Archive for April, 2013

How to Talk to a Sick Friend

Sunday, April 14, 2013 // Uncategorized

Here’s some practical advice on how to talk to a sick friend from Leety Pogrebin’s essay in The Wall Street Journal.

  • ESSAY
  • April 12, 2013, 7:12 p.m. ET

For a Sick Friend: First, Do No Harm

Conversing with the ill can be awkward, but keeping a few simple commandments makes a huge difference.

 

By LETTY COTTIN POGREBIN

‘A closed mouth gathers no feet.” It’s a charming axiom, but silence isn’t always an option when we’re dealing with a friend who’s sick or in despair. The natural human reaction is to feel awkward and upset in the face of illness, but unless we control those feelings and come up with an appropriate response, there’s a good chance that we’ll blurt out some cringe-worthy cliché, craven remark or blunt question that, in retrospect, we’ll regret.

Take this real-life exchange. If ever the tone deaf needed a poster child, Fred is their man.

“How’d it go?” he asked his friend, Pete, who’d just had cancer surgery.

“Great!” said Pete. “They got it all.”

“Really?” said Fred. “How do they know?”

[image] Ellen WeinsteinA few simple commandments makes a huge difference when conversing with the ill.

 

Later, when Pete told him how demoralizing his remark had been, Fred’s excuse was, “I was nervous. I just said what popped into my head.”

We’re all nervous around illness and mortality, but whatever pops into our heads should not necessarily plop out of our mouths. Yet, in my own experience as a breast-cancer patient, and for many of the people I have interviewed, friends do make hurtful remarks. Marion Fontana, who was diagnosed with breast cancer eight years after her husband, a New York City firefighter, died in the collapse of the World Trade Center, was told that she must have really bad karma to attract so much bad luck. In another case, upon hearing a man’s leukemia diagnosis, his friend shrieked, “Wow! A girl in my office just died of that!”

You can’t make this stuff up.

If we’re not unwittingly insulting our sick friends, we’re spouting clichés like “Everything happens for a reason.” Though our intent is to comfort the patient, we also say such things to comfort ourselves and tamp down our own feelings of vulnerability. From now on, rather than sound like a Hallmark card, you might want to heed the following 10 Commandments for Conversing With a Sick Friend.

 

1. Rejoice at their good news. Don’t minimize their bad news. A guy tells you that the doctors got it all, say “Hallelujah!” A man with advanced bladder cancer says that he’s taking his kids to Disneyland next summer, don’t bite your lip and mutter, “We’ll see.” Tell him it’s a great idea. (What harm can it do?) Which doesn’t mean that you should slap a happy face on a friend’s grim diagnosis by saying something like, “Don’t worry! Nowadays breast cancer is like having a cold!”

The best response in any encounter with a sick friend is to say, “Tell me what I can do to make things easier for you—I really want to help.”

 

2. Treat your sick friends as you always did—but never forget their changed circumstance. However contradictory that may sound, I promise you can learn to live within the paradox if you keep your friend’s illness and its constraints in mind but don’t treat them as if their illness is who they are. Speak to them as you always did (tease them, kid around with them, get mad at them) but indulge their occasional blue moods or hissy-fits. Most important, start conversations about other things (sports, politics, food, movies) as soon as possible and you’ll help speed their journey from the morass of illness to the miracle of the ordinary.

 

3. Avoid self-referential comments. A friend with a hacking cough doesn’t need to hear, “You think that’s bad? I had double pneumonia.” Don’t tell someone with brain cancer that you know how painful it must be because you get migraines. Don’t complain about your colicky baby to the mother of a child with spina bifida. I’m not saying sick people have lost their capacity to empathize with others, just that solipsism is unhelpful and rude. The truest thing you can say to a sick or suffering friend is, “I can only try to imagine what you’re going through.”

 

4. Don’t assume, verify. Several friends of Michele, a Canadian writer, reacted to her cancer diagnosis with, “Well, at least you caught it early, so you’ll be all right!” In fact, she did not catch it early, and never said or hinted otherwise. So when someone said, “You caught it early,” she thought, “No, I didn’t, therefore I’m going to die.” Repeat after me: “Assume nothing.”

 

5. Get the facts straight before you open your mouth.Did your friend have a heart or liver transplant? Chemo or radiation? Don’t just ask, “How are you?” Ask questions specific to your friend’s health. “How’s your rotator cuff these days?” “Did the blood test show Lyme disease?” “Are your new meds working?” If you need help remembering who has shingles and who has lupus, or the date of a friend’s operation, enter a health note under the person’s name in your contacts list or stick a Post-it by the phone and update the information as needed.

 

6. Help your sick friend feel useful. Zero in on one of their skills and lead to it. Assuming they’re up to the task, ask a cybersmart patient to set up a Web page for you; ask a bridge or chess maven to give you pointers on the game; ask a retired teacher to guide your teenager through the college application process. In most cases, your request won’t be seen as an imposition but a vote of confidence in your friend’s talent and worth.

 

7. Don’t infantilize the patient. Never speak to a grown-up the way you’d talk to a child. Objectionable sentences include, “How are we today, dearie?” “That’s a good boy.” “I bet you could swallow this teeny-tiny pill if you really tried.” And the most wince-worthy, “Are we ready to go wee-wee?” Protect your friend’s dignity at all costs.

 

8. Think twice before giving advice.Don’t forward medical alerts, newspaper clippings or your Aunt Sadie’s cure for gout. Your idea of a health bulletin that’s useful or revelatory may mislead, upset, confuse or agitate your friend. Sick people have doctors to tell them what to do. Your job is simply to be their friend.

 

9. Let patients who are terminally ill set the conversational agenda.If they’re unaware that they’re dying, don’t be the one to tell them. If they know they’re at the end of life and want to talk about it, don’t contradict or interrupt them; let them vent or weep or curse the Fates. Hand them a tissue and cry with them. If they want to confide their last wish, or trust you with a long-kept secret, thank them for the honor and listen hard. Someday you’ll want to remember every word they say.

 

10. Don’t pressure them to practice ‘positive thinking.’ The implication is that they caused their illness in the first place by negative thinking—by feeling discouraged, depressed or not having the “right attitude.” Positive thinking can’t cure Huntington’s disease, ALS or inoperable brain cancer. Telling a terminal patient to keep up the fight isn’t just futile, it’s cruel. Insisting that they see the glass as half full may deny them the truth of what they know and the chance to tie up life’s loose ends while there’s still time. As one hospice patient put it, “All I want from my friends right now is the freedom to sulk and say goodbye.”

Though most of us feel dis-eased around disease, colloquial English proffers a sparse vocabulary for the expression of embarrassment, fear, anxiety, grief or sorrow. These 10 commandments should help you relate to your sick friends with greater empathy, warmth and grace.

—Ms. Pogrebin is the author of 10 books and a founding editor of Ms. magazine. Her latest book is “How to Be a Friend to a Friend Who’s Sick,” from which this essay is adapted.A version of this article appeared April 13, 2013, on page C3 in the U.S. edition of The Wall Street Journal, with the headline: For a Sick Friend, First, Do No Harm.

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A Former Practitioners Reflections On Health Care Reform

Tuesday, April 9, 2013 // Uncategorized

 

Interesting.
 
  • The Wall Street Journal
  • OPINION
  • April 7, 2013, 6:12 p.m. ET

Reflections of a Medical Ex-Practitioner

The glow of the personal relationship with patients is being extinguished.

 

By ED MARSH

A fundamental principle in medicine is that if you get the diagnosis wrong, you’ll probably apply the wrong therapy. A corollary is that if the therapy isn’t working, increasing the dose may make things worse. That’s where we are with ObamaCare.

There are shortcomings aplenty in the health-care field, and changes and improvements are required. But never have I seen so many good intentions leading irreversibly to hell.

Personal experience is by its nature parochial. Yet when it invalidates much of what passes for wisdom, there may be value in sharing it. Here are some facts that may illuminate:

When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment.

Related Video

Editorial board member Joe Rago on how ObamaCare will change the practice of medicine. Photos: Getty Images

 

After eight years of postgraduate study, I opened a solo pediatrics practice in a community of 10,000 souls an hour from Boston. A number of lean years passed before I could build a robust practice. Yet the experience was exactly what I—and I think many of my colleagues—sought: a personal, direct and unimpeded relationship between me and those who chose to become my patients.

A major cause of financial stringency was that there was almost no insurance that covered pediatric care in the office setting. Many pediatricians felt denigrated because the care that they were providing was not regarded as sufficiently consequential to be covered by third parties, as was that of their brethren in internal medicine. Surveys always showed pediatricians to be the poorest-paid of all the specialties.

By current standards, the lack of third-party coverage would be impermissible. But treating patients without insurance meant that I had to give my acute attention to the price of every medical intervention. The costs could have a direct and painful impact on a family’s budget. So I had to know the prices for most of the medications I prescribed and of most of the tests I might order. I learned to play for time by waiting, when it was safe to, before ordering an X-ray or a test—and to substitute less-expensive medications for more costly ones wherever possible.

Chad Crowe

I developed pastimes that were diverting but would permit me to be available to patients 24-7, requiring coverage by a substitute only for a two-week vacation annually. Few physicians nowadays would undertake such an onerous schedule, and yet many of the inconveniences are offset by benefits. If you are caring for your own patients, you know them and their ailments and can manage a great deal over the telephone (or by email these days), with minimal cost to them and minimal intrusion into your own life. By contrast, covering for another physician almost invariably means inefficiency—additional time to learn the patients’ relevant history, and often either a direct patient encounter or an outpatient facility visit, all of which greatly add to the cost.

Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so “more” became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for. If I was reluctant, perhaps weighing the cost to them, patients speculated there must be some hidden reason. Perhaps I was, in some obscure way, feathering my own nest. Misgivings arose.

This mistrust heightened—and became rational—when “prepaid” group practices became more prevalent. Physician compensation is tied to “efficiencies,” which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid premiums.

Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One underexamined aspect of defensive medicine is those excessive referrals to diminish responsibility.

My income rose substantially and pediatricians in general thought that they had arrived in the Promised Land. The submission of some paper to some anonymous third party would not put a dent in any patient’s grocery bills. And the consequences of profligacy disappeared, while rational income-building strategies—aka gaming the system—appeared. For instance, since telephone calls weren’t reimbursable, additional office visits, which were, supervened.

“Preventive care” became the touchstone. The concept is obvious, but the evidence for its value, and especially its potential for savings, is rarely conclusive.

Insurance relationships drove practice relationships. Patients were more likely to come to me because their insurance told them to, and more likely to leave, despite our congeniality, because their insurance required it. Thus our dealings were less personally rewarding, for my patients and for me.

When it became increasingly difficult to work according to my principles, I closed my practice, first joining a “prepaid” group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one’s patients is being extinguished.

The medical economist Rashi Fein observed in 1986 that there are only three ways to limit the extravagant demand for medical care: “Inconvenience,” the practice used in the military, where one must wait interminably for care. “Rules,” the third-party approach by which layers of rules and thousands of regulations are devised, most recently in a fool’s quest to contain costs under ObamaCare. And “Price.” This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient. Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding.

There is no shortage of evidence. ObamaCare will, deliberately and by design, destroy what—while imperfect—has served very well. We have gotten to this point after years of good intentions making bad problems worse. To double down on the very therapy that has brought the system to its present sorry pass is a toe-ticket to the morgue.

Dr. Marsh now raises Christmas trees in Ipswich, Mass.

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