Tuesday, April 23, 2013

Ways we think about medical care

kw: book reviews, nonfiction, medicine

Considering the number of times I have had to be my own doctor, one might expect me to be quite skeptical and resistant to doctors' advice. So when I saw Your Medical Mind: How to Decide What is Right for You by Jerome Groopman and Pamela Hartzband (both MD's), I hoped two things. Firstly, that they would refrain from telling me what I think, and secondly, that I would find how rare or common my experience and medical thinking style is. I was pleasantly gratified on both counts.

In the second chapter, both Jerry and Pam (who are husband and wife, but they play it down) present their own histories. In their own ways, both were strong "believers" in medicine who became more skeptical as time passed. They have learned to think about a suggested treatment: sometimes they will go along, and at other times ignore the recommendation or modify it. It quite much parallels my own path. Because of a few instances, I am very, very glad to benefit from 21st Century medicine. Yet I have learned just how fallible doctors are (about as fallible as I am, and that has grown on me also!).

Some people by nature and perhaps upbringing are very much believers in medicine and not only take all their doctor's recommendations, they may be quite proactive and push for more care. Others are doubters and push back if they push at all, but more frequently ignore most medical advice and only partake of medical care in the most dire circumstances. I don't know if the split is 50-50 or skewed. But I think of my grandmother. She had her first child in a hospital, in 1918. She was not at all pleased and vowed not to enter a hospital again. She had her second and third children (my Mom was #2) at home on the kitchen table, assisted by her husband. At age 81, she hosted me for a couple of months when I moved to her town and was apartment hunting. She was strong and witty. The next year she had a stroke and died a day later without regaining consciousness. My mother said, "It is a good thing she didn't wake up in the hospital. She would have died anyway, of fear or rage, I am not sure which."

The book's chapters center on stories, of a patient wrestling with the decision whether to take a statin for moderately high cholesterol (a twin of my wife's dilemma); of Jerry regretting allowing a back operation and Pam deciding to skip an MRI for a sprained ankle because it was prescribed earlier than usual; of a man brought back from death's door by the transplant of a nearly discarded liver; of treatments that didn't work, and those that did.

One amazing chapter shows how people's thinking evolves once they fall ill. In a typical case, a healthy person in middle or late-middle age might write a Living Will or Advance Directive. I have helped my father do so, not in late-middle age, but at the age of 89. One frequently hears, "Oh, I don't want any heroics. I wouldn't want to live with (horrible disease of your choice) anyway." Then when (horrible disease) arises, many people change their mind. They find that, if you live with a condition for a while, you adjust, and can still find much to enjoy. Only in cases of chronic agony do we find people demanding a "Kevorkian remedy". The authors state several times that a person in good health simply cannot imagine what he or she might think once major illness occurs. I liken it to the way we tell our kids, "Just wait until you have kids." We know they can't imagine it; they can only live it.

I found it no surprise that the authors recommend a balanced attitude: take everything with a grain of salt, but be wise and don't reject your doctor's advice out of hand (what did you see the doctor for, otherwise?). My own attitude is that of a contract foreman. My doctor is hired help. He (my current doc is male) has knowledge I don't have, and knows a gaggle of experts who have more specialized knowledge, and can do things he and I cannot do. I seek their advice, but make them talk me into any treatment they think I need. When you need a doctor, you really need one!

I am sure glad for the surgeon I was directed to in 2000, for my cancer surgery. He brought me back from death's door. He was a "contractor" to whom I trusted my life, and whom I empowered to make decisions when I could not (because I was anesthetized). He faithfully discharged his task (it took him 5 hours). Surgery is the prime example of our occasional need to empower another to temporarily control our life.

But in the more usual cases, I find myself in long-term negotiations with my doctor over blood pressure—to medicate or not—and my weight and level of exercise. In such things, I am more comfortable being able to have a say in how I am treated. Absent a life-or-death scenario, continued negotiation is a great kind of relationship to have with a doctor. You just need to have one who is comfortable with that. If your doctor is a "My way or the highway!" sort, take the hint and take the highway. Get a doctor who will negotiate, but also knows when to say, "Hold on, there, this one can kill you quick. Let's do something NOW!"

I sure love it when doctors are not only good physicians, but can also write so well. Kudos to this couple.

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