Archive for tag: philosophy

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.

How an ND differs from a DO and Other Integrative Thoughts

Whew. I'm finished with the boards! At least for now. I didn't realize how much time and energy I was giving to studying and preparing for that big exam until the day after. Even the evening after the exam I was still energized and excited. The day after however, I was totally burned out and my brain felt like mush. The emotion of the experience was wholly exhausting.

Cheers to getting through part 1 NPLEX!

On an easier note, how did I celebrate? First, my girlfriends and I toasted each other's success of making it through while we complained about the hard questions. The rest of the week was a difficult mix of catching up on work while also trying to catch up on sleep. And when the weekend came, I paid attention to my heart-mind by attending the Integrate Chicago conference and going out to enjoy Chicago's restaurant week.

My view in a lecture on the philosophy of care at Integrate Chicago.

Integrate Chicago is a conference put on by students of medicine from different disciplines. The organizing board included students from UIC and Loyola med schools, as well as an ND student from NUHS, and many DO students from The Chicago College of Osteopathic Medicine (CCOM). One of the most enlightening talks I attended was about the clinical application of Osteopathic Manipulative Medicine (OMM). I learned that most doctors of osteopathy (DOs) do not actually practice their manipulative medicine, which I always thought was what set them apart from MDs. The presenters were passionate about bringing OMM back into regular practice. As part of their presentation, they demonstrated a few things that can be used on hospital inpatients, such as those who have recently undergone open-heart surgery, as well as techniques for outpatient care such as an acute sinus infection. I took notes!

Not only did I learn how a more traditional osteopath uses their medicine, but I also learned that DOs describe themselves as "exactly like MDs," except that they get more training in diagnosing and treating musculoskeletal conditions. The presenters stressed that as DOs, they always use the appropriate drugs as indicated for the sinus infection or other disease, but will combine these conventional treatments with their manual therapies to help speed healing time.

This presentation was particularly helpful for me, because as an ND student I often field the question, "So, are you like a DO?" Now I can be confident in saying that we are much different than DOs and why, at least based on what I learned from the doc and students from CCOM.

The presenters opened their talk by briefly mentioning the Tenets of Osteopathic Medicine, which include a belief that "the body is capable of self-regulation, self-healing, and health maintenance." Despite this, there was a resounding affirmation in their talk that they are no different from MDs. Their treatments consist of the appropriate medications first, with their OMM used as an adjunct to this care. There was no further mention, beyond their introduction, of the body's ability to heal itself, nor their application of such a tenet in treatment strategy.

Herein lies a major difference in our medicines. An ND forms her treatment plan around supporting the Vis and addressing the basic determinants of health, which may be truly very basic (air and epinephrine, as in anaphylaxis) yet important for all cases. Also, an ND IS different from an MD, and this distinction is both important to us and necessary for treating within our philosophy of the body-mind-spirit as a whole.

We need all of these styles of medicine, each one has its strengths and integrating them all seems like an effective way to make sure each patient gets the best, most individualized care. I came away from this conference confident in what I am studying. I could keep up with the anatomy and biomechanics talk of the DOs, I could nod in understanding at the anti-inflammatory diet, I knew the biochemical pathways implicated in replacing curcumin for NSAIDs, and I understood the uses of and references to pharmaceuticals. I also better understand what challenges I will come against, even in the integrated medical environment. Thankfully, the skepticism often comes from a limitation of knowledge, and if the audience is already prepared to throw off some of their dogma, then with time, there's nothing some extra education can't fix.