Reflections in a Head Mirror

We have to believe that even the briefest of human connections can heal. Otherwise, life is unbearable.
-Agate Nesaule    


The patient arrived at the rural clinic near Guazapa, El Salvador, in his mother’s arms with a mouth gag tied in place and his hands wrapped in bandages. As his mother put him gently onto the examination table, his muscles twitched hard, tearing the paper bed cover and forcing the gag out of his mouth. “Be calm,” his mother whispered to him in Spanish. He remained contorted but visibly quieted as our pediatrician, Dr. Mike, held him.    

Oh, oh, I thought. We are miles from a hospital and a three-hour plane flight from anything familiar. We have a very sick kid on our hands. How will we handle this?    

While I watched from my exam station across the room, the mother shared her story. What I initially assumed was an emergency turned out to be just another day in the life of this family. The patient had been born in the final years of the Salvadoran civil war in a poor, rural community with no functioning infrastructure. Severe oxygen deprivation during his birth caused significant brain damage. It is safe to assume that he received almost no medical care as an infant; only the love and care of his family had allowed him to survive at all. Now, 21 years later, his mother was bringing him to a medical mission clinic staffed by volunteer North American physicians, nurses, pharmacists and healers.    

During his childhood, his family had found that cloth gags and hand wraps could keep him from inadvertently biting and scratching himself. The mother calmly related the joys and challenges of his life. Dr. Mike had helped care for patients with this same diagnosis back home and I am certain that he was mentally cataloguing all of the potential treatments and support options that would be offered to this family back in the States. What did we have to offer here that would make a difference?    

Julia interpreted. Nurses Kathi and Jean helped. Nurse Practitioner Gail brought her experience. Dr. Mike supported the patient while performing a gentle, thorough examination. He peered in the ears and throat, listened to his heart and felt his abdomen. He pressed the muscles of the arms and legs. He warmly complimented the mother on the exceptional care she had provided for her son.    

The mother smiled. Despite the challenges, this child was the biggest joy in her life. But, she wanted to know, can you help him? His biggest problem is sleep. Can you help him to sleep?    

We had arrived in El Salvador with only the most basic medications; we had things like vitamins, calcium, iron, anti-parasite pills, mild pain medications, and basic treatment for coughs and colds. Well, Dr. Mike said, we could try giving him one of the cold medications at bedtime to make him a bit drowsy. That might help.    

Thank you, the mother said. Suddenly, the patient’s arm flew up around Dr. Mike’s neck, surprising everyone. What was wrong?    

He is giving you a hug, his mother told Julia. He wants to thank all of you, too. Dr. Mike held the young man in his arms for several seconds before passing him to my wife, Kathi.    

Most of the patients we saw during our days in El Salvador came to us with routine concerns: coughs, headaches, and sore throats. Watching this family, though, reminded me powerfully that, no matter how severe the problem, there is power in touch and value in just being there. As the examination wrapped up, the mother repositioned the mouth gag. After hugs, good wishes and thanks to everyone in the room, the mother and her son were soon on their way back home.

 A life spent making mistakes is not only more honorable but more useful than a life spent in doing nothing.
-GB Shaw


After over twenty years working as a head and neck cancer surgeon, much of what I do has become routine. Even the operations that once kept me awake at night or the procedures that required a trip to the library are just part of a day’s work.    

I am certain that most vocations have the same experience. The commercial airliner pilot plans her weekend while she is constantly scanning the displays and switches arrayed around her. The construction engineer carries on unrelated conversations while aligning girders that will support giant buildings. The bus driver listens to the radio as he guides his vehicle for the hundredth time through the switchbacks and the mountain passes. Things that used to command every bit of attention no longer require that degree of intensity.    

Every once in a while, though, something comes along that brings everything back into a sharp-edged focus:    

I had  performed dozens of procedures on patients with voice box cancer over the years. My experience told me that this operation would be difficult because of this particular patient’s previous radiation, but otherwise should be straightforward.    

What I found, though, was anything but routine. Nests of cancer cells were scattered throughout the tissues and a new separate cancer was identified. The original plan was quickly abandoned, and, while the patient lay on the table, I went to the family center to have a detailed discussion with her husband and children. I returned to the operating room and continued to work. Over the course of the day, there was another change of plans, another trip to the family center, and phone consultations with colleagues. I ended up performing a procedure about which I had only read. I re-checked everything. Several hours later than originally anticipated, we were finally finished.    

Sitting in the recovery room waiting for her to wake up, I realized that I was in need of some recovery as well. I had spent much of the day outside of my “comfort zone” in a place requiring my full attention, all of the insight I could muster, a bit of creativity, and reliance on others. Now, I could return to the routine of postoperative care and paperwork. Although drained, I was energized and alert. I felt alive.    

Happily, she did just fine, thanks to the good advice I received from my colleagues. I slept very soundly that evening.  

The following is feedback received for this blog: Wish I could work with you. I know I'd learn so much. - rlbates http://rlbatesmd.blogspot.com/ I work in Law Enforcement and I read your post, nodding yep....yep...yep... Mostly, after 21 years, I am comfortable where I am. Due to a tragedy at another station in our troop, I volunteered to work the desk for them on a Sunday, midnight shift. I was brought way out of my comfort zone, not knowing the area, not knowing the troopers I would be working with and not used to that shift. At the end of a quiet night, I was glad I had done it. It not only helped the members of that station, but it also helped me to realize, and appreciate, how comfortable I am at the job I do at my home station. - Holly Wood

Insanity: Doing the same thing over and over and expecting different results.
- Albert Einstein
     

As medical students rotating through the wards, we spent a significant portion of each day ordering laboratory tests and then chasing down the results. We wanted to investigate our patients’ illnesses and, just as importantly, we wanted to be prepared for any question with which our professors might surprise us during Attending Rounds.      

One day, as I was hurriedly checking boxes on a laboratory order form, my resident challenged me to justify one of the blood tests I was requesting. “You can order that test after you answer these two simple questions ...” His eyes narrowed. “First of all, what exactly are you going to do with the results? And, second, who is going to pay for it?”

He became increasingly impatient while quizzing me about all of the potential outcomes. Clearly, I would need to spend my afternoon reading in the library. I also admitted that I had no idea how much the test would cost or whether the patient’s insurance would provide coverage. It turned out that this was, indeed, a very expensive blood test that was only performed in an out-of-state laboratory. The results would not be available for several days. Checking that box would have cost the patient several hundred dollars; by the time the result was available, it would have been all but meaningless. “Aha!” my resident chided me triumphantly, “Do you still want that test? You need to make an effort to understand the impact and cost of everything you order.” I had learned a lesson and sheepishly tore up the slip.    

My memorable medical school incident came back to me last week while reading an editorial in the New England Journal of Medicine. Dr. Howard Brody reminds us that high-cost care is not necessarily better care and that a study of regional variation recently showed that “nearly one third of health care costs could be saved without depriving any patient of beneficial care.” Cost-effective care is possible.      

Since physicians order tests, Brody suggests physicians need to be at the forefront to curb healthcare expenses. As a start, he proposes that each medical specialty create a “Top Five" list of its most commonly ordered, expensive tests and treatments for which there is little evidence of any meaningful benefit. The specialty would then be charged with educating its own members.  In “In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” In the best of worlds, this approach represents utilization oversight driven by providers rather than insurers or government.    

Resource consumption — be it money, time, supplies, or energy — is a real-life dilemma in every medical center; in medical care, there are just so many places where simple decisions carry a fiscal wallop. Three quick examples: Technology is routinely touted as providing improved safety and efficiency, but, sometimes, it adds cost without any proven benefit whatsoever. Adding one more test or ordering one more consultation at the end of a clinic visit “just to be certain” quickly adds up when repeated hundreds of times each month. And, of course, any provider who can spell “PET Scan” can order one.    

We can all play a role in cutting costs. I tend to avoid technology unless I can show that it is truly going to benefit a particular patient. For example, I recently saw a patient for a second opinion. His community physician had recommended an extremely expensive test. After reviewing his records, I told him that there was no reason to have the test performed. He was understandably skeptical. “Why did the other doctor think I needed it?” He frowned. “She said it would be very useful. Shouldn’t you order it anyway?” We had a long conversation. Deciding not to “do something” can be a hard sell.    

Even now as we engage in a national discussion about health care, it seems that the questions still come down to these two: What exactly are you going to do with the results? Who is going to pay for it? On both an individual level and as a society where we all depend on each other, these two questions are just as relevant — and difficult — today as they were when my resident made me stop and think about a box that I had checked on a laboratory slip so many years ago.    
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Reference: Brody H, “Medicine’s Ethical Responsibility for Health Care Reform – The Top Five List,” N Engl J Med 2010 (Jan 28); 362:283-285
(NEJM.org 10.1056/NEJMp0911423).