like to point out especially the virtual mapping of neurasthenia, a syndrome “identified” by the pioneer American neurologist George Beard in 1869, on to contemporary notions of chronic fatigue syndrome and fibromyalgia.  For Beard the symptoms of neurasthenia include mental and physical fatigue, insomnia, headache, general muscular achiness, irritability, and inability to concentrate.  What have we here if not the symptoms of chronic fatigue syndrome and fibromyalgia, with the only difference, really, residing in the biomedically elusive cause of the symptoms.  Whereas neurasthenia was attributed by Beard and other nineteenth-century neurologists to nervous weakness, i.e., “debility of the nerves,” the contemporary variants are ascribed to a heretofore undetected low-grade virus.

The same mapping chain applies to stomach and digestive discomfort.  Long before the arrival of “irritable bowel syndrome,” for which there has never been a basis for differential diagnosis, there were terms like enteralgia, adult colic, and that wonderfully versatile eighteenth- and nineteenth-century medical-cum-literary condition, dyspepsia.   Before children were “diagnosed” with ADHD, they were given the diagnosis ADD (attention deficit disorder) or MBD (minimal brain dysfunction), and before that, beginning in the early 1960s, the same kids were diagnosed with hyperactivity (hyperkinetic syndrome).  Military medicine has its own chronology of syndromal particulars.  Major building blocks that lead to our understanding of combat-related stress and its sequelae include PTSD, during America’s war in Vietnam; combat fatigue and war neurosis during WWII; shell shock and “soldier’s heart” during WWI; and nostalgie during the Napoleonic Wars and American Civil War.

The functionality of neurasthenia and its modern descendants is that they are symptomatically all-inclusive but infinitely plastic in individual expression.  It is still a blast to read Beard’s dizzying catalog of the symptoms of neurasthenia in the preface to Modern American Nervousness (1881).  Here is a small sampling:

Insomnia; flushing; drowsiness; bad dreams; cerebral irritation; dilated pupils; pain, pressure, and heaviness in the head; changes in the expression of the eye; asthenopia [eye strain]; noises in the ears; atonic voice; mental irritability; tenderness of the teeth and gums; abnormal dryness of the skin, joints, and mucous membranes; sweating hands and feet with redness; cold hands and feet; pain in the feet; local spasms of muscles; difficulty swallowing; convulsive movements; cramps; a feeling of profound exhaustion; fear of lightning; fear of responsibility; fear of open places or closed places; fear of society; fear of being alone; fear of fears; fear of contamination; fear of everything.[1]

This same model, if less extravagant in reach, pertains to chronic fatigue syndrome and fibromyalgia.  Any number of symptoms point to these conditions, but no single clustering of symptoms is essential to the diagnosis or able to rule it out.  In the world of global syndromes, the presence and absence of specific symptoms serve equally well as diagnostic markers.[2]

As many historians have pointed out, the development and marketing of new drugs plays a significant role in the labeling (and hence medicalizing) of these syndromes.  From time immemorial, young children, especially boys, have had a hard time sitting still in school and focusing on the task before them.  But it was only with the release of Ritalin (methylphenidate) in the early 1960s that these time-honored developmental lags (or were they simply developmental realities?) were gathered into the diagnosis “hyperkinetic syndrome.”

Psychiatry has been especially willing to accommodate the drug-related charge to syndromize new variants of existing syndromes. “Panic disorder” became a syndrome only after Upjohn released a new benzodiazepine, alprazolam, for which it sought a market within the broad universe of anxiety sufferers.  Conveniently, the release of the drug in 1980 coincided with the release of the 3rd edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), which obligingly found a place for “panic disorder” (and hence alprazolam) in its revised nosology.  DSM-III was no less kind to Pfizer; it helped the manufacturer find a market for its newly released MAOI antidepressant, phenelzine, by adding “social phobia” to the nomenclature.[3]

Critics write about the creeping medicalization of virtually every kind of  discomfort, dis-ease, despondency, dysfunction, and dysphoria known to humankind.[4]  As a society, we are well beyond medicalizing the aches and pains that accompany everyday life.  We are at the point of medicalizing life itself, especially the milestones that punctuate the human life cycle. This is the viewpoint especially of French social scientists influenced by Foucault, who seem to think that the “medicalization” of  conception (via, for example, embryo freezing) or the “pharmacologization” of menopause via hormone therapy takes us to the brink of a new de-naturalizing control of biological time.[5]

I demur.  What we see in medicalization is less the “pathologization of existence”[6] than a variably successful effort to adapt to pain and malaise so that life can be lived.  The adaptation resides in the bi-level organizing activity that fuels and sustains the labeling process.  It is comforting to group together disparate symptom clusters into reified entities such as neurasthenia or chronic fatigue syndrome or fibromyalgia.  It is also comforting, even inspiriting, to associate with fellow sufferers, even if their fibromyalgia manifests itself quite differently than yours.  All can organize into support groups and internet self-help communities and fight for recognition from organized medicine and society at large.  These people do something about their pain.  And they often feel better, even if they still hurt all over.  If nothing else, they have accessed a collective illness identity that mitigates self-doubts and alienation.[7]

But there may be other ways of adapting to chronic pain amplified, all too often, by chronic misery that veers into psychiatric co-morbidity.  The problem with adapting to nonspecific suffering by labeling, medicalization, support groups, self-help literature, and the like is the pull to go beyond living with pain to living through the illness identity constructed around the pain.  For some there are other possibilities.  There is psychotherapy to address the misery, which may or may not prove helpful.  There is the stoic resolve, more typical of the nineteenth century, to live with pain without collapsing one’s identity into the pain and waiting for the rest of the world to acknowledge it.[8] There is the pursuit of symptomatic relief unburdened by illness identity and the existential angst  that accompanies it.  And there is a fourth way that leads back to my father’s medicine.

In the post-WWII era, there were no support groups or self-help literature or internet communities to validate diffuse syndromal suffering.  But there were devoted family physicians, many of whom, like William Stepansky, were psychiatrically oriented and had the benefit of postgraduate psychiatric training.  A caring physician can validate and “hold” a patient’s pain without assigning the pain a label and trusting the label to mobilize the patient’s capacity to self-soothe.  He or she can say medically knowledgeable things about the pain (and its palliation) without “medicalizing” it in the biomedically reductive, remedy-driven sense of our own time.

Primary care physicians who listen to their patients long enough to know them and value them become partners in suffering.  They suffer with their patients not in the sense of feeling their pain but in the deeper sense of validating their suffering, both physical and mental, by situating it within a realm of medical understanding that transcends discrete medical interventions.

Am I suggesting that fibromyalgia sufferers would be better off if they had primary care physicians who, like my father, had the time and inclination to listen to them in the manner of attuned psychotherapists?  You bet I am.  The caring associated with my father’s medicine, as I have written, relied on the use of what psychoanalysts term “positive transference,” but absent the analytic goal of  “resolving” the transference (i.e., of analyzing it away) over time.[9]  Treating patients with chronic pain – whether or not syndromal – means allowing them continuing use of the physician in those ways in which they need to use him.

A parental or idealizing transference, once established, does two things.  It intensifies whatever strategies of pain management the physician chooses to pursue, and it provides the physician with relational leverage for exploring the situational and psychological factors that amplify the pain.  Of course, the general physician’s willingness to be used thusly is a tall order, especially in this day and age.  It signifies a commitment to holistic care-giving over time, so that issues of patienthood morph into issues of suffering personhood.  My father’s psychological medicine – of which contemporary notions of patient- and relationship-centered care are pale facsimiles — could not eliminate the pain of his syndromal sufferers.  But it provided them with a kind of support (and, yes, relief) that few contemporary sufferers will ever know.

[1] G. M. Beard, American Nervousness, Its Causes and Consequences (NY: Putnam, 1881), pp. viii-ix.

[2] K. Barker, “Self-help literature and the making of an illness identity: the case of fibromyalgia syndrome (FMS),” Social Problems, 49:279-300, 2002.

[3] D. Healy, The Anti-Depressant Era (Cambridge: Harvard University Press, 1997), pp. 187-189.

[4] E.g., Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore: Johns Hopkins, 2007).

[5] A. J. Suissa, “Addiction to cosmetic surgery: representations and medicalization of the body,” Int. J. Ment. Health Addiction, 6:619-630, 2008, at p. 620.

[6] R. Gori & M. J. Volgo, La Santé Totalitaire: Essai sur la Medicalization de l’Existence (Paris: Denoël, 2005).

[7] Barker, “Self-help literature and the making of an illness identity,” op. cit.

[8] There are some powerful examples of such adaptation to pain in S. Weir Mitchell’s Doctor and Patient, 2nd edition (Phila: Lippincott, 1888), pp. 83-100.

[9] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 86.  More than a half century ago, the American psychoanalyst Leo Stone wrote of “the unique transference valence of the physician.”  Patients formed transference bonds with their analysts partly because the latter, as physicians, were beneficiaries of “the original structure of the patient-doctor relationship.”  Small wonder that Stone deemed the physician’s role “the underlying definite and persistent identity which is optimum for the analyst.”  L. Stone, The Psychoanalytic Situation: An Examination of Its Development and Essential Nature (NY: International Universities Press, 1961), pp. 17, 15, 41.

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

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My Father’s Empathy

Posted on June 16, 2012 | Leave a comment

My late father, William Stepansky, was the most empathic caregiver I have ever known.  Until recently, however, I never thought of him that way.  Indeed, I never had the sense that he “practiced” medicine one way or another, simply that he lived out his medical calling.  I thought nothing of having a father who taped the Hippocratic Oath to his dresser and read it every morning.

My father’s “empathy” did not grow out of medical training; it was the stuff of life experience. His family’s emigration from Russia followed the Hitler-like savagery of the Ukrainian Pogroms that followed World War I.  Anti-Semite thugs murdered his grandfather on his own doorstep several years before his father, Pincus, mother, Vittie (then pregnant with him), and older sister, Enta began their uncertain journey to America in 1921.  Pincus, a highly decorated Russian war veteran, a member of the 118th (Shuiskii) Infantry Regiment of the 30th Infantry Division, was the recipient of what my father termed the Russian equivalent of our own Congressional Medal of Honor.  “He was a sergeant,” he would tell me, “but a colonel had to salute him first.” On the battlefield he was wounded three times in the chest and once left for dead.  Stripped of his decorations by the bandits who raided his native village of Stavishche, he arrived in the new world penurious and crippled with chest pain.

My father, who was born in Kishinev, Rumania during the first leg of his family’s 1,900-mile journey across continental Europe, was six-months old when they arrived in Boston Harbor.  A year later, they left Boston and made their home in the densely Jewish enclave in South Philadelphia.  Throughout my life, my father shared two memories of his own father; they attest, respectively, to the positive and negative poles of the wounded soldier-tailor’s dedication to high culture. The first is of Pincus gamely limping across long city blocks with his young son in tow; he was taking his young son, my father, to his weekly violin lesson with his first teacher, the local postman.  Pincus never left the music room, and when the lesson was over, he took his son’s violin and lovingly wiped it down with a special cloth brought solely for that purpose.

The second memory is of Pincus imperiously ordering his son to bring his violin and perform whenever neighbors, friends, or relations gathered in the family’s small apartment.  A shy, retiring child, my father urgently wanted not to play. But his father’s directives were issued from on high with military-like peremptoriness that brooked neither contradiction nor delay.  And so my father got his violin and he played, perhaps through tears, perhaps through rage.

My father, at age 15, watched his father die of heart disease. In February, 1943, having completed his third-year of pharmacy training, he was called up by the army and served as a surgical technician in a medical battalion attached to the 80th Infantry Division of Patton’s Third Army.  In France, Belgium, and Germany, he worked alongside battlefield surgeons who fought to keep wounded GIs alive in a surgical clearing company only a short remove from the front line.  I learned a bit about the visceral reality of wound management in the European Theatre during his final years, when I interviewed him and several of his surviving comrades for The Last Family Doctor.  The prosaic summary of his duties in his army  discharge of January, 1946 – “Removed uncomplicated cases of shrapnel wounds, administered oxygen and plasma, sterilized instruments, bandages, clothing, etc.  Gave hypodermic injections and performed general first aid duties” – only hints at this reality.

My father, so I learned, held down wounded GIs for anesthesia-less suturing, assisted with frontline battlefield surgery, much of which involved amputation, and then, after the day’s work, went outside to bury severed arms and legs. He experienced close fighting in the woods of Bastogne during the freezing winter of 1945, when the techs worked 20-hour shifts to keep up with the inflow of casualties.  One can only wonder at the impact of such things on the constitution of a gentle and soft-spoken 22-year-old pharmacy student whose passion, before and after the war, was the violin, and who carried Tolstoy’s War and Peace in his backpack throughout his European tour.

A different man might have emerged from my father’s childhood and wartime experience emotionally constricted, withdrawn, intimidated by authority figures or, obversely (or concurrently) enraged by them.  In my father’s case, a lifelong performance anxiety – the legacy of a militaristic father repeatedly ordering him to play violin before visitors — was vastly counterbalanced by an enlarged empathic sensibility that enabled him to understand and contain his patients’ anxieties about their health, their relationships, their ability to love and to work.  Wrestling as he did with his own anxieties and memories of the war, which included the liberation of Dachau and Buchenwald, he became a physician who accepted utterly his patients’ prerogative to share their anxieties with him, even to project their anxieties into him.  He was, after all, their doctor.

My father was not only an astute diagnostician but also a gifted psychotherapist, and the amalgam of these twin talents was an ability to titrate his disclosures, to tell patients what they needed to know, certainly, but in a manner he thought they could bear.  His psychologically attuned approach to patient care is now associated with the paternalism of a different era.  But it was also an aspect of his ability, rare among physicians, to diagnose suffering and to discern the limits of this or that patient’s ability to cope with it.[1]  This style of practice was wonderfully appreciated by his patients, some of whom, after leaving the area, travelled a distance for yearly appointments with him.  No doubt they wanted to experience the “holding environment” of his person.

Premed students who grind away at biology and chemistry have no idea what my father and his cohort of war-tested physicians, many first- and second-generation immigrants, overcame for the privilege of studying medicine.  I would not wish his life story – of which I relate only a few particulars here – on any of them.  And yet, we might ponder the desirability of subjecting premed students to some muted version of his experience in order to nurture whatever elements of empathic temperament they possess.  Specifically, medical educators can take steps to ensure that premeds are not subverted by medicine’s  “hidden curriculum” – its institutional pull away from patient-centered values and practices – while they are still in college, especially when they complete their med school applications and present for their interviews.  And they can work harder to find clinical teachers who do not endorse shame, humiliation, and intimidation as credible educational strategies for acculturating young doctors into the profession.[2]

If we wish to steer contemporary medical students toward compassionate, or at least adequately sensitive, care-giving – and here I echo what others have said[3] – then we need to provide them with clinical teachers who are dissatisfied with a passive conception of role modeling and actually model discrete and specifiable behaviors in their interactions with patients.[4]  Sadly, the literature continues to provide examples of clinical training during medical school and residency that is denigrating, demoralizing, and ultimately desensitizing.  We end up with clinical teachers (not all, by any means, but no doubt a good many) who long ago capitulated to the hidden curriculum and devote themselves to readying the next generation of trainees for a like-minded (or better, a survival-minded) capitulation.  With this intergenerational dynamic in place, we are at the point of Marshall Marinker’s devastating “Myth, Paradox and the Hidden Curriculum” (1997), which begins:  “The ultimate indignity teachers inflict upon students is that, in time, they become us.”[5]

My father and his cohort of med students who trained during and shortly after WWII were resistant to shaming and intimidation.  They had experienced too much to be diverted from a calling to practice medicine.  But then their teachers too had experienced a great deal, many working alongside their future students – the pharmacists, medics, techs, and GIs – in casualty clearing stations, field hospitals, VA hospitals, and rehab facilities in Europe and America.  Teachers emerging from the war years encountered a generation of mature students whose wartime experience primed them to embrace medicine as patient care.  And the students, for their part, encountered teachers whose own wartime experience and nascent cold war anxieties tempered budding Napoleonic complexes.  High tech medicine, bioethics, and patient rights all lay in the future. Generalists like my father were trained to provide care that was caring; their ministrations were largely “medicinal, manual, and mentalistic, which is to say, psychological.”[6]  In the kind of training they received, the notion of  castigating as “unprofessional” med students whose patient-centered concerns and queries slowed down the breakneck pace of team rounds – a documented reality these days[7] – would literally have been non-sensical.

But that was then and this is now.  Today medical culture has in key respects become subversive of the ideals that drew my father and his cohort to medicine.  And this culture, which revolves around the sacrosanctity of an academic hierarchy that, inter alia, insists on perfection, denigrates uncertainty, privileges outcome over process, and, in the clinical years, engages students adversarially, is far too entrenched to be dislodged with manifestos, position papers, and curricular reforms.  What educators can do is seek out medical students whose empowerment derives less from high grades and artfully constructed admissions essays and more from life experience in the trenches – in any trenches. We don’t need to send premeds off to war to make them resistant to the hidden curriculum, but we should encourage premed experience robust enough to deflect its pull and let those of caring temperament develop into caring physicians.

Perhaps we need students who are drawn less to biochemistry than to the vagaries of human chemistry, students who have already undertaken experiential journeys that bring into focus the humanistic skyline of their medical horizons.  What Coulehan[8] terms “socially relevant service-oriented learning” should not be confined to residency training.  We need more students who come to medicine after doing volunteer work in developing nations; fighting for medical civil rights; staffing rural and urban health clinics; and serving public health internships.[9]  And if this suggestion is quixotic, let’s at least have premed students spend the summer before senior year in the trenches, as I proposed in “The Hunt for Caring Med Students.”  Such strategies will not create empathic caregivers de novo, but they will nurture the empathic temperament of those so endowed and, one hopes, fortify them a little better against the careerist blandishments of the hidden curriculum.  It would be nice if, a generation hence, other sons (and daughters) could write about their fathers’ (and mothers’) special kind of therapeutic empathy.

[1] E. J. Cassell, “Diagnosing suffering: a perspective,” Ann. Intern. Med., 131:531-534, 1999.

[2] J. White, et al., “’What do they want me To say?’: the hidden curriculum at work in the medical school selection process: a qualitative study,” BMC Med. Educ., 12:1-9, 2012; U. H. Lindström, et al., “Medical students’ experiences of shame in professional enculturation,” Med. Educ., 45:1016-1024, 2011; A. H. Brainard & H. C. Brislen, “Learning professionalism: a view from the trenches,” Acad. Med., 82:1010-1014, 2007; P. Haidet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians,” J. Gen. Intern. Med., 21:S16-20, 2006; Mary Seabrook, “Intimidation in medical education: students’ and teachers’ perspectives,” Stud. Higher Educ., 29:59-74, 2004.

[3] Haidet & Stein, “Role of the student-teacher relationship”; N. Ratanawongsa, et al., “Residents’ perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements,” J. Gen Intern. Med., 21:758-763, 2006; J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; B. Maheux, et al., “Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools, Med. Educ., 34:630-634, 2000; J. H. Burack, et al., Teaching compassion and respect: attending physicians’ responses to problematic behaviors,” J. Gen. Intern. Med., 14:49-55, 1999.

[4] See further Burack, “Teaching compassion and respect,” p. 54.

[5] M. Marinker, “Myth, paradox and the hidden curriculum,” Med. Educ., 31:293-298, 1997, quoted at p. 293; cf. Haidet & Stein, “Role of student-teacher relationship,” p. 3: “The relational processes of the hidden curriculum assure the perpetuation of its content” (authors’ emphasis).

[6] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 114.

[7] Brainard & Brislen, “Learning professionalism,” p. 1011.

[8] Coulehan, “Today’s professionalism,” p. 896.

[9] For examples of such physicians and their role in the revitalization of primary care medicine in the 1970s, see Stepansky, Last Family Doctor, pp. 130-133.

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

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My Doctor, My Friend

Posted on January 10, 2012 | Leave a comment

In a piece several months ago  in the Boston Globe, “Blurred Boundaries Between Doctor and Patient,” columnist and primary care internist Suzanne Koven writes movingly of her patient Emma, whom Koven befriended over the last 15 years of Emma’s life.  “Emma and I met frequently to gossip, talk about books and politics, and trade stories about our lives,” she remarks.  “She came to my house for dinner several times, and my husband and kids joined me at her 90th birthday party.  When, at 92, Emma moved reluctantly into a nursing home, I brought her the bagels and lox she craved – rich, salty treats her doctor had long discouraged her from eating.  Here’s the funny part:  I was that doctor.”

Koven writes perceptively of her initial concern with doctor-patient boundaries (heightened, she admits, by her status as “a young female physician”), her ill-fated efforts to maintain her early ideal of professional detachment, and, as with Emma, her eventual understanding that the roles of physician and friend could be for the most part “mutually reinforcing.”

As a historian of medicine interested in the doctor-patient relationship, I reacted to Koven’s piece appreciatively but, as I confessed to her, sadly.  For her initial concern with “blurred boundaries” and her realization after years of practice about the compatibility of friendship with primary medical care only underscore the fragmented and depersonalized world of contemporary medicine, primary care included.  By this, I mean that the quality of intimacy that grows out of most doctoring has become so shallow that we are led to scrutinize doctor-patient “friendship” as a problematic (Is it good?  Is it bad?  Should there be limits to it?) and celebrate instances of such friendship as signal achievements.   Psychoanalysts, be it noted, have been pondering these questions in their literature for decades, but they at least have the excuse of their method, which centrally implicates the analysis and resolution of transference with patients who tend to become inordinately dependent on them.

My father, William Stepansky, like many of the WWII generation, befriended his patients, but he befriended them as their doctor.  That is, he understood his medicine to include human provisions of a loving and Hippocratic sort.  Friendly two-way extramedical queries about his family, contact at community events, attendance at local weddings and other receptions – these were not boundary-testing land mines but aspects of community-embedded caregiving.  But here’s the rub:  My father befriended his patients as their doctor; his friendship was simply the caring dimension of his care-giving.  What, after all, did he have in common with the vast majority of his patients?  They were Protestants and Catholics, members of the Rotary and Kiwanis Clubs who attended the local churches and coached little league baseball and Pop Warner football.  He was an intellectual East European Jew, a serious lifelong student of the violin whose leisure time was spent practicing, reading medical journals, and tending to his lawn.

And yet to his patients, he was always a special friend, though he himself would admit nothing special about it:  his friendship  was simply the human expression of his calling.  He did not (to my knowledge) bring anyone bagels and lox or pay visits to chat about books or politics, but he provided treatment (including ongoing supportive psychotherapy) at no charge, accepted payment in kind, and visited patients in their homes when they became too elderly or infirm to come to the office.  Other routine “friendly” gestures included charging for a single visit when a mother brought a brood of sick children to the office during the cold season.  And when elderly patients became terminal, they did not have to ask – he simply began visiting them regularly in their homes to provide what comfort he could and to let them know they were on his mind.

When he announced his impending retirement to his patients in the fall of 1990, his farewell letter began “Dear Friend” and then expressed regret at “leaving many patients with whom I have shared significant life experience from which many long-term friendships have evolved.”  “It has been a privilege to serve as your physician for these many years,” he concluded.  “Your confidence and friendship have meant much to me.”  When, in my research for The Last Family Doctor, I sifted through the bags of cards and letters that followed this announcement, I was struck by the number of patients who not only reciprocated my father’s sentiment but summoned the words to convey deep gratitude for the gift of their doctor’s friendship.

In our own era of fragmented multispecialty care, hemmed in by patient rights, defensive medicine, and concerns about boundary violations, it is far from easy for a physician to “friend” a patient as physician, to be and remain a physician-friend.  Furthermore, physicians now wrestle with the ethical implications of “friending” in ways that are increasingly dissociated from a medical identity.  Many choose to forego professional distance at the close of a work day.  No less than the rest of us, physicians seek multicolored self states woven of myriad connective threads; no less than the rest of us, they are the Children of Facebook.

But there is a downside to this diffusion of connective energy.  When, as a society, we construe the friendship of doctors as extramedical, when we pull it into the arena of depersonalized connecting fostered by social media, we risk marginalizing the deeper kind of friendship associated with the medical calling: the physician’s nurturing love of the patient.   And we lose sight of the fact that, until the final two decades of the 19th century,  when advances in cellular biology, experimental physiology, bacteriology, and pharmacology ushered in an era of specific remedies for specific ailments, most effective doctoring – excluding only a limited number of surgeries – amounted to little more than just such friendship, such comfortable and comforting “friending” of sick and suffering people.

And this takes us back to Suzanne Koven, who imputes the “austere façade” of her medical youth to those imposing 19th-century role models “whose oil portraits lined the walls of the hospital [MGH] in which I did my medical training.”  Among the grim visages that stared down from on high was that of the illustrious James Jackson, Sr., who brought Jenner’s technique of smallpox inoculation to the shores of Boston in 1800, became Harvard’s second Hersey Professor of the Theory and Practice of Medicine in 1812, and was a driving force in the founding of MGH, which opened its doors in 1821.  Koven cites a passage from the second of Jackson’s Letters to a Young Physician (1855) in which he urges his young colleague to “abstain from all levity” and “never exact attention to himself.”

But why should absence of levity and focal concern with the patient be tantamount to indifference, coolness, the withholding of physicianly friendship?  Was Jackson really so forbidding a role model?  Composing his Letters in the wake of the cholera epidemic of 1848, when “regular” remedies such as bleeding and purging proved futile and only heightened the suffering of  thousands, Jackson cautioned modesty when it came to therapeutic pretensions.  He abjured the use of drugs “as much as possible,” and added that “the true physician takes care of his patient without claiming to control the disease in all cases.” Indeed he sought to restore “cure” to its original Latin meaning, to curare, the sense in which “to cure meant to take care.”  “The physician,” he instructed his protégé,

“may do very much for the welfare of the sick, more than others can do, although he does not, even in the major part of cases, undertake to control and overcome the disease by art.  It was with these views that I never reported any patients cured at our hospital.  Those who recovered their health before they left the house were reported as well, not implying that they were made so by the active treatment they had received there.  But it was to be understood that all patients received in that house were to be cured, that is, taken care of” [Letters to a Young Physician, p. 16, Jackson’s emphasis].

And then he moved on to the narrowing of vision that safeguarded the physician’s caring values, his cura:

“You must not mistake me.  We are not called upon to forget ourselves in our regard for others.  We do not engage in practice merely from philanthropy.  We are justified in looking for both profit and honor, if we give our best services to our patients; only we must not be thinking of these when at the bedside.  There the welfare of the sick must occupy us entirely” [Letters to a Young Physician, pp. 22-23].

Koven sees the Hippocratic commitment that lies beneath Jackson’s stern glance and, with the benefit of hindsight, links it to her friendship with Emma. “As mutually affectionate as our friendship was,” she concludes, “her health and comfort were always its purpose.”  Indeed.  For my father and any number of caring generalists, friendship was prerequisite to clinical knowing and foundational to clinical caring.  It was not extramural, not reserved for special patients, but a way of being with all patients.  And this friendship for his patients, orbiting around a sensibility of cura and a wide range of procedural activities, was not a heavy thing, leaden with solemnity.  It was musical.  It danced.

In the early 60s, he returns from a nursing home where he has just visited a convalescing patient.  I am his travelling companion during afternoon house calls, and I greet him on his return to the car.  He looks at me and with a sly grin remarks that he has just added “medicinal scotch” to the regimen of this elderly gentlemen, who sorely missed his liquor and was certain a little imbibing would move his rehab right along.  It was a warmly caring gesture worthy of Osler, that lover of humanity, student of the classics, and inveterate practical joker.  And a generation before Osler, the elder Jackson would have smiled.  Immediately after cautioning the young physician to “abstain from all levity,” he added: “He should, indeed, be cheerful, and, under proper circumstances, he may indulge in vivacity and in humor, if he has any.  But all this should be done with reference to the actual state of feeling of the patient and of his friends.”  Just so.

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

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Posted in Doctor-Patient Communication, Nineteenth-Century Medicine, Primary Care, Psychoanalysis

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Hail the House Call

Posted on December 22, 2011 | 1 comment

It is now 35 years since George Engel, an internist at the University of Rochester Medical School, formulated his biopsychosocial model of medicine (Science, 196:129, 1977).  Concerned with the reductionism and fragmentation inherent in scientifically guided specialist care, Engel called on his colleagues to locate biomedical interventions on a larger biopsychosocial canvas.  Drawing on the version of general systems theory popular in the 1970s, Engel argued that clinical assessment properly embraced a hierarchy of discrete biological, personal, and transpersonal levels, any combination of which might enter into the meaning of illness, whether acute or chronic.  Even in ostensibly biomedical conditions such as diabetes, cancer, and heart disease, Engel held, it was not simply deranged cells and dysfunctional organs that accounted for pathophysiology.  His model made a strong knowledge-related (i.e., epistemic) claim:  that hierarchically ordered layers of intra- and interpersonal stressors were causal factors in disease as it expressed itself  in this or that person.  It followed for Engel that personality structure; adaptive resources and “ego strength”; psychodynamic conflicts; two-person conflicts; family-related conflicts; conflicts in the workplace – these factors, in various combinations, entered into the scientific understanding of disease.

In devising the biopsychosocial model, Engels was influenced by the psychoanalysis of his day.  It is for this reason that biopsychosocial medicine is typically, and, I believe, erroneously, identified with the kind of “psychosomatic medicine” that analysis gave birth to in the quarter century following World War II (Psychosom. Med., 63:335, 2001). More generally still, it is conflated with psychosocial skills, especially as they enter into doctor-patient communication.  Because Engel’s model is not an algorithm for determining which levels of the patient “system” are implicated in this or that instance of illness, it has been criticized over the years for failing to guide clinical action, including the ordering of therapeutic goals (Comp. Psychiatry, 31:185, 1990).  Self-evidently, the model has proven very difficult to teach (Acad. Psychiatry, 28:88, 2004) and equally difficult to integrate into the conventional medical school curriculum (Psychosom. Med., 63:335, 2001).

These findings are hardly surprising.  It is difficult to teach doctors-in-training how to apply a biopsychosocial model when real-world doctoring rarely places them in regular contact with the transmedical “systems” invoked by the model.  This was not always the case.  Consider the house call, that site of biopsychosocial consciousness-raising throughout the 19th  and well into the 20th century.  It was in the home of the patient, after all, that the physician could actually experience the psychosocial “systems” that entered into the patient’s illness:  the patient’s personality, but also the patient as spouse, parent, sibling, son or daughter, all apprehended within the dynamics of a living family system.  And of course there was the home environment itself, a psychosocial container of medically salient information.  Wise clinicians of the early 20th century did not need the assistance of a biopsychosocial model to understand the role of the house call in cultivating the physician’s biopsychosocial sensibility.  Here is Harvard’s Francis Peabody in “The Care of the Patient” (1927):

“When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life.  He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline.  What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears” [JAMA, 88:877, 1927].

Three decades after Peabody’s lecture, I began riding shotgun when my father, William Stepansky, made his daily round of house calls in rural southeastern Pennsylvania.  Sometimes, especially with the older patients he visited regularly, I came into the house with him, where I was warmly welcomed, often with a glass of milk and home baked treats, as the doctor’s son and travelling companion.  From my time on the road, I learned how my father’s clinical gaze met and absorbed the anxious gazes of family members.  It became clear, over time, that his medical obligation was not only to the patient, but to the patient-as-member-of-a-family and to the family-as-medically-relevant-part-of-the-patient.  In a lecture to the junior class of his alma mater, Jefferson Medical college, in 1965, he made this very point in differentiating the scope of the family physician’s clinical gaze from that of the pediatrician and internist.  Unlike the latter, he observed, the family physician’s interventions occurred “within the special domain of the family,” and his treatment of the patient had to be continuously attentive to the “needs of family as an entity.”  It was for this reason, he added, that “family medicine must teach more than the arithmetic sum of the contents of specialties” (my father’s emphasis).  Here, in the mid-60s, my father posited a medical-interventional substratum to what would emerge a decade or so later, in the realm of psychotherapy, as family systems theory and “structural family therapy.” And then, 12 years before Engels came on the scene, he offered his conception of  “a solid intellectual approach to medicine”:

“To me this means relating the effects of the body systems one upon the other in health and disease through knowledge of the basic sciences – i.e., biochemistry and physiology – through some understanding of the social and environmental stresses on the patient, and finally through insight into the psychological influences of personality structure as it affects health and disease.”

Of course, physicians long before my father and long before Francis Peabody understood that medical treatment of the individual might entail interventions with transpersonal “systems.”  Witness the Victorian physicians of well-off American families of the 1870s and 1880s described by the historian Nancy Theriot (Amer. Studies, 26:69, 1990; Signs, 19:1, 1993; J. Hist. Behav. Sci., 37:349, 2001).  Making home visits to overwrought postpartum women in the throes of what was then termed “puerperal insanity” – we have only the far less evocative “postpartum depression” – these knowing family physicians dissuaded their patients from the drastic surgical interventions available to them (such as ovariotomy).  They recommended instead a change in the family “system” to accommodate the parturient’s urgent need for “time out” from the burdens of household management, childrearing, and husband-pleasing, to which care of a newborn was now superadded.  Is it any wonder that the matrons of these well-run Victorian households became “insane,” and that their insanity took the form, inter alia, of vile language, refusal to dress appropriately, refusal to resume housework, indifference to their children’s daily needs, and even – horribile dictu –  refusal to hold their newborns?  And yet these same women, flouting Victorian conventions with postpartum abandon, often returned to bourgeois sanity after the family physician, with the weight of medical authority, simply prescribed a daily period of solitude when the new mother, perhaps sitting alone in the family garden, was not to be disturbed – not by anyone.  Biopsychosocial intervention aimed at the family “system” was never so elegantly simple.

Interventions of this sort are hardly unknown among contemporary providers, some small percentage of whom continue to visit their patients in their homes.   Further, as one of my correspondents has reminded me, all family medicine residencies employ full-time behaviorists, usually psychologists, who help trainees develop a biopsychosocial model of care. But outside of these programs the biopsychosocial model remains where it has always been – on the fringe of a medical world of fragmented and technology-driven specialist care.  In this sense, it is no different than the house call, which lives on among some 4,000 physicians in the U.S. and through a very few university hospital-based “house call programs.”  But let there be no mistake:  these physicians and these programs are at the far margins of primary care.  When the American Academy of Family Physicians polled its active members in 2008 on the settings in which they saw patients, respondents from urban and rural regions alike reported an average of 0.6 house calls a week.  (My father, in the 50s and 60s, averaged 3-4 a day.)  If this figure represents the rate at which house call-making doctors make house calls, then it is fair to say that the house call has long since ceased to be an intrinsic – and intrinsically humanizing – dimension of primary care.  This is why I pay tribute to the Great American House Call.  It is a relic of an era when biopsychosocial medicine suffused general practice without the aid of a biopsychosocial model.

Addendum

Unbeknown to many, the healthcare reform bill passed by Congress in March, 2010 contains an “Independence at Home Act” that provides physicians with financial incentives to treat their oldest and sickest patients in their homes.  To wit, house call-making doctors will share in cost saving if they can “prove” their in-home care reduced hospital use and left their patients satisfied.   So much for the scientific bona fides of biopsychosocial medicine.  It’s about the money, stupid.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.  Photo copyright © 2011  by Michael D. Stepansky.  All rights reserved.

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Posted in Family Doctors, Then & Now, General Practice, Primary Care, Psychoanalysis

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