Archive March 29, 2020

Stitching a Safety Net

My guest op-ed from the Pittsburgh Jewish Chronicle from March 26th, 2020. Sometimes the heroes can’t do it alone, and sometimes even the people who feel most helpless are doing more than they can imagine. Like Neville Longbottom in the first Harry Potter novel, perhaps we will be the ones whose ten points for courage standing up to our friends and family will make the most difference.

Keep Breathing

There’s a stretch of the Pennsylvania Turnpike, between Lebanon and Reading, that I always seem to drive at night, when my family has fallen asleep in the car, and our road-trip playlist has returned to Ingrid Michaelson’s “Keep Breathing.”  You may know the song, with the spiraling crescendo at the end that goes, “All I can do is keep breathing,” a dozen or more times, as I hurtle through the darkness. If you don’t, click the link and let it play while you read the rest of this piece.

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Lifeworld Turned Upside Down

I haven’t written in ages. Even before the COVID-19 pandemic began there was always something getting in the way of the next installment of this blog. And all of a sudden, in the last 10 days, there is nothing.

I live in Allegheny County, one of the 7 Pennsylvania counties now under a stay-at-home order from Governor Wolf. I now have nothing but time. And what I am thinking about in this copious time that I have is how my views of healing must change in the face of calamity.

I have spent my career, 9 years of training and a dozen of practice, developing an art of medicine that is intensely personal, spiritual, and individualized. Touch, eye contact, and social intimacy with a person and their loved ones are the bedrock of how I care for people. At the moment, they are also toxic, the moral equivalent of a frontal lobotomy, or giving thalidomide to a pregnant woman. What kind of a doctor am I going to be now?

I have been quietly suspicious of the rise of telemedicine, fueling the demand for immediate gratification at the expense of building a lasting relationship with a trusted provider. Now my colleagues and I in primary care find ourselves dependent on it, racing to learn, and to teach our patients, how to use Zoom in a way that is secure, meaningful, and natural enough to actually have a real visit.

I have been slowly retraining my physical exam skills, with the help of Abraham Verghese and colleagues’ Stanford Medicine 25, learning the nuances of examining the tongue and honing my skills with an ophthalmoscope. Now, when doing direct ophthalmoscopy is tantamount to using coronavirus shaving cream, I will need to invent the skill of getting a patient with shoulder pain to perform a Hawkins and Neer test on themselves while I watch on my mobile phone.

I have been getting ever-more-proficient at observing body language in the exam room. Now I will be doing most of my visits looking at a disembodied head and shoulders that looks like it has been filtered through a funhouse mirror because no one in America knows how to make themselves look normal on a selfie camera.

So in this moment of Hamiltonian calamity, when the world has turned upside down, I am grateful to Adeline Goss, a senior neurology resident at UCSF, for her piece in last week’s JAMA. Goss is what we called a “non-trad” in my medical school years – someone who came to medical school after a “non-traditional” pre-medical career in the real world, in her case as a public radio reporter.

That career taught her rich lessons in how to listen to people’s stories, the kind of skills I value above all else in medicine. Yet as a doctor, Goss reached a point where she realized she was taking shortcuts on those skills, rushing people, directing their conversation instead of letting the conversation direct her, and assuming masks of interest instead of being interested.

Breaking out of those shortcuts has led her to develop new listening habits, which are already bearing fruit. I won’t spoil her story; you can click on the link above and let her tell it. But in this crisis, I realize I will need my own new habits, and fast. It would be all too easy to default into simple triage mode: sick enough to go to the hospital, not so sick but probably infected with COVID19 and needs to stay home and not speak to anyone, or chronically sick but needing elective procedures or visits with specialists that can’t happen in this climate so they’ll just have to wait.

I hope that, like Adeline Goss, I can find a different way, even under the incredible weight that I feel, to heal people. To learn to listen again – since I can’t easily rush them off to a specialist, draw lab tests, or inject their knees with steroids, really focusing on the clues in their story, the forgotten notes from past visits that help me form a pattern, the “non-medical” worries like a failing business or crushing loneliness that are the real reasons for the visit. I like to think that I am good at these things, but I know how I feel at least 30% of the time at the end of the visit – like I have done something just to feel like I did something.

The new setup gives me the chance to call people back as often as I want – my telehealth visits seem to be about 5-10 minutes shorter than before and as on time as I care to make them, with limited physical exam, no need to write orders before the person checks out or goes for labs, and no need to wait for the room to free up before we start or the patient to negotiate traffic. I can have more frequent, richer conversations with more people – and the visit with me can be a vital connection to another person instead of another chore in a long day.

There is only one story in the news today, and that is COVID19. It’s up to me, and people like me, to remember that the other stories, billions of them, that made up the Lifeworlds of all the people who have COVID19, who will yet get it, and who will never get it, have not ended. Those stories are still going on, and they just got a hell of a lot more complicated. I pray that, like God that hears prayer, I can spare both of my ears from the news to hear those stories.

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