Thursday, April 4, 2013

Basketball, The Presence of Suffering, and the Practice of Medicine

It's the first week of April, and we're on the verge of the penultimate games of the NCAA Basketball Tournaments.  Since only four teams remain, chances are good that your favorite team is out of the tournament.  As someone who has experienced that feeling 25 times over the years (but who's really counting?), I offer my condolences.  To the few who still have a team in the tourney, condolences are pending for 75% of you.

In honor of March Madness, I offer a challenge.  Watch the video below and follow the narrator's instructions to count the number of times the team with the white shirts passes the ball.



In medicine, the team with the white shirts passing the ball back and forth represents many of the activities of medicine.  Look at all the energy which goes into deciding on the best chemotherapy regimen, the optimal time to extubate, whether to proceed with a coronary artery bypass graft or manage medically, or to get a PET scan to rule out metastases before operating. Also, it represents titrating analgesics to reach the patient's goal for pain control, discussing code status, talking about the last game to establish rapport, and educating about the benefits of hospice.

The team with the black shirts represents many things as well.  Your pager going off three times in five minutes while trying to talk to a patient, the patient in the window bed launching unhelpful editorial comments, that pesky ache adjacent to your right shoulder blade, your kid waking you up three times the night before, the patient you had last year with the same diagnosis who responded unexpectedly poorly to the usual treatment, and that presentation you're scheduled to make in two days which you haven't started. It's also the TV being on in your patient's room with the channel tuned to the game featuring your favorite school. (Should it take a palliative care rotation to help one learn the value of turning off the TV?)

Medical school taught us well how to watch the team wearing the white shirts. There's so much happening in the video of medicine, it's easy to miss the suffering of the patient and their loved ones.  In his classic treatise, "The Nature of Suffering and the Goals of Medicine," Eric Cassell defined suffering as a threat to the integrity of personhood.  One should not equate this with a horrible symptom: The pain of natural childbirth is typically excruciating yet transient and soon eclipsed  by the joy of the newborn child.  Cancer pain which is now controlled by morphine may still "cause" suffering if the person fears the inability to fulfill one of their central roles in life.  What if the pain comes back and I'm unable to make it through my son's graduation?  What if the response to cisplatin/etoposide isn't durable? How long will it be before the other shoe drops? Unique to the individual and potentially isolating, one person may struggle with these questions given a particular illness or symptom while another person may struggle with an entirely different set of questions.  We maintain hope that by keeping our eyes on the ball, maybe the questions will stop appearing.  When faced with a serious, incurable illness, if a question fades you can count on another to appear, all the way through the loved ones' grieving process and beyond. We have shockingly little control over this fact. 

I take pride in my expertise at watching the guys in the white shirts pass the ball around.  This pride led to slight embarrassment when I watched the video at an AAHPM pre-conference conducted by Epstein and Back entitled, "Witnessing Suffering: An Introduction to Mindful Practice and Mindful Communication." I say embarrassment, because admittedly I found myself just as surprised at the end of the video as when I saw the video the first time about a year ago. 

What to do with suffering we may not be able to "fix"? First, learn to recognize it.  You don't stand a chance to fix something that you haven't diagnosed.  Second, pay attention so you don't miss it.  Here's where things get more complicated.  You are still responsible for keeping your eyes on the ball.  One might argue that suffering should be "the ball."  You won't find any argument here, but the rest of it is still there.  Mindfulness, or the practice of bringing one’s complete attention to the present experience on a moment-to-moment basis, may help you with all the layers present, some which may opacify the lens through which suffering may be found. 

If this isn't something you've considered before, you can start by thinking of the this as an exercise in efficiency.  Where there is suffering, you will likely find what is most important to your patient at that moment and from there, decide how much focus to place on everything else.  Which of your many potential actions will maximally reduced the suffering?  You will find yourself closer to the heart of patient-centered goals of care.

Sometimes, there are no balls, no players- nothing which can be "fixed" and only a patient, a physician, and suffering.  In this moment, you cannot fulfill the task of fixing problems which society assigns to physicians and we to ourselves.  In our own isolation, we can be mindful of it in the present moment, be aware of the feeling of inadequacy, increase our focus on the person sitting in front of us and thus offer hope of reducing that person's isolation. 

Need research regarding the benefits of mindfulness to the clinician? Here's just one study.  It demonstrated that primary care physician participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care.

Have I piqued your curiosity with this brief introduction?  Ample information about mindfulness exists on the internet.  Epstein and Back pointed to an intriguing four day workshop as an opportunity for clinicians who face serious illness and mortality in their practice to learn more about the topic.

by: Lyle Fettig (@lfettig)

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