Wednesday, February 20, 2019

Introversion and Hospice & Palliative Care: Insights from ‘Quiet’ by Susan Cain

by Ben Skoch (@skochb)

I made some interesting observations during my first ever trip to the AAHPM National Assembly in Boston, almost a year ago. It seemed to me that I was not the only one favoring my phone screen over introducing myself to hundreds of new people. My new Twitter follower to friends IRL ratio (‘In Real Life,’ for those wondering) was about 25:1. I noticed people often trying to find seats in a lecture hall at least a few spaces away from others, to a point where some rooms looked like those old science problems involving the diffusion of a gas.



I wondered to myself how many people here are introverts like me? Some months after that conference, I decided to poll the #HPM Twitter family to see if I could get a sense of how many identify as introverts. While 72 responses may not seem like an overwhelming sample size, I couldn’t help but feel at least partially validated with three-quarters identifying as introverts. Does the field of Hospice and Palliative Medicine naturally attract introverted people?


It wasn’t until I read “Quiet: The Power of Introverts in a World That Can’t Stop Talking” by Susan Cain, that I discovered some potential explanations. At one point in the text she describes her interviews with Harvard Business School students who learn best in “learning teams” and describe socializing as “an extreme sport (47),” situations that would make any reserved person naturally uncomfortable. I recognized some of her sentiments seemed to overlap significantly with my years of medical training, and I couldn’t help but think that she was describing so much of my life. I sure did not use my first trip to AAHPM’s Annual Assembly (in Boston no less, just minutes from the entertainment enthusiasts that Cain describes) as a chance to socialize as much as physically possible.

But what really piqued my interest was later in the book when some parallels between the natural tendencies of introverts and the work required in the world of Hospice and Palliative Medicine started to become more apparent. A few examples:

Introverts might be wired to handle the emotional ups and downs of Palliative Medicine more naturally. How often have those in Hospice and Palliative Medicine heard, “That must be so hard,” or “Isn’t that so sad all of the time?” Cain describes an interview with Janice Dorn, MD PhD (Psychiatry and Neuroscience) who counsels people involved in the trade market. Dorn says “introverts…are more successful at regulating their feelings…they protect themselves better from the downside (158).” She suggests that this may be in large part due to the way we are wired, as extroverts are more excitable and are more likely to “find themselves in an emotional state we might call ‘buzz.’” So perhaps introverts are better biologically equipped to handle sad and tough conversations.

It’s an introvert’s natural tendency to let others talk. I am confident that one of the most important things I do for my patients is to listen as they tell their stories. By providing “therapeutic silence” and “active listening,” I offer them a chance to explore their emotions. This is how I build trust so that we can work together to make personalized decisions. In her book, Cain presents the findings of psychologists John Brebner and Chris Cooper, “who have shown that extroverts think less and act faster…introverts are ‘geared to inspect’ and extroverts are ‘geared to respond (166).” Many physicians find it difficult to simply sit and listen, as evidenced by a study from 2018 that showed a median time of 11 seconds before physicians interrupted their patients.1 Perhaps this is a system flaw. As students, we are continually encouraged to be more extroverted; then during residency, we are trained to ask specific questions and document succinctly to be as efficient as possible. By the time one becomes an attending physician, we unconsciously adhere to this learned sequence. Or perhaps some of us are just wired to listen longer and let others talk, and we simply need to find a niche where this is useful.

Maybe the most compelling connection between Quiet and Hospice and Palliative Medicine is when Cain describes how introverts might get the most out of life. “The secret to life is to put yourself in the right lighting…Use your natural powers – of persistence, concentration, insight, and sensitivity – to do work you love and work that matters (264).” When people who work in Hospice and Palliative Medicine are asked to describe their work, common answers are rewarding, satisfying, gratifying, etc. I think this is likely because many in Palliative Care are introverted and they have simply found the “right lighting” for their natural abilities: an unflappable personality in the face of a wide range of emotions, listening intently to their patients, and using persistence, concentration, insight, and sensitivity to help patients and families struggling with some of life’s greatest challenges.

We all have special gifts that make us unique, and it is up to us to figure out how to use those gifts to help others and make the world a better place. As Cain details well in Quiet, it may be that extroverts have an advantage in utilizing their gifts in our modern society. Maybe our culture inhibits some introverts from recognizing their strengths and talents until later in life when they discover pastimes, relationships, and work that enhance these traits. Perhaps the world needs introverts to flourish like those examples Cain highlights: Dr Seuss, Rosa Parks, JK Rowling, and many others. Once introverts find their “right lighting,” they can build a life that is fulfilling and do work that matters. Maybe they will even wind up in a field like Hospice and Palliative Medicine where there is a connection between the strengths of introverts and the nature of this sacred work. I think if you are an introvert looking for work that is abundantly rewarding and can be a natural fit for your God-given abilities, perhaps Hospice and Palliative Medicine is worth your consideration. It might be the dream job that gets you excited to start each day, even if you have a hard time showing it.

Ben Skoch, DO, MBA, is a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

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References

1. “Quiet: The Power of Introverts in a World That Can’t Stop Talking” by Susan Cain

2. Ospina, NS et al. Eliciting the Patient’s Agenda- Secondary Analysis of Recorded Clinical Encounters. Journal of General Internal Medicine. January 2019; 34: 1: 36–40.

Wednesday, February 20, 2019 by Pallimed Editor ·

Monday, February 11, 2019

Goodbye to Compounded Analgesic Creams

by Drew Rosielle (@drosielle)

Annals of Internal Medicine has just published one of the better trials of compounded analgesic creams I've yet to see, and unfortunately it's pretty damning.

It's a randomized, double-blind, placebo-vehicle controlled, intention-to-treat, 3 parallel armed study of 3 different compounded creams for adult patients (median age ~50 years, ~50% women) with localized chronic pain (the 3 groups had neuropathic, nociceptive, or mixed pain syndromes). It took place at Walter Reed. Each arm had about 130 subjects (which, for this type of research, and compared to many other investigations of compounded creams, is quite a lot). Patients needed to have chronic pain (longer than 6 weeks), rated at least 4/10, and localized to a body area or two extremities. Broadly speaking about half the subjects' pain was incited by an injury or surgery. Pain was classified as nociceptive vs neuropathic vs mixed based on a pain physician's assessment, more or less. About 20% of patients were on systemic opioids.

Subjects were prescribed one of 3 compounded creams (or the placebo/vehicle cream which was PLO) and asked to apply it to their painful region three times a day:
  • Neuropathic: 10% ketamine, 6% gabapentin, 0.2% clonidine, and 2% lidocaine
  • Nociceptive: 10% ketoprofen, 2% baclofen, 2% cyclobenzaprine, and 2% lidocaine
  • Mixed: 10% ketamine, 6% gabapentin, 3% diclofenac, 2% baclofen, 2% cyclobenzaprine, 2% lidocaine

The primary outcome was average pain score after 1 month of treatment. They presented several prespecified secondary outcomes too. The study had 90% power to detect a pain reduction of 1.2 (out of 10) points with 60 patients per treatment arm, which they met.

Basically there weren't any statistically, let alone clinically, meaningful differences between the groups, regardless of pain type. For all groups, pain was reduced at a month by around 1-1.4/10 points on the 0-10 NRS, regardless of receiving active drug or placebo cream. Secondary outcomes including patient judgement of a positive outcome (ie, the percent of patients who reported they considered the cream a success) were the same between all the groups too (around 20%). Health related quality of life did not differ either between groups at a month.



This study is one of the largest and best-designed study I'm aware of of these creams, and the findings are pretty clear: such creams benefit patients via placebo mechanisms, aka they don't work.

Note that there is a separate body of research on some other topicals which should not be confused with this study. Eg, the 5% lidocaine patch for post-herpetic neuralgia, topical capsaicin for a variety of neuropathies, and at least some topical NSAIDs for osteoarthritis, and topical opioids. I'm not broadly endorsing those either - it's complicated - however they weren't tested here and the take home point is we should stop making our patients pay exorbitant out of pocket costs for these compounded analgesic placebos, not necessarily those others.

Particularly for painful axonal neuropathies, many of us struggle with how to control those adequately, especially chemotherapy induced ones which don't respond well to most systemic drugs, and I've ordered plenty of fancy creams in the past for my patients, most of whom paid out of pocket for them, and I think it's time to stop doing that.

For more Pallimed posts about journal reviews.
For more Pallimed posts by Drew click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.

References

1 Brutcher RE, Kurihara C, Bicket MC, Moussavian-Yousefi P, Reece DE, Solomon LM, et al. "Compounded Topical Pain Creams to Treat Localized Chronic Pain: A Randomized Controlled Trial." Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-2736

Monday, February 11, 2019 by Drew Rosielle MD ·

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