Lessons from Dr. Gawande, Enabling Well-Being

I am finally reading a book I got for Christmas, Being Mortal by Atul Gawande, a surgeon and a storyteller. The 10 hours of flights to and from Boston for an interview in Vermont are what finally got me to crack this book. It is a remarkable read, especially poignant in these last few weeks of medical school as I prepare to navigate this world as a doctor. It's a little funny to think that I require 18 more days, 432 more hours of life, before I can officially identify as a doctor. I feel like I'm already there. There is nothing like reading about the significance of a few comfortable and happy hours at the end of life to make the 432 hours between me and graduation day seem an insignificant barrier from doctorhood.

Early morning departure from Billings, headed east

In his book, Gawande writes again and again about the "vital questions" a doctor can ask a patient to understand things: "What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?" He writes that as doctors, "We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being."

Gawande is writing from the perspective of a surgeon and the cases he presents are from his personal life and from his professional life of advising terminally ill patients about their choices for surgery. Those of you reading this are most likely like me, we are not going to be surgeons, we are not going to be radiation oncologists or geriatric doctors (at least not officially, until Medicare recognizes our medicine...), but we are going to be enabling well-being for our patients, every day through primary care.

A poignant paragraph in "Being Mortal"

In our ideal naturopathic world, all of our patients are willing and able to attend to their basic determinants. They are willing and able to eat healthy foods, sleep through the night, reduce their work stress, leave their toxic relationships, eliminate endocrine-disrupting cleaners and other environmental exposures from their lives, and make time for rest and relaxation. But reality is that most everyone cannot improve all of these things so readily as we would like. We know our natural therapies will work better if the patient will just take care of these things! And we know that we can effectively use very low force interventions if everything else in life is made healthy. But, the majority of patients are just not going to show up to our offices ready, willing, and able to make all the changes necessary to their lives at that very moment.

While observing during an interview day for a residency position, I listened to a 40-something female tell about how in the past 4 months she has found a care facility for her disabled son, has got her troubled daughter into counseling, has changed her diet, has found a job, and has started seeing a counselor herself, but that she still lives at home with an abusive partner. This woman has better mental clarity, her stress is markedly reduced, and she feels good about having purpose in her work, but she knows one major obstacle to cure still remains and it will, for a while still.

Snowy April day in New England en route to interview

As NDs counseling patients and their families at the end of life, we can certainly ask Dr. Gawande's questions: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?

But, we can also use these questions in caring for our patients who are not yet at the end of life. We can make sure they understand their picture of health and the possible outcome with treatment, or without it. We can ask them about their fears or their hopes in consulting us for our specialty, which is natural medicine. We can discuss the trade-offs they are willing to make for our natural therapies to work well -- are they willing to turn off the TV at night? Change their dinner menu? Make time for exercise in their already busy day? We can ask if the plan we've created serves their understanding of their health picture and their goals. These questions serve to create well-being for the patient, and therefore, they are part of everyday doctoring. It is this style of what I believe is called "Interpretive" doctoring that I hope to remember and use with my patients. This means advising patients of their options and giving your insight into which option you think best fits their needs. The place to start is by asking Dr. Gawande's questions, or at least keeping them very close in mind.